DHS ANALYTICAL 

STUDIES 67

Gaps in Service Utilization and 

Service Provision: An Analysis of 

DHS and SPA Malaria Data from

Malawi, Senegal, and Tanzania

September 2018

This publication was produced for review by the United States Agency for International Development. It was prepared by 

Cameron Taylor, Anne Linn, Wenjuan Wang, and Hamdy Moussa. ˉ

DHS Analytical Studies No. 67 

Gaps in Service Utilization and Service Provision: 

An Analysis of DHS and SPA Malaria Data 

from Malawi, Senegal, and Tanzania

Cameron Taylor 

Annē Linn 

Wenjuan Wang 

Hamdy Moussa 

ICF 

Rockville, Maryland, USA 

September 2018 

Corresponding author: Cameron Taylor, The Demographic and Health Surveys (DHS) Program, ICF, 530 

Gaither Road, Suite 500, Rockville, MD 20850, USA; phone: +1 301-572-0922; fax: +1 301-407-6501; 

email: cameron.taylor@icf.com 
Acknowledgment: The authors would like to thank Lia Florey for her careful review and expert advice. 

Additional thanks go to Sarah Yang for creating graphics, Coralie N’Gbichi for assisting with the literature 

review, and DHS Program survey managers Michelle Winner and Jean de Dieu Bizimana for their valuable 

assistance in providing country-specific context. 

Editor: Diane Stoy 

Document Production: Joan Wardell 

This study was conducted with support provided by the United States Agency for International 

Development (USAID) through The DHS Program (#AID-OAA-C-13-00095). The views expressed are 

those of the authors and do not necessarily reflect the views of USAID or the United States Government. 

The DHS Program assists countries worldwide in the collection and use of data to monitor and evaluate 

population, health, and nutrition programs. Additional information about The DHS Program can be obtained 

from ICF, 530 Gaither Road, Suite 500, Rockville, MD 20850 USA; telephone: +1 301-407-6500; fax: 

+1 301-407-6501; email: info@DHSprogram.com; internet: www.DHSprogram.com. 

Recommended citation: 

Cameron Taylor, Annē Linn, Wenjuan Wang, and Hamdy Moussa. 2018. Gaps in Service Utilization and 

Service Provision: An Analysis of DHS and SPA Malaria Data from Malawi, Senegal, and Tanzania. DHS 

Analytical Studies No. 67. Rockville, Maryland, USA: ICF. 
iii 

CONTENTS 

TABLES ........................................................................................................................................................ v 

FIGURES .................................................................................................................................................... vii 

1 INTRODUCTION .............................................................................................................................. 1 

2 COUNTRY PROFILES .................................................................................................................... 5 

2.1 Malawi ................................................................................................................................. 5

2.1.1 Malaria profile ......................................................................................................... 5 

2.1.2 Health system ........................................................................................................ 5

2.1.3 Case management ................................................................................................. 5 

2.2 Senegal ............................................................................................................................... 6

2.2.1 Malaria profile ......................................................................................................... 6

2.2.2 Health system ........................................................................................................ 6

2.2.3 Case management ................................................................................................. 6

2.3 Tanzania ............................................................................................................................. 7

2.3.1 Malaria profile ......................................................................................................... 7

2.3.2 Health system ........................................................................................................ 7

2.3.3 Case management ................................................................................................. 8

3 METHODS ....................................................................................................................................... 9

3.1 Overview of SPA and DHS Surveys ................................................................................... 9

3.1.1 Service Provision Assessment surveys ................................................................. 9

3.1.2 Demographic and Health Surveys ......................................................................... 9

3.1.3 Harmonization of health facilities between DHS and SPA .................................. 10

3.2 Data ................................................................................................................................... 10

3.2.1 Malawi .................................................................................................................. 11

3.2.2 Senegal .................................................................................................................. 12

3.2.3 Tanzania .............................................................................................................. 14

3.3 Definition of Key Variables ................................................................................................ 15

Indicators in the Service Provision Assessment (SPA) survey ......................................... 15

3.3.1 Service availability ............................................................................................... 15

3.3.2 Trained personnel ................................................................................................ 16

3.3.3 National malaria diagnosis/treatment guidelines and mRDT protocol ................. 17

3.3.4 Supplies ............................................................................................................... 18

3.3.5 Diagnostic capacity .............................................................................................. 19

3.3.6 Antimalarial availability ......................................................................................... 21

3.3.7 Malaria service readiness index ........................................................................... 21

3.4 Indicators from the Demographic and Health Survey (DHS) ............................................ 22

3.4.1 Care-seeking for fever in children ........................................................................ 22

3.4.2 Diagnostic testing for children with fever ............................................................. 23

3.4.3 Appropriate treatment with ACT ........................................................................... 23

4 Results .......................................................................................................................................... 25

4.1 Malawi ............................................................................................................................... 25

4.1.1 Service availability ............................................................................................... 25

4.1.2 Trained personnel ................................................................................................ 26
iv 

4.1.3 National guidelines ............................................................................................... 28

4.1.4 Supplies ............................................................................................................... 30

4.1.5 Diagnostic capacity .............................................................................................. 31

4.1.6 ACT availability .................................................................................................... 32

4.1.7 Service readiness ................................................................................................ 35

4.1.8 Malaria endemicity ............................................................................................... 35

4.2 Senegal ............................................................................................................................. 36

4.2.1 Service availability ............................................................................................... 36

4.2.2 Trained personnel ................................................................................................ 37

4.2.3 National guidelines ............................................................................................... 39

4.2.4 Supplies ............................................................................................................... 41

4.2.5 Diagnostic capacity .............................................................................................. 42

4.2.6 ACT availability .................................................................................................... 44

4.2.7 Service readiness ................................................................................................ 46

4.2.8 Malaria endemicity ............................................................................................... 46

4.3 Tanzania ........................................................................................................................... 47

4.3.1 Service availability ............................................................................................... 47

4.3.2 Trained personnel ................................................................................................ 48

4.3.3 National guidelines ............................................................................................... 50

4.3.4 Supplies ............................................................................................................... 52

4.3.5 Diagnostic capacity .............................................................................................. 53

4.3.6 ACT availability .................................................................................................... 55

