The synthesis of malaria programme funding and control progress data from countries worldwide confirms that global malaria donor funding is generally well targeted to the countries with highest malaria transmission and case and death rates. Higher donor funding per person at risk was also associated with greater increases in household ITN ownership among African countries, confirming similar observations made earlier [10, 15, 17, 21]. Outside Africa, increased donor funding was associated with larger proportional malaria case and death rate declines.
Outside Africa, all-source programme funding per case averted or death averted tended to be lower in the countries with higher donor malaria support per person at risk (Table 2). These gradients illustrate an overall effective targeting of global donor allocations to countries with highest return on malaria investments. Nevertheless, there was large variation among countries within each group in programme funding per case or death averted, with overlapping ranges across the three tertiles of countries. Apparently, donor allocations partially counterbalance the enormous differences among countries in levels of domestic funding per person at risk and per case or death averted (Figure 1c and d), but they do not completely turn around the cross-country imbalances so as to maximize the possible health impact for available global funding.
The presented ‘costs’ per case or death averted should not be considered as cost-effectiveness ratios, which are typically lower (more favourable) [22, 23], for three reasons. First, case/death levels averaged over year 2000−2003 served as the baseline against which cases and deaths averted were calculated; however, in reality, case and death rates in the non-African countries evaluated might well resurge to above 2000−2003 levels if malaria programme funding and control stopped altogether. Second, the time horizon for cases and deaths averted was limited to 2010, without including additional impact achieved over 2011–2012 from the – comparatively large – programme spending in 2009–2010. Third, total funding on all malaria services included case management and programme administration, rather than just the cost of any single intervention.
Although donor malaria funding is generally well targeted to the highest-need countries with lowest ITN coverage and highest case and death rates at baseline, there remain exceptions. As noted before [10, 24–26], donor funding per person at risk was very high in some small countries of relatively low malaria burden and high income, including Bhutan, Comoros, Laos, Suriname, and in Africa Sao Tome and Principe and Equatorial Guinea (both excluded from analyses), Gabon, Namibia and Swaziland. In contrast, Burkina Faso, the Democratic Republic of Congo, Mali, Cote d’Ivoire and Nigeria had surprisingly low donor malaria funding relative to their populations at risk.
A full mapping of malaria funding needs and gaps was beyond the scope of the current study, and would have to consider not only actual programme allocations but also countries’ domestic funding capacity. In addition, economies of scale will tend to lower costs per person reached in large-scale, nation-wide programmes in the highest-endemic countries, compared to settings with only focal malaria that require more expensive pre-elimination and elimination strategies . Also, effective progress in control does not necessarily mean that impact would be sustained after lowering the inputs – as experiences with malaria resurgence in Sri Lanka, Madagascar and other countries have shown. According to WHO estimates, overall global funding for malaria control falls short of the global need [3, 8, 9], and increasing overall malaria funding is equally important as optimizing funding allocations. Nevertheless, the large variation in funding per person at risk (Additional file 1) and the only moderately strong association between funding per case or death averted and level of national donor funding per person at risk (Table 2) suggest a scope for further enhancing value for money in international malaria financing, through more strategic allocation of available funding toward the highest-endemic countries with the highest continued need.
In 2011, the Global Fund revised its eligibility, prioritization and counterpart financing policy. From 2012 onwards all supported countries are required to make a minimum domestic government co-funding contribution, of a proportion increasing with country income and with the years of each grant [28, 29]. The increased counterpart financing requirement on upper-middle income countries should result in a gradual shift of portfolio allocations toward lower-income countries. This policy change therefore has the potential to facilitate better targeting of Global Fund funding to benefit countries with the highest continuing need, an approach also emphasized in the Global Fund’s 2012–2016 Strategy ‘Investing for impact’.
Uncertainties and potential inaccuracies in country ITN coverage and case and death trend estimates [20, 21, 31] limited the power to assess associations between funding and health impact. The methods for producing estimates of cases and deaths outside of Africa adjust the number of reported cases to take into account the proportion of cases that are not captured by a surveillance system. While helping to make numbers more comparable between countries, and filling gaps where data are missing, the estimates rely on relationships between variables that are uncertain, and draw upon data that may have been imprecisely measured, or measured in previous years and projected forward. Thus estimates of the number of malaria cases or deaths are accompanied by a large degree of uncertainty, and inferences concerning trends are less certain than those made directly from good quality surveillance data. In particular, the number of malaria deaths is estimated by using a fixed case fatality rate which does not take into account varying access to treatment. For sub-Saharan Africa, lack of data on malaria cases and deaths narrowed the analysis to household ownership of ITNs. Although a reasonable predictor of ITN usage [32, 33] and associated reductions in under-five mortality, malaria parasitaemia and anaemia [34–36], ownership of one or more ITNs is not a precise indicator of the extent to which universal protection for all household members is achieved.
A further limitation is incompleteness and varying quality of data on domestic government financing. Of the 90 malaria-endemic countries analysed, eight did not report domestic malaria funding to WHO for any of the years 2003 to 2009, and 25 countries did not report domestic funding in 2009. Under-reporting is plausible notably for domestic spending on malaria case management, which is typically not allocated specifically to the malaria programme but rather absorbed within districts’ overall health budgets. While donor funding is sometimes allocated predominantly to commodity needs of malaria programmes [10, 15, 21], domestic contributions may more often concern the infrastructure, staff and programme management . A recent assessment of global malaria funding over 2006 to 2010 found similar annual funding levels as this study for the Global Fund and other donors, but slightly higher domestic funding – the latter based on government budgets reported by grant recipients to the Global Fund, as opposed to the programme expenditures reported to WHO used here .
Because of these imperfections in both national funding and health outcome data, this study assessed their relationship only across groups of countries, and not at the level of individual countries. Importantly, whether in country groups or at the level of individual countries, ‘ecological’ correlations as found in the current observational analysis will not necessarily indicate a true causal impact of programme funding. Among several alternative explanations, programme funding may be associated with increased progress if donors’ funding allocation criteria would effectively prioritize those countries with best programme implementation capacity. Notably the Global Fund selects proposals for grants based on technical soundness and demonstrated effectiveness, followed by performance-based grant renewal . The current low per-person-at-risk donor in some countries in part reflects the challenges that these countries face with effective implementation owing to security concerns, civil strife, limited technical, managerial and strategic planning capacity. Re-allocating funding to such countries may not necessarily yield equally high returns on investment as observed in other countries.
Finally, the study did not consider allocative and technical efficiency in malaria programmes as determinants of progress in control. In reality, not only the funding amount, but also the appropriateness of its allocation across prevention, diagnosis and treatment services, and the − varying − efficiency in delivering these services  will influence the relations between funding and health outcome.
To refine these analyses will require improving country-level case and death trend estimates, based on the WHO’s new guidelines for scaling-up malaria diagnosis  and for malaria surveillance [39, 40], and the ongoing roll-out of parasitological diagnosis notably in African countries . On the financing tracking side, new standards are needed for reporting of national malaria programme financing, to improve quality, transparency, and completeness .