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01.12.2017 | Research article | Ausgabe 1/2017 Open Access

BMC Medicine 1/2017

State of inequality in malaria intervention coverage in sub-Saharan African countries

BMC Medicine > Ausgabe 1/2017
Katya Galactionova, Thomas A. Smith, Don de Savigny, Melissa A. Penny
Wichtige Hinweise

Electronic supplementary material

The online version of this article (doi:10.​1186/​s12916-017-0948-8) contains supplementary material, which is available to authorized users.



Scale-up of malaria interventions over the last decade have yielded a significant reduction in malaria transmission and disease burden in sub-Saharan Africa. We estimated economic gradients in the distribution of these efforts and of their impacts within and across endemic countries.


Using Demographic and Health Surveys we computed equity metrics to characterize the distribution of malaria interventions in 30 endemic countries proxying economic position with an asset-wealth index. Gradients were summarized in a concentration index, tabulated against level of coverage, and compared among interventions, across countries, and against respective trends over the period 2005–2015.


There remain broad differences in coverage of malaria interventions and their distribution by wealth within and across countries. In most, economic gradients are lacking or favor the poorest for vector control; malaria services delivered through the formal healthcare sector are much less equitable. Scale-up of interventions in many countries improved access across the wealth continuum; in some, these efforts consistently prioritized the poorest. Expansions in control programs generally narrowed coverage gaps between economic strata; gradients persist in countries where growth was slower in the poorest quintile or where baseline inequality was large. Despite progress, malaria is consistently concentrated in the poorest, with the degree of inequality in burden far surpassing that expected given gradients in the distribution of interventions.


Economic gradients in the distribution of interventions persist over time, limiting progress toward equity in malaria control. We found that, in countries with large baseline inequality in the distribution of interventions, even a small bias in expansion favoring the least poor yielded large gradients in intervention coverage while pro-poor growth failed to close the gap between the poorest and least poor. We demonstrated that dimensions of disadvantage compound for the poor; a lack of economic gradients in the distribution of malaria services does not translate to equity in coverage nor can it be interpreted to imply equity in distribution of risk or disease burden. Our analysis testifies to the progress made by countries in narrowing economic gradients in malaria interventions and highlights the scope for continued monitoring of programs with respect to equity.
Additional file 1: Tables SA1. and SA2 that list by country: country name, ISO3 code, mean population weighted PfPR 2-10 , and corresponding DHS/MIS survey used in 2015 tabulations and 2005–2015 year trend analyses. (DOCX 37 kb)
Additional file 2: Tables detailing country estimates corresponding to level and degree of inequality for each of the malaria intervention coverage indicators including ACTs (Tables SA3-SA9). (DOCX 93 kb)
Additional file 3: Plots of 2015* level and degree of inequality for each of the malaria intervention coverage indicators including ACTs (Figure SA1-SA2). (DOCX 84 kb)
Additional file 5: Table SA10. 2015* malaria parasite prevalence estimates according to rapid diagnostic tests based on country DHS/MIS surveys. (DOC 45 kb)
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