4.3.7 Service readiness ................................................................................................ 57

4.3.8 Malaria endemicity ............................................................................................... 57

5 DISCUSSION AND CONCLUSIONS ............................................................................................ 59

5.1 Key Findings of Malaria Service Readiness Components by Facility ............................... 59

5.1.1 Trained personnel ................................................................................................ 59

5.1.2 National guidelines ............................................................................................... 59

5.1.3 Diagnostic capacity .............................................................................................. 60

5.1.4 ACT availability .................................................................................................... 60

5.1.5 Malaria Service readiness .................................................................................... 61

5.2 Key Findings of Malaria Service Readiness by Endemicity .............................................. 61

5.2.1 Study limitations ................................................................................................... 61

5.2.2 Conclusions .......................................................................................................... 62

REFERENCES ............................................................................................................................................ 65

APPENDIX INDICATOR CONSTRUCTION .............................................................................................. 69
v 

TABLES 

Table 1 Malawi standardized health facilities .......................................................................... 12 

Table 2 Senegal standardized health facilities ........................................................................ 13 

Table 3 Tanzania standardized health hacilities ..................................................................... 15 

Table 4 Source of advice or treatment for children with fever and availability of malaria 

services by facilities in Malawi .................................................................................... 25 

Table 5 Diagnosis of fever and malaria training of personnel by facilities in Malawi .............. 27 

Table 6 Diagnosis of fever and availability of national malaria guidelines and protocol by 

facilities in Malawi ....................................................................................................... 28 

Table 7 Diagnosis of fever and availability of malaria diagnostic supplies by facilities in 

Malawi ....................................................................................................................... 30 

Table 8 Diagnosis of fever and malaria diagnostic capacity by facilities in Malawi ................ 32 

Table 9 Type of antimalarial drug used and availability of antimalarial drugs by facilities 

in Malawi ..................................................................................................................... 34 

Table 10 Source of advice or treatment for children with fever and components of malaria 

service readiness by facilities in Malawi ..................................................................... 35 

Table 11 Malaria service readiness by malaria endemicity and facility in Malawi .................... 36 

Table 12 Source of advice or treatment for children with fever and availability of malaria 

services by facilities in Senegal .................................................................................. 37 

Table 13 Diagnosis of fever and malaria training of personnel by facilities in Senegal ............ 38 

Table 14 Diagnosis of fever and availability of national malaria guidelines and protocol by 

facilities in Senegal ..................................................................................................... 40

Table 15 Diagnosis of fever and availability of malaria diagnostic supplies by facilities in 

Senegal....................................................................................................................... 42 

Table 16 Diagnosis of fever and malaria diagnostic capacity by facilities in Senegal .............. 43 

Table 17 Type of antimalarial drug used and availability of antimalarial drugs by facilities 

in Senegal ................................................................................................................... 45 

Table 18 Source of advice or treatment for children with fever and components of malaria 

service readiness by facilities in Senegal ................................................................... 46 

Table 19 Malaria service readiness by malaria endemicity and facility in Senegal .................. 47 

Table 20 Source of advice or treatment for children with fever and availability of malaria 

services by facilities in Tanzania ................................................................................ 48 

Table 21 Diagnosis of fever and malaria training of personnel by facilities in Tanzania ........... 49 

Table 22 Diagnosis of fever and availability of national malaria guidelines and protocol by 

facilities in Tanzania ................................................................................................... 51 

Table 23 Diagnosis of fever and availability of malaria diagnostic supplies by facilities in 

Tanzania ..................................................................................................................... 53 

Table 24 Diagnosis of fever and malaria diagnostic capacity by facilities in Tanzania ............. 54 

Table 25 Type of antimalarial drug used and availability of antimalarial drugs by facilities 

in Tanzania ................................................................................................................. 56 

Table 26 Source of advice or treatment for children with fever and components of malaria 

service readiness by facilities in Tanzania ................................................................. 57 

Table 27 Malaria service readiness by malaria endemicity and facility in Tanzania ................. 58 

Appendix Table A.1 Facilities offering malaria diagnosis/treatment services ................................ 70 

Appendix Table A.2 Facilities offering curative child care services ............................................... 71 
vi 

Appendix Table A.3 mRDT training ............................................................................................... 71 

Appendix Table A.4 Microscopy training ........................................................................................ 72 

Appendix Table A.5 Case management and treatment training .................................................... 73 

Appendix Table A.6 Diagnosis and treatment of malaria guidelines ............................................. 74 

Appendix Table A.7 mRDT protocol .............................................................................................. 74 

Appendix Table A.8 mRDT supplies .............................................................................................. 75 

Appendix Table A.9 Microscopy supplies ...................................................................................... 75 

Appendix Table A.10 Microscopy diagnostic capacity ..................................................................... 76 

Appendix Table A.11 mRDT diagnostic capacity ............................................................................. 76 

Appendix Table A.12 Diagnostic capacity ........................................................................................ 77 

Appendix Table A.13 Antimalarial availability .................................................................................. 78 

Appendix Table A.14 Malaria service readiness .............................................................................. 79 
vii 

FIGURES 

Figure 1 Components of diagnostic capacity ............................................................................ 20 

Figure 2 Components of malaria service readiness ................................................................. 22 

Figure 3 Diagnosis of fever by malaria training of personnel in Malawi ................................... 27 

Figure 4 Diagnosis of fever by availability of national malaria guidelines for 

diagnosis/treatment in Malawi .................................................................................... 29 

Figure 5 Diagnosis of fever by availability of malaria RDT protocol in Malawi ......................... 29 

Figure 6 Diagnosis of fever by availability of malaria diagnostic supplies in Malawi ................ 31 

Figure 7 Diagnosis of fever by malaria diagnostic capacity in Malawi ..................................... 32 

Figure 8 Diagnosis of fever by malaria training of personnel in Senegal ................................. 39 

Figure 9 Diagnosis of fever by availability of national malaria guidelines for 

diagnosis/treatment in Senegal .................................................................................. 40 

Figure 10 Diagnosis of fever by availability of malaria RDT protocol in Senegal ....................... 41 

Figure 11 Diagnosis of fever by availability of malaria diagnostic supplies in Senegal .............. 42 

