This article has Open Peer Review reports available.
Simple versus composite indicators of socioeconomic status in resource allocation formulae: the case of the district resource allocation formula in Malawi
© Manthalu et al; licensee BioMed Central Ltd. 2010
Received: 10 June 2009
Accepted: 6 January 2010
Published: 6 January 2010
The district resource allocation formula in Malawi was recently reviewed to include stunting as a proxy measure of socioeconomic status. In many countries where the concept of need has been incorporated in resource allocation, composite indicators of socioeconomic status have been used. In the Malawi case, it is important to ascertain whether there are differences between using single variable or composite indicators of socioeconomic status in allocations made to districts, holding all other factors in the resource allocation formula constant.
Principal components analysis was used to calculate asset indices for all districts from variables that capture living standards using data from the Malawi Multiple Indicator Cluster Survey 2006. These were normalized and used to weight district populations. District proportions of national population weighted by both the simple and composite indicators were then calculated for all districts and compared. District allocations were also calculated using the two approaches and compared.
The two types of indicators are highly correlated, with a spearman rank correlation coefficient of 0.97 at the 1% level of significance. For 21 out of the 26 districts included in the study, proportions of national population weighted by the simple indicator are higher by an average of 0.6 percentage points. For the remaining 5 districts, district proportions of national population weighted by the composite indicator are higher by an average of 2 percentage points. Though the average percentage point differences are low and the actual allocations using both approaches highly correlated (ρ of 0.96), differences in actual allocations exceed 10% for 8 districts and have an average of 4.2% for the remaining 17. For 21 districts allocations based on the single variable indicator are higher.
Variations in district allocations made using either the simple or composite indicators of socioeconomic status are not statistically different to recommend one over the other. However, the single variable indicator is favourable for its ease of computation.
Health care systems adopt various ways of allocating resources to sub-national areas and agencies. The four commonly used methods are: i) political patronage ii) historical allocations iii) bids by local governments and iv) needs-based resource allocation formulae . Political patronage entails government rewarding loyal constituencies and potential strongholds. Under historical allocation, funds are allocated according to past year's expenditures adjusted by inflation and efficiency changes. Under the third mechanism, central Government will allocate resources by scrutinizing uncapped budget submissions made by Local Authorities, funding activities that are in line with overarching national strategies. The needs based resource allocation formula entails central Government allocating resources based on a mathematical formula that integrates need for health care. The allocation of resources usually takes place in the context of devolution where services are delivered by lower level jurisdictions.
Formula funding has become a preferred method of allocating resources in many publicly financed health systems. Some of the merits of needs-based resource allocation formulae include that resources are allocated to areas of high priority, where they can secure the highest marginal health benefit. Besides, a well designed formula allows financial resources to be allocated to providers in proportion to services that they deliver. Formula funding also presents a widely accepted mechanism for setting budgets for devolved organizations .
In most African countries, health expenditures across different districts or regions have not matched with need for health care . This is largely attributable to inheritance of past inequitable systems and allocation patterns that ensued from such systems. Explicit resource allocation formulae hence ensure that the share of total resources allocated to an area is based on indicators of relative need for health care .
The resource allocation formula for funding districts in Malawi was reviewed in 2007/08 with a view to improving its ability to reflect need and capture differential costs of service provision across districts. The basic indicator of health care need in the formula is population by district which is weighted by stunting. Stunting was selected as an indicator of overall socioeconomic status of a district such that districts with higher rates have lower socioeconomic status overall and vice versa. It is referred to as a simple or single variable indicator in this paper. It is expressed as percentage of children under-five, by district, whose height-for-age falls below minus 3 standard deviations from the median height-for-age of a standard reference population used in the Multiple Indicator Cluster Survey 2006. Stunting has been recommended as a reliable measure of overall socioeconomic deprivation [3, 4].
