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The quality of malaria care in 25 low-income and middle-income countries
  1. Erlyn Macarayan1,2,
  2. Irene Papanicolas3,
  3. Ashish Jha1,2
  1. 1Harvard Global Health Institute, Harvard University, Cambridge, Massachusetts, USA
  2. 2Department of Health Policy and Management, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
  3. 3Department of Health Policy, London School of Economics and Political Science, London, UK
  1. Correspondence to Dr Ashish Jha; ajha{at}


Introduction Even with accessible and effective diagnostic tests and treatment, malaria remains a leading cause of death among children under five. Malaria case management requires prompt diagnosis and correct treatment but the degree to which this happens in low-income and middle-income countries (LMICs) remains largely unknown.

Methods Cross-sectional study of 132 566 children under five, of which 25% reported fever in the last 2 weeks from 2006 to 2017 using the latest Malaria Indicators Survey data across 25 malaria-endemic countries. We calculated the per cent of patient encounters of febrile children under five that received poor quality of care (no blood testing, less or more than two antimalarial drugs and delayed treatment provision) across each treatment cascade and region.

Results Across the study countries, 48 316 (58%) of patient encounters of febrile children under five received poor quality of care for suspected malaria. When comparing by treatment cascade, 62% of cases were not blood tested despite reporting fever in the last 2 weeks, 82% did not receive any antimalarial drug, 17% received one drug and 72% received treatment more than 24 hours after onset of fever. Of the four countries where we had more detailed malaria testing data, we found that 35% of patients were incorrectly managed (26% were undertreated, while 9% were overtreated). Poor malaria care quality varies widely within and between countries.

Conclusion Quality of malaria care remains poor and varies widely in endemic LMICs. Treatments are often prescribed regardless of malaria test results, suggesting that presumptive diagnosis is still commonly practiced among cases of suspected malaria, rather than the WHO recommendation of ‘test and treat’. To reach the 2030 global malaria goal of reducing mortality rates by at least 90%, focussing on improving the quality of malaria care is needed.

  • malaria
  • health systems
  • health policy

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  • Contributors EKM wrote the first draft of the Article, analysed the data and produced the tables and figures. EKM and IP designed the study. IP and AJ substantially revised the Article and set the research directions. All authors contributed to data interpretation, provided substantial feedback on the Article and approved the submitted version.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

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

  • Data availability statement Data may be obtained from a third party and are not publicly available.

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