Figure 12 Diagnosis of fever by malaria diagnostic capacity in Senegal ................................... 44 

Figure 13 Diagnosis of fever by malaria training of personnel in Tanzania................................ 50 

Figure 14 Diagnosis of fever by availability of national malaria guidelines for 

diagnosis/treatment in Tanzania ................................................................................ 51 

Figure 15 Diagnosis of fever by availability of malaria RDT protocol in Tanzania ..................... 52 

Figure 16 Diagnosis of fever by availability of malaria diagnostic supplies in Tanzania ............ 53 

Figure 17 Diagnosis of fever by malaria diagnostic capacity in Tanzania .................................. 55 

Figure 18 Summary table of results ............................................................................................ 64 

1 

1 INTRODUCTION 

Barriers to the prompt and effective diagnosis and treatment of malaria exist at both the community and 

health facility level. Household surveys measure malaria case management at the population level with 

standard indicators that assess treatment-seeking behavior, access to diagnostic testing, and access to 

appropriate treatment. Performance on these indicators varies widely from country to country. Among 

countries with Demographic and Health Surveys (DHS) or Malaria Indicator Surveys (MIS) completed 

between 2014 and 2016, advice and treatment was sought for a median of 47% of children under age 5 with 

fever [1]. 

Although there are nearly universal policies for the diagnostic confirmation of suspected malaria cases, a 

median of only 52% of children with fever had blood taken from their finger or heel for testing, which is a 

proxy for malaria testing. Despite its importance within the case management strategy, access to diagnostic 

testing has not expanded at the same rate as access to prevention efforts [2]. As malaria cases have increased, 

the number of malaria rapid diagnostic tests (mRDTs) distributed to National Malaria Control Programs 

(NMCPs) in Sub-Saharan Africa decreased by 19% between 2015 and 2016. This could be due to the timing 

of orders, and fewer orders by programs in a year after greater commodities were available [1]. During the 

same period, countries procured a greater number of artemisinin-based combination therapy (ACT) 

treatment courses. Among children with fever who received any antimalarial treatment in 2014-2016, 54% 

received an ACT, the recommended first-line treatment; the percentage had increased from 39% during the 

2010-2012 survey period [1]. 

To achieve universal access to malaria diagnosis and treatment, it is essential to know the types of facilities 

in endemic countries where the population seeks care and the malaria service readiness of these facilities. 

To investigate the gaps between the seeking and provision of malaria services, this study examines malaria 

service utilization data in children under age 5 with fever from the household-based Demographic and 

Health Survey (DHS) and provision of care data from the facility-based Service Provision Assessment 

(SPA) from Malawi, Senegal, and Tanzania. Facilities categorized as “malaria service ready” were those 

with 1) personnel trained in either mRDT, microscopy, or case management and treatment of malaria in 

children, 2) national guidelines for the diagnosis and treatment of malaria, 3) diagnostic capacity with valid 

mRDT tests and microscopy equipment, and 4) unexpired ACTs available on the day of the survey. Facility 

types were harmonized by managing authority and facility level between the DHS and SPA surveys to 

examine the types of facilities where individuals seek care and the malaria service readiness of the facilities. 

To explore the variation in malaria service readiness by malaria transmission in each country, geographic 

coordinate data collected during survey fieldwork were used to stratify the SPA facilities by malaria 

prevalence. All of this information provides a more detailed description of where malaria specific training 

and services should be targeted when working in limited resource settings. 

Understanding the service readiness and service readiness gaps of facilities is essential, particularly when 

new policies are introduced, such as the World Health Organization (WHO) policy for the diagnostic 

confirmation of suspected cases and treatment of cases with ACT [3]. Prior research has identified both 

progress and gaps in malaria service readiness. For example, innovations in rapid diagnostic testing lead to 

increased financing and massive increases in the procurement of mRDTs. However, availability of these 

commodities is only the first step. The procurement of mRDTs without reinforcement of other factors, such 
2 

as an efficient delivery system and staff who are trained to perform the tests, interpret the results, and treat 

the patient accordingly does not result in facilities that are malaria service ready [4]. 

Service readiness naturally affects the quality of care. Studies across Sub-Saharan Africa after malaria case 

management policy changes have identified barriers [5] to malaria service readiness. This research has 

shown that although there have been improvements in case management over time, the quality of care 

remains inadequate [6,7]. Different interpretations of the new policy for administering 

Artemether+Lumefantrine (AL) for uncomplicated malaria were found in Angola, where local malaria 

control staff enhanced training materials to improve understanding of the new policy and to provide more 

precise directions for health workers who conducted consultations[8]. After the introduction of AL as the 

first-line antimalarial in Kenya, one study confirmed the widespread availability of AL, and gaps in the 

availability of age-specific dosages, as well as a shortage of posted guidelines and staff who had received 

in-service training on the new case management guidelines [9]. In contrast, a malaria health facility survey 

in Malawi found that most facilities had staff trained in case management but lacked both ACTs and 

essential equipment such as microscopes and thermometers [10]. A survey of public health facilities in 

Sudan, conducted 5 years after the transition from chloroquine to ACTs as the recommended first-line 

antimalarial, found gaps in ACT availability, in-service training, job aids, and supervision [11]. 

The managing authority plays a definite role in malaria service readiness[5]. Although the private sector in 

some countries may be more sophisticated than the public sector and may serve as a primary source of fever 

treatment, mRDT availability was found to be poorer in the private sector in nine of 10 countries in a 10-

country survey [12]. This diminished availability was a barrier to the goal of universal diagnosis. Studies 

in both Uganda and Somalia, where fever treatment is primarily sought through the private sector, found 

that private sector providers prescribed treatments that did not conform with the national policy [13], 

although Ugandan facilities had a high availability of ACTs [14]. 