It has been argued that a single variable indicator of need can be susceptible to rapid changes or fluctuations which might not reflect actual patterns of need . Its advantage, however, is that it is much easier to compute. The composite indicator, on the other hand, requires differential weighting of variables which can be achieved by either employing expert opinion or through a principal components analysis. In many countries where the concept of need has been incorporated in resource allocation, composite indicators of socioeconomic status such as deprivation and asset indices have been used (see Zere et al. 2007, McIntyre et al. 2000). This paper examines, using the Malawi district resource allocation formula, whether there are differences between weighting population with simple and composite indicators of socioeconomic status in terms of allocations made to districts, holding all other factors in the formula constant.
Brief country profile
Health and development indicators for Malawi
Life expectancy at birth, male/female (years)
Total fertility rate
One year olds fully immunized against measles, 2007/08 (%)
Infant mortality rate (per 1000 live births), 2006 (%)
Under-five mortality rate (per 1000 live births), 2006
Maternal mortality ratio (per 100, 000 live births)
Literacy rates, male/female (%)
Stunting in under-five children, 2006 (%)
Gross domestic product per capita, US$ PPP
Gini coefficient, 2005
Human development index, 2005
Adult HIV prevalence rate (15-49 years) (%)
Physician per population ratio
Nurse per population ratio
The epidemiological profile of Malawi is characterized by a high prevalence of communicable diseases including malaria, tuberculosis and HIV and AIDS; an increasing burden of non-communicable diseases such as cancer, hypertension, diabetes, cardiovascular diseases and mental illnesses and high incidence of maternal and child health problems.
District resource allocation in Malawi
The district health system in Malawi is organised into two levels of care: i) primary - provided by health centres, dispensaries and community health workers and ii) secondary - provided by district hospitals and mission hospitals of equivalent capacity. Four districts have referral hospitals which provide tertiary health care but these are financed and managed separately from the district health system.
There are two categories of resources that are allocated to districts: recurrent and development. Recurrent allocations meet the operational costs of all health facilities in a district, while development funding is meant for capital expenditures such as construction or rehabilitation of health centres and purchase of big medical equipment. The district resource allocation formula applies only to the recurrent budget.
Until 2000/01, the allocation of district health funding was determined purely based on population. As such, allocations were directly proportional to district populations. The formula was subsequently revised by including the variables, poverty and under-five mortality to strengthen its ability to reflect need. In 2007/08, the formula was revisited again by replacing the previous proxy measures of need with stunting and including a variable that captures differences in the cost of delivering health care across districts. There are four variables in the current resource allocation formula and they are: stunting, index for differential costs of service provision, bed capacity and OPD utilization.
Where x i is the allocation for district i,
V ni is the value of variable n for district i,
a n is the weight for variable V n
The weights a i for the variables are currently determined by policy makers.
Developing a composite indicator of need
Population size in a geographical area is the primary indicator of need . It can be weighted by other indicators of relative need for health such as deprivation and asset indices as well as variables that proxy burden of disease to capture other dimensions of need that cannot be captured by population only. In this study we focus on asset indices as indicators of health care need. The premise for including the asset index as an indicator of health care need is that it is a measure of socioeconomic status and there is a well established relationship between health and socioeconomic status . The report of the Commission on Social Determinants of Health 2008 points out that the relationship is graded such that poorer individuals have poorer health .
Asset indices have been widely used because of the challenges in using standard measures of socioeconomic status that use income . Income measures are difficult because they demand collecting accurate data which is expensive especially for low income countries. In addition, adjusting data for individuals who have multiple sources of income is rigorous. Further, income data does not capture income in kind e.g. maize or animals which may be traded and this leads to inaccurate estimation of actual income. Consumption expenditures are sometimes employed but these too are costly to collect .
Using an asset based indicator of need has got its own problems. Such measures are more reflective of longer run household socioeconomic status failing to take into account short term shocks to the household. The quality of assets is not captured and certain variables may have different relationship with socioeconomic status across the population .
There are important assumptions which are made when deriving the asset index. The first assumption is that variables are additive i.e. if an individual ranks poorly with respect to two or more variables, then that individual should be more deprived than one who ranks poorly on the basis of only one of them. Secondly, the variables should be weighted differently. This shows the relative importance of the variables included in the analysis .
