From environmental exposure to disease burden: Institutional capacity, structural vulnerability, and global malaria inequality, 2000–2023

Malaria burden varies markedly between countries with similar environmental conditions. We examined national associations between malaria incidence, institutional capacity, economic development, structural vulnerability and selected environmental indicators during 2000–2023. An ecological panel comprised 4,382 complete country-years across 186 countries. Year-fixed-effects models related log(incidence + 1) to standardised predictors, with country-clustered uncertainty. Vulnerability was positively associated with incidence (β = 0.931, p = .007), whereas GDP per capita was inversely associated (β = −2.014, p < .001). Institutional capacity and the selected environmental indicators were not statistically significant after adjustment. With country-and-year fixed effects, vulnerability attenuated to β = 0.406 (p = .232), while GDP remained inversely associated. Excluding the malaria-related ND-GAIN indicator retained the positive year-effects association; excluding the whole health sector and changing sector coverage affected the findings. GDP showed a relatively consistent association; vulnerability depended on specification and composite construction. National aggregation, incomplete source provenance and potential confounding limit interpretation. These ecological associations do not establish causal pathways. Subnational environmental, intervention and health-system data are needed to investigate the proposed mechanisms.