As this report describes, facility level is also a determinant of malaria service readiness. Historically, lowerlevel facilities do not have sufficient diagnostic capacity because of lack of microscopes or specialized staff 

who are trained in microscopy. However, the introduction of mRDTs has removed a barrier for service 

readiness for lower-level health facilities, because these tests make parasitological diagnosis feasible at 

lower levels and lead to improved targeting of malaria treatment [15]. In addition, it has been widely shown 

that low level care providers such as community health workers, when appropriately trained and supervised, 

are capable of delivering high quality care for uncomplicated malaria cases with mRDTs to diagnose cases 

[16] and administration ACTs for treatment [17,18]. Twenty-six malaria-affected countries have adopted 

the WHO policy of integrated community case management (iCCM), through which malaria can be treated 

at the community level and outside of health facilities[1]. While in some settings, care for fever cases is 

widely sought through iCCM, this report examines only facility-based care-seeking because the SPA survey 

is facility-based [19]. 

In analyzing service readiness by malaria endemicity, this report uses an approach similar to a study that 

examined health system readiness by malaria endemicity in Kenya, Namibia, and Senegal. This study 

demonstrated an increase in service readiness with increasing malaria endemicity in rural areas, and no 

relationship between endemicity and service readiness in the urban areas [5]. A study in the lower 

endemicity setting of Vanuatu demonstrated the importance of service readiness in countries that are striving 

to eliminate malaria [20]. 
3 

This prior research demonstrated the importance of and barriers to malaria service readiness as related to 

the goals of universal access to diagnosis and treatment, particularly during the period of 2006-2010 when 

many of the current policies on diagnosis and treatment were initially implemented. Since barriers still 

exist, this report takes the analysis a step further by using existing data from household and facility surveys 

to analyze service readiness among the facilities where treatment-seeking for malaria actually occurs. The 

results will allow for better prioritization of interventions that can improve service readiness in the facilities 

where, as determined by their utilization, there is the greatest need. 

5 

2 COUNTRY PROFILES 

2.1 Malawi 

2.1.1 Malaria profile 

Malaria is hyperendemic in 95% of Malawi. In most of the country, transmission occurs year round, with 

peaks after the beginning of the annual rains in November. Transmission is highest in lowland areas that 

are hotter, wetter and more humid, particularly around the lakeshore. In the 2017 Malawi MIS, 24% of 

children under age 5 tested positive for malaria by microscopy [21]. P. falciparum accounts for 98% of 

malaria infections and all severe cases and malaria deaths [22]. 

2.1.2 Health system 

Care through the public health system in Malawi is delivered at primary, secondary, and tertiary levels. 

Facilities at the primary level include health posts, dispensaries, maternity facilities, health centers, and 

community or rural hospitals where primary and preventive care services are provided primarily by 

community health workers. Secondary level care is provided at district hospitals, which serve as referral 

facilities that provide inpatient and outpatient services. Central hospitals that provide tertiary level services 

are referral hospitals for the district hospitals. With decentralization, the health system gave authority to the 

district health management teams to deliver secondary and primary health services in the district [23]. 

In addition to the public sector facilities, private sector facilities in Malawi include not-for-profit and forprofit facilities. Private not-for-profit facilities include independent church-affiliated facilities that belong 

to the Christian Health Association of Malawi (CHAM) and are primarily located in rural areas. These 

facilities charge user fees for care other than basic preventive and curative care services for which they are 

contracted by District health officers to provide free of charge. The private for-profit sector also operates 

health facilities and health programs. The public sector supports private sector facilities and faith-based 

organizations (FBOs) by providing staff training, public sector staffing for facilities, supervision, 

medicines, and vaccines [23]. 

2.1.3 Case management 

Malawi’s national malaria policy states that mRDTs should be performed on all patients suspected of having 

uncomplicated malaria in order to obtain parasitological confirmation before beginning treatment [24]. 

Since the policy was adopted in 2010, mRDTs have been distributed to all facilities. The NMCP’s goal is 

broadening access to testing and treatment services by increasing the number of village clinics. 

In 2007, the NMCP implemented a policy that recommended ACT as the treatment for uncomplicated 

malaria. Artemether+Lumefantrine (AL) is the recommended first-line ACT. For patients with symptoms 

of severe malaria, pre-referral treatment begins immediately with artesunate, followed by microscopy 

testing (if possible) or mRDT, and then referral to a hospital for treatment with parenteral artesunate. In 

areas more than 5 km from a health facility, health surveillance assistants (HSAs) conduct integrated 

community case management (iCCM), in which they conduct mRDTs, treat children under age 5 with ACT, 

and administer pre-referral artesunate to children with symptoms of severe malaria [24]. 
6 

2.2 Senegal 

2.2.1 Malaria profile 

Malaria is endemic throughout Senegal with the country divided into two epidemiological zones. In the 

tropical zone, transmission is year-round, with peaks during the rainy months. In the Sahelian zone, 

transmission is lower, with the highest transmission during October and November, which are at the end of 

the rainy season, and small outbreaks in the low transmission season [25]. Malaria testing with microscopy 

in the Continuous DHS, 2016 among children age 6-59 months found malaria prevalence to be 1% [26]. 

Ninety-nine percent of infections are due to P. falciparum [27].

2.2.2 Health system 

The operations of Senegal’s health system are implemented at the district level. Each of the 76 health 

districts has at least one health center, which is a secondary health facility with a medical team that provides 

direct care and oversees the district’s prevention efforts. Health centers are attached to the district’s health 

posts, staffed by a nurse or midwife, which generally serve as the first level of contact with the population. 

Health posts are responsible for a number of health huts, which have trained community health workers and 

the necessary structure and equipment for providing basic services that include the diagnosis and treatment 

of uncomplicated malaria. Since 2008, community case management of malaria can be provided by home 

care providers, who are lower-level community health workers who work from their own homes rather than 

in a specific health facility. 

Tertiary facilities include hospital centers that provide specialized care. These hospitals, which are found at 

the regional, departmental or communal level, typically provide care coverage for approximately 150,000 

residents. There are also seven national hospital centers in Dakar. The health system has a network of 

regional pharmacies that supply the facilities and care providers of the corresponding regions. These 

regional pharmacies receive supplies from the national pharmacy. In addition to public sector facilities, 

there are also a number of private clinics and health posts throughout the country [27]. 

2.2.3 Case management 

Case management guidelines in Senegal specify that all suspected malaria cases should be confirmed with 

mRDTs, and that all uncomplicated cases be treated with ACT [19]. The algorithm became slightly more 

complicated during 2015 and 2016, when it was specified that all children under age 5 with fever should 

be tested for malaria (irrespective of symptoms of other illness), and that febrile patients over age 5 should 

be tested only if they showed no symptoms of other illness. In 2017, the policy required testing all febrile 

patients with mRDT, regardless of other symptoms [25]. 

