Malaria prevention and control are major foreign assistance objectives of the U.S. Government (USG). In May 2009, President Barack Obama announced the Global Health Initiative (GHI), a comprehensive effort to reduce the burden of disease and promote healthy communities and families around the world. Through the GHI, the United States will help partner countries improve health outcomes, with a particular focus on improving the health of women, newborns, and children. The President's Malaria Initiative (PMI) is a core component of GHI, along with HIV/AIDS and tuberculosis programs. PMI was launched in June 2005 as a 5-year, $1.2 billion initiative to rapidly scale up malaria prevention and treatment interventions and reduce malaria-related mortality by 50% in 15 high-burden countries in sub-Saharan Africa by 2010. With passage of the 2008 Lantos-Hyde Act, funding for PMI was extended and, as part of the GHI, the goal of PMI was adjusted to reduce malaria-related mortality by 70% in the original 15 countries by the end of 2015. Programming of PMI activities follows the core principles of GHI: encouraging country ownership and investing in country-led plans and health systems; increasing impact and efficiency through strategic coordination and programmatic integration; strengthening and leveraging key partnerships, multilateral organizations, and private contributions; implementing a woman- and girl-centered approach; improving monitoring and evaluation; and promoting research and innovation. Madagascar was in the third wave of eight new PMI countries in 2008 which brought the total to 15 focus countries. Full implementation began in Madagascar with FY 2008 funding. Malaria is a major health problem in Madagascar, although its epidemiology varies considerably in different regions of the country. On the East Coast transmission is stable and perennial, while the West Coast has a long, rainy transmission season and a brief dry season. Almost one-third of the Central Highlands is above 1,500 meters elevation, where malaria transmission rarely occurs. In the rest of the Central Highlands, however, transmission is seasonal and moderately unstable with occasional epidemics. The semi-desert South has highly seasonal and unstable transmission and is also vulnerable to epidemics. In the most recent large-scale epidemic in the Central Highlands in the late 1980s, an estimated 30,000 people died.