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Taking the health aid debate to the subnational level: the impact and allocation of foreign health aid in Malawi
  1. Robert Marty1,
  2. Carrie B Dolan1,
  3. Matthias Leu2,
  4. Daniel Runfola1
  1. 1AidData, The College of William and Mary, Williamsburg, Virginia, USA
  2. 2Department of Biology, The College of William and Mary, Williamsburg, Virginia, USA
  1. Correspondence to Robert Marty; ramarty{at}


Objective Cross-national studies provide inconclusive results as to the effectiveness of foreign health aid. We highlight a novel application of using subnational data to evaluate aid impacts, using Malawi as a case study.

Design We employ two rounds of nationally representative household surveys (2004/2005 and 2010/2011) and geo-referenced foreign aid data. We examine the determinants of Malawi's traditional authorities receiving aid according to health, environmental risk, socioeconomic and political factors. We use two approaches to estimate the impact of aid on reducing malaria prevalence and increasing healthcare quality: difference-in-difference models, which include traditional authority and month-of-interview fixed effects and control for individual and household level time-varying factors, and entropy balancing, where models balance on health-related and socioeconomic baseline characteristics. General health aid and four specific health aid sectors are examined.

Results Traditional authorities with greater proportions of individuals living in urban areas, more health facilities and greater proportions of those in major ethnic groups were more likely to receive aid. Difference-in-difference models show health infrastructure and parasitic disease control aid reduced malaria prevalence by 1.20 (95% CI −0.36 to 2.76) and 2.20 (95% CI 0.43 to 3.96) percentage points, respectively, and increased the likelihood of individuals reporting healthcare as more than adequate by 12.1 (95% CI 1.51 to 22.68) and 14.0 (95% CI 0.11 to 28.11) percentage points. Entropy balancing shows similar results.

Conclusions Aid was targeted to areas with greater existing health infrastructure rather than areas most in need, but still effectively reduced malaria prevalence and enhanced self-reported healthcare quality.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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  • Handling editor Seye Abimbola.

  • Contributors RM originally designed the study and collected, analysed and interpreted the data. All authors contributed to the study design. CD assisted interpreting the data and assisted with the literature review. RM wrote the manuscript and conducted the literature review. All authors substantially revised the manuscript, and all authors approved the final version of the manuscript.

  • Funding This project received financial support from the US Agency for International Development (grant number AID-OAA-A-12-00096), the College of William and Mary Department of Biology, the College of William and Mary Public Policy Program, and the College of William and Mary Office of Graduate Studies and Research.

  • Disclaimer The funder had no role in the study design, analysis, interpretation of results, writing of the report, nor in the decision to submit this article for publication.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data are available.

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