In 2006, AL became the first-line treatment [28]. The mRDTs and ACTs are provided free-of-charge by the 

public health system. For severe cases, patients identified at the community or health post level are given 

pre-referral rectal artesunate and then referred to a health center or hospital. At the health center or hospital 

level, patients with severe malaria should be treated with injectable artesunate, which is then followed with 

oral ACT. 

The goal of the NMCP is to reach pre-elimination, which is defined as an annual incidence of fewer than 5 

cases per 1,000 by 2020. Since the incidence varies throughout the country, all interventions are targeted 
7 

by incidence. In districts with higher incidence, a proactive community case management strategy, in which 

a community health worker conducts a weekly door-to-door sweep of the village to seek out fever cases, is 

used to detect symptomatic cases early and to provide prompt case management [29]. The districts with the 

lowest incidence districts use focal screen and treat, focal test and treat, and focal drug administration 

strategies. 

In addition, the strategy in pre-elimination areas involves the training of laboratory technicians on the LoopMediated Isothermal Amplification (LAMP) technique for molecular-level diagnosis, and the Real-Time 

Quantitative Reverse Transcription Polymerase Chain Reaction (qrt-RTPCR) at the central level [27]. 

2.3 Tanzania 

2.3.1 Malaria profile 

In the Tanzania Mainland, 95% of the population lives in high-risk malaria areas. The Tanzanian population 

is the third largest population at risk of stable malaria in Africa, with 59% of the population living in hypoendemic areas (where parasitemia is <10%), and 41% in meso, holo, or hyper-endemic areas (where 

parasitemia is >10%) [30]. Transmission peaks seasonally at the end of the rainy season, which is in March 

and April in the Central and Southern areas of the country with a single rainy season and in November and 

again in April in the Eastern, Northern, and Western areas that have bimodal rainfall that is spread over a 

long period [30]. The 2017 Tanzania MIS performed mRDT testing and found the malaria prevalence 

among children age 6-59 months to be 7%. 

The Zanzibar Malaria Elimination Program (ZAMEP) began focusing on malaria elimination after a 2009 

assessment found that local transmission could be reduced to zero through universal coverage of vector 

control and the establishment of a case surveillance system [31]. The prevalence of malaria from the 2017 

Tanzania MIS in both Unguja and Pemba is <1%, which is similar to findings from the DHS, MIS, and 

other ZAMEP surveys, which determined that prevalence has remained stable since 2007 with no epidemics 

occurring during that time. 

In both Tanzania Mainland and Zanzibar, more than 95% of malaria cases are P. falciparum.

2.3.2 Health system 

A central district government structure is the basis of Mainland Tanzania’s National Health System. In this 

structure, the Ministry of Health and Social Welfare (MoHSW), the President’s Office of Regional 

Administration, and the local government share the responsibility for the delivery of public health services. 

The central level develops policies and guidelines, which are implemented by the regional health teams. 

Health facilities include dispensaries, health centers, and hospitals, which operate in a hierarchical manner. 

The health facilities may be administered by the government, faith-based voluntary organizations, or other 

private organizations, and may be parastatal in nature. Dispensaries at the primary level in villages serve 

between 6,000 and 10,000 residents, secondary level health centers serve between 50,000-80,000 in a ward, 

and district hospitals provide tertiary level care for more than 250,000 residents and refer cases to the 

regional and consultant hospitals. 

In Zanzibar, health services are delivered through public, private (both for-profit and non-profit), and 

government health facilities, some of which are administered by military or defense forces. In the 
8 

hierarchical system in Zanzibar, primary level care is provided at primary health care units (PHCUs) and 

primary health care cottages (PHCCs) that also provide inpatient care and x-ray services. At the secondary 

level, the district and regional hospitals provide care. Specialized hospitals provide care at the tertiary level. 

Under the policy of devolution, the provision of public health services, particularly preventive services, has 

been delegated to district health management teams in Zanzibar’s 11 districts. 

2.3.3 Case management 

As malaria prevalence decreases, the malaria strategic plan for Mainland Tanzania aims to “ensure that 

symptoms and signs of malaria in the general population are recognized early and that appropriate 

management is provided promptly at the individual, family, community, and facility levels.” All individuals 

with signs and symptoms of malaria should have access to appropriate, timely malaria diagnosis and 

treatment, with special emphasis on biologically and socioeconomically vulnerable populations. To ensure 

universal access, the government policy requires that all suspected cases in both the public and private 

sectors are confirmed by a diagnostic test. The government seeks to provide “high-standard, accessible, 

affordable, equitable, and quality assured testing” through the public sector, ensuring that diagnostics are 

affordable to public sector patients through a global partnership mechanism. At the same time, the 

government aims to facilitate this kind of testing through the establishment of alternative malaria testing 

points outside of facilities, which include accredited dispensing drug outlets (ADDOs) and communitybased services like iCCM which provide subsidized malaria diagnostics that are regulated by the 

government. 

For treatment, the government seeks to provide “highly efficacious, accessible, affordable, equitable, and 

quality-assured antimalarials” through the public sector, and to facilitate their provision in the private sector. 

The ACTs (with AL as the first-line treatment) are the recommended treatment for uncomplicated malaria 

cases and are provided free in public facilities for vulnerable groups [32]. Private sector facilities are 

encouraged to offer ACTs at the lowest possible price. Private markets provide presumptive treatment and 

sell ineffective antimalarials, which violate national policy. The establishment of ADDOs and the 

subsidization of ACTs attempt to address both these issues. Injectable artesunate is the recommended 

treatment for severe malaria. 