A multivariate statistical technique called principal components analysis (PCA) is used to derive the asset index. Principal components analysis describes the variation of a set of variables as a set of linear combinations of the original variables, in which each consecutive linear combination is derived so as to explain as much as possible of the variation in the original data, while being uncorrelated with other linear combinations . PCA works best when variables are highly correlated and their distribution varies across households .
Where PC i is principal component i;
a ik represents the weight for the k th variable for the i th principal component
i.e. the sum of the squared weights is equal to one . Typically, the asset index is assumed to be the first principal component--that is, the first linear combination.
where a ik is the value of asset k for household i, a k is the sample mean, s k is the sample standard deviation, and f k are the factor scores or weights associated with the first principal component.
In this study we developed asset indices using principal components analysis. Data were obtained from the Malawi Multiple indicator Cluster Survey (MICS) 2006. They were available for only 26 out of the 28 districts because the two districts have only been recently established. The survey treated these two districts as part of the districts to which they originally belonged before they were demarcated. Variables were expressed as categorical variables with the dichotomous responses of 'Yes', coded 1, if the household possessed that variable and 'No', coded 0, if they did not. Most of the variables that were included in the asset index have been used in similar studies in developing countries (see Houweling et. al 2003, Vyas and Kumaranayake 2006, and Zere et. al. 2007). The spearman rank correlation test was used to check correlation of the all variables included in the PCA. Variables which were not significant at the 1% significance level were excluded from the analysis. Stata/SE 10.0 and Microsoft Excel 2003 were used for the analysis.
Scoring weights derived from Principal Component Analysis
Source of Water Supply
Piped into dwelling, household uses bottled water
Piped outside dwelling
Tube well/borehole, tube well with powered pump, cart with small tank/drum
Surface water, rainwater collection
Type of toilet facility
Flush toilet of any type
Pit latrine with slab, pit latrine with slab and foot rest
Pit latrine without slab/open pit
Pit latrine with slab and cover, pit latrine with slab/cover and foot rest
No toilet, composting toilet, hanging toilet/latrine
Type of floor material
Tiles, cement, carpet, wood planks, other
Type of roofing material
Thatch, sod, rustic mat, palm/bamboo
Source of fuel for cooking
Electricity, all types of gas, kerosene
Simple and composite socioeconomic indicators by district
Normalised asset indices
Population weighted by asset indices
Population weighted by Stunting
Proportion of population weighted by asset indices (%)
Proportion of population weighted by stunting (%)
Comparison of results from formulae employing either the simple or composite indicators of socioeconomic status
i) District proportions of national population
The objective of this study was to assess whether there are differences in the resources allocated to districts in Malawi when either simple or composite indicators of socioeconomic status are used to weight population, holding all other factors in the allocation formula constant.
We used PCA to derive asset indices for 26 districts. The results indicate that the two types of indicators are highly correlated and so are the district allocations made using either of them. An interesting result, however, is that allocations are higher for 21 districts when the single variable indicator is used. For Blantyre, Lilongwe and Mzimba districts the values of the asset indices are considerably higher than those of the single variable indicator. A possible explanation for this could be that stunting prevalence rates for these districts were underestimated. Blantyre and Lilongwe are the country's largest cities while Mzimba district contains the third largest city, Mzuzu. These three districts have the largest populations with an average of 1,249,988 while the rest of the districts have an average of 372,654. In addition, populations in the three cities are likely to be more heterogeneous than in the rest of the districts. In the Malawi Multiple Indicator Cluster Survey 2006, district sample sizes were equal, at 1,200 households per district. For Blantyre, Lilongwe and Mzimba districts, therefore, there is possibility that, although the uniform sample sizes were calculated to provide statistically reliable estimates, they were not representative enough to effectively estimate the true population stunting rates.
