Vertical and horizontal equity of funding for malaria control: a global multisource funding analysis for 2006-2010

International and domestic funding for malaria is critically important to achieve the Sustainable Development Goals. Its equitable distribution is key in ensuring that the available, scarce, resources are deployed efficiently for improved progress and a sustained response that enables eradication.

We used concentration curves and concentration indices to assess inequalities in malaria funding by different donors across countries, measuring both horizontal and vertical equity. Horizontal equity assesses whether funding is distributed in proportion to health needs, whereas vertical equity examines whether unequal economic needs are addressed by appropriately unequal funding. We computed the Health Inequity Index and the Kakwani Index to assess the former and the latter, respectively. We used data from the World Bank, Global Fund, Unicef, President's Malaria Initiative and the Malaria Atlas Project to assess the distribution of funding against need for 94 countries. National gross domestic product per capita was used as a proxy for economic need and 'population-at-risk' for health need.

The level and direction of inequity varies across funding sources. Unicef and the President's Malaria Initiative were the most horizontally inequitable (pro-poor). Inequity as shown by the Health Inequity Index for Unicef decreased from -0.40 (P<0.05) in 2006 to -0.25 (P<0.10) in 2008, and increased again to -0.58 (P<0.01) in 2009. For President's Malaria Initiative, it increased from -0.19 (P>0.10) in 2006 to -0.38 (P<0.05) in 2008, and decreased to -0.36 (P<0.10) in 2010. Domestic funding was inequitable (pro-rich) with inequity increasing from 0.28 (P<0.01) in 2006 to 0.39 (P<0.01) in 2009, and then decreasing to 0.22 (P<0.10) in 2010. Funding from the World Bank and the Global Fund was distributed proportionally according to need. In terms of vertical inequity, all sources were progressive: Unicef and the President's Malaria Initiative were the most progressive with the Kakwani Indices ranging from -0.97 (P<0.01) to -1.29 (P<0.01), and -0.90 (P<0.01) to -1.10 (P<0.01), respectively.

Our results suggest that external funding of malaria treatment tends to be allocated to countries with higher health and economic need but not in proportion to their relative health need and income when compared to other countries. While malaria eradication might require funders to disproportionally allocate funding that goes beyond (financial and health) need, our analysis highlights that funders might potentially be targeting in excess certain countries. Regular assessments of need and greater coordination among donors are necessary for equitable resource allocation, to improve and sustain progress with malaria control and elimination.