In Zanzibar, the policies of diagnostic confirmation and treatment with ACT concur with those of the 

Mainland. Instead of AL, Artesunate+Amodiaquine (ASAQ) is the first-line antimalarial, with the addition 

of Primaquine as a gametocytocidal drug. A surveillance system established to pursue elimination rapidly 

detects a high proportion of all new malaria infections. In addition, the passive case detection system, which 

is treatment-seeking at health facilities, must detect and treat imported infections. To accomplish this, there 

has been an additional focus on improving prompt health-seeking behavior. The malaria epidemic early 

detection system has been expanded to include an existing mobile phone case reporting system that includes 

all public and private facilities through which malaria has become a notifiable disease. With these systems, 

each parasitologically confirmed case is evaluated through a case investigation to determine the source of 

the malaria infection and the possibility of onward transmission. For locally acquired infections, active case 

detection activities and investigation of vector control activities are pursued. For imported cases, 

neighboring households are alerted and asked to report any suspected malaria cases. To address 

asymptomatic cases in the case of active foci for transmission, mass drug administration campaigns are also 

implemented. 
9 

3 METHODS 

3.1 Overview of SPA and DHS surveys 

3.1.1 Service Provision Assessment surveys 

Service Provision Assessment (SPA) surveys are sample surveys of formal-sector health facilities. 

Pharmacies and individual doctors’ offices are usually not included in SPA surveys. Typically, the SPA 

surveys collect data from 400-700 facilities, which have been selected from a comprehensive list of health 

facilities in a country (sampling frame), categorized by facility type, managing authority (public and nonpublic), and region. The sample provides indicators at the national level for the different facility types and 

managing authority, as well as aggregate indicators at the regional level. The SPA surveys can also be 

conducted in a census of facilities, depending on the total number of facilities in the country. 

Hospitals are oversampled because of their small numbers in a country. Subsequently, the data are weighted 

during analysis to ensure that the data are proportionally representative. To do this, the sample weight is 

applied to the data to ensure that the contribution of facilities to the total is proportionate to their share in 

the country. 

The SPA surveys utilize four main questionnaires: 1) inventory questionnaires, 2) health worker or provider 

questionnaires 3) observation protocols and 4) exit interview questionnaires. 

The SPA surveys are typically administered by 10 to 15 teams, with each including three to four 

interviewers, who are usually health workers. The interviewers collect data from the most knowledgeable 

person(s) available for each service with the inventory questionnaire. Specific sections of the inventory 

questionnaire assess the laboratories and pharmacies in these health facilities. A key feature of the inventory 

questionnaire is that interviewers verify the existence of specific items such as medicines and commodities. 

Within a facility, the team interviews health providers with the health worker or provider interview 

questionnaire. The sample of health providers is taken from the providers who are present in the facility on 

the day of the survey. In each facility, the aim is to interview seven to eight providers about the range of 

services they provide, in-service training or training updates, and working conditions at the facility. 

Using observation protocols, the interviewers observe client-provider consultations for three priority 

services: antenatal care (ANC), family planning, and the curative care of sick children. The number of 

consultations observed depends on the number of providers and clients in the facility that day. Interviewers 

also use the client exit interview questionnaire to interview clients who were observed and are leaving the 

facility. 

3.1.2 Demographic and Health Surveys 

The Demographic and Health Surveys (DHS) are nationally representative household surveys that provide 

data for a wide range of monitoring and impact evaluation indicators in the areas of population, health, and 

nutrition. The DHS surveys have large sample sizes (usually between 5,000 and 30,000 households) and 

are conducted about every 5 years to allow comparisons over time. 
10 

The sample is generally representative at the national, residential (urban or rural), and regional level. The 

survey utilizes a stratified two-stage cluster design. During the first stage, enumeration areas (EA) are drawn 

from a census file. In each EA selected, the second stage involves drawing a sample of households from an 

updated list of households. The DHS surveys are typically implemented by the national statistical office in 

a country with data collection typically lasting between 5 to 6 months. 

In malaria-endemic countries, many DHS surveys include questions about malaria that are included in the 

Household and Women’s Questionnaires. These questions generate data that can be used to assess progress 

in the core household malaria indicators that are detailed in the Roll Back Malaria Partnership to End 

Malaria (RBM) Household Survey Indicators for Malaria Control guidance document [33]. 

The Household Questionnaire lists all household members and determines their eligibility for interviews 

and biomarker testing. Questions about household characteristics, such as ownership and the use of 

mosquito nets, are included in the Household Questionnaire. 

The Women’s Questionnaire is used for interviewing women of reproductive age about a recent birth 

history, pregnancy status, and use of intermittent preventive treatment of malaria during pregnancy. The 

Women’s Questionnaire also collects information about each woman’s children under age 5, such as careseeking, diagnostic testing, and access to prompt treatment with antimalarials for children with reported 

fever. 

3.1.3 Harmonization of health facilities between DHS and SPA 

Facilities listed in the Women’s Questionnaire as a source for care-seeking for recent fever in the DHS and 

facilities sampled in the SPA were harmonized to allow for comparisons between seeking and the provision 

of malaria services at specific facility types. Generally, the DHS questionnaire groups facilities by public, 

religious, private, and other sources, while the SPA categorizes facilities by managing authority 

(government, private, NGO, religious) and facility level (hospital, health center, dispensary, clinic). The 

facility types were harmonized (considering managing authority and facility level) between the DHS and 

SPA surveys in order to examine the types of facilities where individuals seek care and the malaria service 

readiness of those facilities. Efforts were made to group facilities by facility level, although this was not 

possible in all cases due to sample size. This is more apparent in the groupings of facilities at the lower 

district or village level. 

One disadvantage of the SPA surveys is that the data do not provide a complete picture of the health service 

environment. The SPA surveys do not include private health care providers (individual doctors, private 

pharmacies), community-based care (CHWs who provide iCCM), or those in the informal health care sector 

such as traditional healers, markets, and shops. Since the DHS includes options for private healthcare 

providers and informal healthcare providers in the questionnaire options for antimalarial treatment, it is 

impossible to compare these facilities to the data in the SPA. In this report, private healthcare providers and 

those in the informal healthcare sectors are identified as “any other source” in the analysis tables. 

3.2 Data 

To investigate the gaps between the seeking and provision of malaria services, we examined malaria service 

utilization data in children under age 5 with fever from the household-based DHS surveys and provision of 
11 

care data from the facility-based SPA surveys conducted in Malawi, Senegal, and Tanzania. These countries 

were included in the analysis because the fieldwork for each country’s DHS and SPA surveys was 

completed within 1 year of each other. Surveys included the 2013-14 Malawi SPA and 2015-16 Malawi 

DHS, 2016 Senegal Continuous SPA and 2016 Senegal Continuous DHS, and the 2014-15 Tanzania SPA 

and 2015-16 Tanzania DHS-MIS. 