From the study findings, district allocations made using the simple and composite indicators of socioeconomic status are not statistically different, holding all other factors in the allocation formula constant. However, the simple indicator is advantageous because it is easy to apply and does not involve complex statistical techniques as compared to the composite indicator. The PCA technique, used in the derivation of the composite indicators, has weaknesses in that selection of variables is based on the judgement of the analyst and there is no theory that guides how weights for the variables are generated .
The authors thank colleagues in the Department of Planning and Policy Development, Ministry of Health, Malawi for their comments on earlier versions of this manuscript.
- Smith PC: Formula funding of public services. 2006, London: RoutledgeGoogle Scholar
- Regional network for equity in health in east and southern Africa: Are we making progress in allocating government health resources equitably in east and southern Africa? Policy Series no. 19. 2008, EQUINET and Health economics unit, University of Cape Town: Harare, 1-4.Google Scholar
- Zere E, McIntyre D: Inequities in under-five child malnutrition in South Africa. International Journal for Equity in Health. 2003, 2 (1): 7-10.1186/1475-9276-2-7.View ArticlePubMedPubMed CentralGoogle Scholar
- WHO Working Group: Use and interpretation of anthropometric indicators on nutritional status. Bulletin of the World Health Organization. 1986, 64 (6): 929-941.PubMed CentralGoogle Scholar
- McIntyre D, Muirhead D, Gilson L, Govender V, Mbatsha S, Goudge J, Wadee H, Ntutela P: Geographic patterns of deprivation and health inequities in South Africa: Informing public resource allocation strategies. 2000, EQUINET: HarareGoogle Scholar
- National Statistical Office: Population and Housing Census: Preliminary Report. Zomba. 2008Google Scholar
- National Statistical Office: Projected Population based on 1998 Malawi Population and Housing Census. Zomba. 2008Google Scholar
- National Statistical Office and UNICEF: Malawi Multiple Indicator Cluster Survey 2006, Final Report. Lilongwe. 2008Google Scholar
- IMF World Economic Outlook database. [http://www.imf.org/external/pubs/ft/weo/2008/02/weodata/weorept.aspx?sy=2006&ey=2013&scsm=1&ssd=1&sort=country&ds=&br=1&c=676&s=NGDPRPC%2CNGDPPC%2CNGDPDPC%2CPPPGDP%2CPPPPC&grp=0&a=&pr1.x=47&pr1.y=10]
- United Nations Development Programme: Human Development Report 2007/08. Fighting Climate Change: Human solidarity in a divided world. 2008, New York, Palgrave MacMillanGoogle Scholar
- National Statistical Office: Welfare Monitoring Survey 2006. Zomba. 2008Google Scholar
- National Statistical Office: Integrated Household Survey 2004-05. Household socioeconomic characteristics. Zomba. 2005, 1.Google Scholar
- Deprivation and Resource Allocation: Methods for small area research. EQUINET methods toolkit. 2003, EQUINET: HarareGoogle Scholar
- Rutstein SO, Johnson K: The DHS Wealth Index. DHS Comparative Reports No. 6. 2004, Calverton, MD, USA: ORC MacroGoogle Scholar
- Commission on social determinants of health: Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. 2008, Geneva: World Health OrganizationGoogle Scholar
- O'Donnell O, van Doorslaer E, Wagstaff A, Lindelow M: Analyzing health equity using household survey data: a guide to techniques and their implementation. 2008, WBI Learning Resource series, Washington DCGoogle Scholar
- Seema Vyas, Kumaranayake L: Constructing socio-economic status indices: how to use principal components analysis. 2006, Oxford University Press and London School of Hygiene and Tropical Medicine, LondonGoogle Scholar
- Zere E, Mandlhate C, Mbeeli T, Shangula K, Mutirua K, Kapenambili W: Equity in health care in Namibia: developing a needs-based resource allocation formula using principal components analysis. International Journal for Equity in Health. 2007, 6: 3-10.1186/1475-9276-6-3.View ArticlePubMedPubMed CentralGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/10/6/prepub
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.