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The US President's Malaria Initiative and under-5 child mortality in sub-Saharan Africa: A difference-in-differences analysis.

Abstract Despite substantial financial contributions by the United States President's Malaria Initiative (PMI) since 2006, no studies have carefully assessed how this program may have affected important population-level health outcomes. We utilized multiple publicly available data sources to evaluate the association between introduction of PMI and child mortality rates in sub-Saharan Africa (SSA).
PMID
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Authors

Mayor MeshTerms
Keywords
Journal Title plos medicine
Publication Year Start




PMID- 28609442
OWN - NLM
STAT- In-Process
DA  - 20170613
LR  - 20170613
IS  - 1549-1676 (Electronic)
IS  - 1549-1277 (Linking)
VI  - 14
IP  - 6
DP  - 2017 Jun
TI  - The US President's Malaria Initiative and under-5 child mortality in sub-Saharan 
      Africa: A difference-in-differences analysis.
PG  - e1002319
LID - 10.1371/journal.pmed.1002319 [doi]
AB  - BACKGROUND: Despite substantial financial contributions by the United States
      President's Malaria Initiative (PMI) since 2006, no studies have carefully
      assessed how this program may have affected important population-level health
      outcomes. We utilized multiple publicly available data sources to evaluate the
      association between introduction of PMI and child mortality rates in sub-Saharan 
      Africa (SSA). METHODS AND FINDINGS: We used difference-in-differences analyses to
      compare trends in the primary outcome of under-5 mortality rates and secondary
      outcomes reflecting population coverage of malaria interventions in 19
      PMI-recipient and 13 non-recipient countries between 1995 and 2014. The analyses 
      controlled for presence and intensity of other large funding sources, individual 
      and household characteristics, and country and year fixed effects. PMI program
      implementation was associated with a significant reduction in the annual risk of 
      under-5 child mortality (adjusted risk ratio [RR] 0.84, 95% CI 0.74-0.96). Each
      dollar of per-capita PMI expenditures in a country, a measure of PMI intensity,
      was also associated with a reduction in child mortality (RR 0.86, 95% CI
      0.78-0.93). We estimated that the under-5 mortality rate in PMI countries was
      reduced from 28.9 to 24.3 per 1,000 person-years. Population coverage of
      insecticide-treated nets increased by 8.34 percentage points (95% CI 0.86-15.83) 
      and coverage of indoor residual spraying increased by 6.63 percentage points (95%
      CI 0.79-12.47) after PMI implementation. Per-capita PMI spending was also
      associated with a modest increase in artemisinin-based combination therapy
      coverage (3.56 percentage point increase, 95% CI -0.07-7.19), though this
      association was only marginally significant (p = 0.054). Our results were robust 
      to several sensitivity analyses. Because our study design leaves open the
      possibility of unmeasured confounding, we cannot definitively interpret these
      results as causal. CONCLUSIONS: PMI may have significantly contributed to
      reducing the burden of malaria in SSA and reducing the number of child deaths in 
      the region. Introduction of PMI was associated with increased coverage of malaria
      prevention technologies, which are important mechanisms through which child
      mortality can be reduced. To our knowledge, this study is the first to assess the
      association between PMI and all-cause child mortality in SSA with the use of
      appropriate comparison groups and adjustments for regional trends in child
      mortality.
FAU - Jakubowski, Aleksandra
AU  - Jakubowski A
AUID- ORCID: http://orcid.org/0000-0001-7698-1392
AD  - Department of Health Policy and Management, Gillings School of Global Public
      Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina,
      United States of America.
FAU - Stearns, Sally C
AU  - Stearns SC
AUID- ORCID: http://orcid.org/0000-0002-1129-0838
AD  - Department of Health Policy and Management, Gillings School of Global Public
      Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina,
      United States of America.
FAU - Kruk, Margaret E
AU  - Kruk ME
AUID- ORCID: http://orcid.org/0000-0002-9549-8432
AD  - Department of Global Health and Population, Harvard T.H. Chan School of Public
      Health, Harvard University, Boston, Massachusetts, United States of America.
FAU - Angeles, Gustavo
AU  - Angeles G
AD  - Carolina Population Center, University of North Carolina at Chapel Hill, Chapel
      Hill, North Carolina, United States of America.
AD  - Department of Maternal and Child Health, University of North Carolina at Chapel
      Hill, Chapel Hill, North Carolina, United States of America.
FAU - Thirumurthy, Harsha
AU  - Thirumurthy H
AD  - Department of Health Policy and Management, Gillings School of Global Public
      Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina,
      United States of America.
AD  - Carolina Population Center, University of North Carolina at Chapel Hill, Chapel
      Hill, North Carolina, United States of America.
LA  - eng
PT  - Journal Article
DEP - 20170613
PL  - United States
TA  - PLoS Med
JT  - PLoS medicine
JID - 101231360
EDAT- 2017/06/14 06:00
MHDA- 2017/06/14 06:00
CRDT- 2017/06/14 06:00
PHST- 2016/11/02 [received]
PHST- 2017/05/09 [accepted]
AID - 10.1371/journal.pmed.1002319 [doi]
AID - PMEDICINE-D-16-03547 [pii]
PST - epublish
SO  - PLoS Med. 2017 Jun 13;14(6):e1002319. doi: 10.1371/journal.pmed.1002319.
      eCollection 2017 Jun.

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