To explore if malaria service readiness varies by level of malaria transmission in each country, geographic 

coordinate data collected during fieldwork were used to stratify SPA facilities by malaria prevalence. 

Facilities in each country were stratified into two equal frequency groups (low and high malaria risk 

categories) based on Plasmodium falciparum (Pf) parasite prevalence rates among children age 2-10 

(PfPR2-10) from the Malaria Atlas Project (MAP). The MAP provides a spatial data layer that describes the 

estimated proportion of children age 2-10 in the general population infected with Pf at any one time, and 

then averaged over the 12 months of 2015. The SPA data include geospatial locations for the actual location 

of the healthcare facility, which permits linkage of MAP data with the SPA data. 

3.2.1 Malawi 

The 2015-16 Malawi DHS, which was conducted between October 19, 2015 and February 17, 2016, is a 

population-based household survey that provides representative estimates for the country as a whole, for 

urban and rural areas, and for each of the three regions and 28 districts of Malawi. All women age 15-49 in 

the selected households were eligible for an individual interview, in which information was collected about 

care-seeking for their children under age 5 with recent fever. A total of 4,774 children under age 5 had a 

reported fever in the 2 weeks before the survey. 

Although most SPA surveys select a representative sample of health facilities, the 2013-14 Malawi SPA 

was a census of all formal-sector health facilities in Malawi. The Central Monitoring and Evaluation 

Division (CMED) of the Malawi Ministry of Health (MoH) provided a master list of 1,060 such facilities. 

Data were collected from 977 facilities, due to the non-response of some health facilities. The results are 

representative at the national level, by facility type and managing authority, and for three regions. The 

fieldwork was conducted in two phases between June 11 to August 20, 2013 and November 13, 2013 to 

February 7, 2014. 

Facility categories were harmonized between the DHS and SPA, as shown in Table 1. The facilities were 

classified as government hospital, government health center, government health post or mobile clinic, 

private facility, Christian Health Association or mission and faith-based, and other sources. Informal 

providers reported in the DHS were grouped into “any other sources.” There is no equivalent category in 

the SPA because it focused on formal-sector facilities. 

 
12 

Table 1 Malawi standardized health facilities

Standardized Name 2015-16 Malawi DHS Facilities 2013-14 Malawi SPA Facilities 

Government hospital Government hospital Government/public: central hospital 

Government/public: district hospital 

Government/public: rural/community hospital 

Government/public: other hospital 

Government health center Government health center Government/public: health center 

Government health post or mobile 

clinic 

Government health post/outreach 

Government has 

Government mobile clinic 

Government/public: maternity 

Government/public: dispensary 

Government/public: clinic 

Government/public: health post 

Private facility Private hospital/clinic 

Private pharmacy 

Private doctor 

Private mobile clinic 

Private fieldworker/chw 

Other private medical sector 

Private for profit: other hospital 

Private for profit: health center 

Private for profit: maternity 

Private for profit: dispensary 

Private for profit: clinic 

NGO: other hospital 

NGO: health center 

NGO: clinic 

Company: health center 

Company: dispensary 

Company: clinic 

Christian health association/ 

mission/faith-based1 

CHAM/mission hospital 

CHAM/mission health center 

CHAM: rural/community hospital 

CHAM: other hospital 

CHAM: health center 

CHAM: maternity 

CHAM: dispensary 

CHAM: clinic 

CHAM: health post 

Mission/faith-based (other than CHAM): 

Other hospital 

Mission/faith-based (other than CHAM): 

Clinic 

Any other source BLM 

Shop 

Traditional practitioner 

Market 

Itinerant drug seller 

Youth drop-in center 

Other 

No SPA equivalent 

1

CHAM= Christian Health Association of Malawi. 

2

BLM= Banja La Mtsogolo (program established by Marie Stopes International). 

In Malawi, the malaria prevalence (PfPR2-10 rate) for the geographic locations of SPA facilities ranged from 

<1% to 37%. Facilities were stratified at the median prevalence of 10.2%, which resulted in 471 facilities 

in the low-risk group and 506 facilities in the high-risk group. 

3.2.2 Senegal 

In 2012, the Senegal Continuous DHS and Senegal Continuous SPA were launched to respond to the 

ongoing need for more frequent data for planning, monitoring, and evaluating health and population 

programs, and to serve as a pilot of the continuous model in an African country. For both the Senegal 

Continuous DHS and SPA, data were collected each year from 2012 through 2017 with reduced standard 

questionnaires. Fieldwork for the two surveys was conducted in two waves of 4 months each during the 
13 

course of each year, for a total of 8 months each year. For this report, we analyzed the 2016 Senegal 

Continuous DHS and 2016 Senegal Continuous SPA data. 

The 2016 Senegal Continuous DHS is a population-based household survey that provides representative 

estimates for the country as a whole, for urban and rural areas, and for each four aggregated geographic 

“grand regions.” Fieldwork was conducted between March 1 and November 25, 2016. All women age 15 

to 49 in the selected households were eligible for individual interviews, in which information was collected 

about the care-seeking of their children under age 5 with recent fever. A total of 740 children under age 5 

had a reported fever in the 2 weeks before the survey. 

The Senegal Continuous SPA was a census of all formal-sector health facilities in Senegal over the fiveyear period of the continuous survey. Each year, the results are representative at the national level, and for 

facility type, managing authority, and the country’s 14 administrative regions. In 2016, the sample included 

50% of all hospitals and health centers and 20% of all health posts, along with their associated health huts. 

Given the limited nature of services provided by health huts, they are not included in the national totals in 

the Senegal Continuous SPA final report. However, health huts are included in this analysis in order to 

develop a complete picture of malaria service readiness in Senegal. Similar to the 2016 Senegal Continuous 

DHS, fieldwork for the 2016 Senegal Continuous SPA was conducted between March and October, 2016. 

