Healthcare Analytics 3 (2023) 100137 Contents lists available at ScienceDirect Healthcare Analytics journal homepage: www.elsevier.com/locate/health A double bootstrap data envelopment analysis model for evaluating malaria spending efficiency in Sub-Saharan Africa Kwadwo Arhin a,∗ , Albert Opoku Frimpong b , Richard Boso c , Kwame Acheampong d a Ghana Institute of Management and Public Administration, Department of Economics, Accra, Ghana b University of Professional Studies, Department of Banking and Finance, Accra, Ghana c Ghana Institute of Management and Public Administration, Department of Operations Management, Accra, Ghana d Akenten Appiah-Menka University of Skills Training and Entrepreneurial Development, Kumasi, Ghana ARTICLE INFO Keywords: Data envelopment analysis Double bootstrap Malaria spending efficiency Environmental factors Sub-Saharan Africa ABSTRACT Malaria is a major cause of morbidity and mortality in many countries in sub-Saharan Africa. The main objective of this study was to examine malaria spending efficiency and its associated factors in sub-Saharan Africa by employing a two-stage double bootstrap data envelopment analysis (DEA). In the first stage, technical efficiency scores are estimated using the output-oriented variable returns to the scale (VRS) framework. In the second stage, the double bootstrap DEA model is used to identify the environmental variables that affect malaria spending efficiency. We estimate the overall malaria spending efficiency score over the study period. This estimate suggests that malaria treatment and prevention outcomes can improve significantly. We find a significant association between efficiency and education, temperature levels, nurses’ and midwives’ density, and the proportion of children of age five who slept in insecticide-treated bed nets. We conclude that policymakers must not only be concerned with improving educational outcomes but also consider ways to mitigate the effects of climate change and improve access to healthcare services. 1. Introduction Malaria remains a major cause of morbidity and mortality in many countries in Sub-Saharan Africa (SSA) [1]. Approximately 93 percent of all malaria cases and 94 percent of malaria-related deaths occur in the region [2] with more than 55 percent of the estimated 241 million cases globally in 2020 being accounted for by six countries: Nigeria (27%), Democratic Republic of Congo (12%), Uganda (5%), Mozambique (4%), Angola (3.4%), and Burkina Faso (3.4%). Children below the age of five years accounted for 77% of the total estimated 627,868 (95% uncertainty range: 583,000–765,000) malaria deaths globally in 2020 alone [3]. More than two decades ago, the World Health Organization (WHO) in partnership with the United Nations Children’s Fund (UNICEF), the United Nations Development Programme (UNDP), and the World Bank (WB) launched the Roll Back Malaria (RBM) program in 1998. The target of the RBM program was to help halve the enormous malaria burden on the health of people and economies from 2000 to 2010 and a further half reduction from 2010 to 2015 [4]. In the era of the Millennium Development Goals (MDGs), a target was set to reduce the Abbreviations: DALYs, Disability-Adjusted Life Years; DALE, Disability-Adjusted Life Expectancy; DEA, Data Envelopment Analysis; GDP, Gross Domestic Product; HALE, Health-Adjusted Life Expectancy; SFA, Stochastic Frontier Analysis; WMR, World Malaria Report ∗ Corresponding author. E-mail addresses: kwarhin@gimpa.edu.gh (K. Arhin), frimpongao@gmail.com (A.O. Frimpong), rboso@gimpa.edu.gh (R. Boso), Kwame.74.acheampong@gmail.com (K. Acheampong). incidence of malaria by 2015 [5]. In line with the current Sustainable Development Goals (SDGs), the targets are to reduce malaria incidence and mortality by 90% and eliminate malaria in at least 35 malaria- endemic countries by 2030 from the 2015 baseline [6,7]. Despite a reduction in the malaria incidence rate from 368 to 222 cases per 1000 populations at risk in the WHO African Region between 2000 and 2019, the progress falls short of the improvements needed to meet the targets set by the WHO in the Global Technical Strategy for malaria 2016–2030 (GTS) and Sustainable Development Goals target 3.3 [3,7,8]. Globally, increasing amounts of resources are being expended on malaria control and elimination. In 2020 alone, US$3.3 billion was invested in combating this plague of which 79 percent went to countries in the WHO African Region. A third of this amount was contributions from the governments of the malaria-endemic countries [9]. Though the US$3.3 billion invested in 2020 represents a 10 percent increase over the 2019 figure, it fell short of the annual investment of US$6.8 billion (or US$3.90 per person at risk of malaria) estimated to be required globally to achieve the targets set out in the Global Technical Strategy for malaria 2016–2030 (GTS) [7,9,10]. Again, the SSA region faces the risk of declining external financing due to its economic growth https://doi.org/10.1016/j.health.2023.100137 Received 24 May 2022; Received in revised form 11 December 2022; Accepted 11 January 2023 2772-4425/© 2023 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).