Facility categories were harmonized between the DHS and SPA, as shown in Table 2. Facilities were 

classified as government hospital or health center, government health post or mobile clinic, government 

health hut, private facility, and any other source. Informal providers reported in the DHS were grouped into 

“any other sources.” There is no equivalent category in the SPA because it focused on formal-sector 

facilities. Due to low numbers of individuals seeking care for fever at government hospitals, government 

hospitals and health centers were combined to generate an adequate sample size for analysis. 

Table 2 Senegal standardized health facilities 

Standardized name 2016 Senegal Continuous DHS Facilities 2016 Senegal Continuous SPA Facilities 

Government hospital or 

health center 

Government hospital 

Government health center 

Government/public: hospital 

Government/public: health center 

Government health post or 

mobile clinic 

Government health post 

Government mobile team 

Government/public: clinic 

Government health hut Other public sector 

Country specific public sector 

Government/public: case de santé 

Private facility Private hospital/clinic 

Private pharmacy 

Private community health worker 

Other private medical 

NGO/private not for profit: hospital 

NGO/private not for profit: health center 

NGO/private not for profit: clinic 

Private for profit: hospital 

Private for profit: health center 

Private for profit: clinic 

Any other source Shop 

Traditional practitioner 

Country specific other sector 

Other 

No SPA equivalent 

In Senegal, the malaria prevalence (PfPR2-10 rate) for the geographic locations of SPA facilities ranged from 

<1% to 24%. Facilities were stratified at the median prevalence of 2.4%, which resulted in 211 facilities in 

the low-risk group and 238 in the high-risk group. 
14 

3.2.3 Tanzania 

The 2015-16 Tanzania DHS-MIS is a population-based household survey that provides representative 

estimates at the national level, for urban and rural areas in the country as a whole and the mainland, at the 

zonal level, and for some, but not all indicators, estimates at the regional level. The 2015-16 Tanzania DHS 

was conducted between August 22, 2015 through February 14, 2016. All women age 15-49 in the selected 

households were eligible for individual interviews, in which information was collected about the careseeking of their children under age 5 with recent fever. In total 1,706 children under age 5 had a reported 

fever in the 2 weeks before the survey. 

The 2014-15 Tanzania SPA was designed to be a sample of all formal-sector health facilities in Tanzania. A 

master list of health facilities with 7,102 verified (active) health facilities in Tanzania was obtained from 

the Ministry of Health and Social Welfare (MoHSW) in Tanzania Mainland and the Ministry of Health 

(MoH) in Zanzibar. Of the 7,102 active health facilities, a sample of 1,200 facilities was selected for the 

survey, which was designed to provide nationally representative results by facility type, managing authority, 

and regionally representative results for the 25 Tanzania Mainland regions and the 5 Zanzibar regions, for 

a total of 30 survey regions. Fieldwork was conducted between October 20, 2014 through February 21, 

2015. Some facilities were revisited because they were not included in Dar es Salaam from March 2 to 13, 

2015. 

Facility categories were harmonized between the DHS and SPA as shown in Table 3. Facilities were 

classified into government hospital, government health center, government clinic/dispensary, private 

facility, mission or faith-based, and other sources. Informal providers reported in the DHS were grouped 

into “any other sources.” There is no equivalent category in the SPA because it focused on formal-sector 

facilities. 

 
15 

Table 3 Tanzania Standardized Health Facilities

Standardized Name 2015-16 Tanzania DHS-MIS Facilities 2014-15 Tanzania SPA Facilities 

Government hospital National/zonal referral/specialized hospital 

Referral regional hospital 

Regional hospital 

District hospital 

Government/public: national referral hospital 

Government/public: regional hospital 

Government/public: district hospital 

Government/public: district-designated hospital 

Government/public: other hospital 

Parastatal: regional hospital 

Parastatal: other hospital 

Government health 

center 

Public health center Government/public: health center 

Parastatal: health center 

Government 

Clinic/dispensary 

Public clinic 

Public dispensary 

Public chw 

Government/public: clinic 

Government/public: dispensary 

Parastatal: dispensary 

Private facility Private hospital 

Private specialized hospital 

Private health center 

Private clinic 

Private dispensary 

Private: other hospital 

Private: health center 

Private: clinic 

Private: dispensary 

Mission/faith-based Religious/voluntary referral spec. hospital

religious/voluntary hospital 

religious/voluntary district hospital 

religious/voluntary health center 

religious/voluntary clinic 

religious/voluntary dispensary 

Mission/faith-based: national referral 

Mission/faith-based: regional hospital 

Mission/faith-based: district hospital 

Mission/faith-based: district-designated hospital 

Mission/faith-based: other hospital 

Mission/faith-based: health center 

Mission/faith-based: clinic 

Mission/faith-based: dispensary 

Any other source Pharmacy 

ADDO1

NGO 

Other 

No SPA equivalent 

1

ADDO: Accredited Drug Dispensing Outlet. 

In Tanzania, the malaria prevalence (PfPR2-10 rate) for the geographic locations of SPA facilities ranged 

from <1% to 23%. Facilities were stratified at the median prevalence of 5%, which resulted in 589 facilities 

in the low-risk group and 599 in the high-risk group. 

3.3 Definition of Key Variables 

Indicators in the Service Provision Assessment Survey (SPA) 

The SPA indicators included in this analysis examine the following: availability of malaria-related services, 

trained personnel, national malaria diagnosis and treatment guidelines, mRDT protocol, and relevant 

supplies, along with malaria diagnostic capacity, antimalarial availability, and malaria service readiness. 

For a more detailed description of the indicator construction, see Appendix A. 

3.3.1 Service availability 

The availability of a basic package of malaria health services is an essential component of malaria control 

and prevention at the facility level. In the SPA survey, health facility supervisors at all facilities were asked 

about the availability of client services. These services can include the diagnosis and treatment of malaria, 

curative care for sick children, and preventive services offered through ANC, all of which are relevant for 

malaria. However, this report focuses on the diagnosis and treatment services and the curative care for sick 
16 

children. For the remainder of this report, unless otherwise specified, the term facilities refer to those that 

offer malaria diagnosis/treatment or sick child curative services. 

In high transmission settings, children under age 5 are one of the groups that are most vulnerable to malaria. 

The SPA is a useful tool for assessing the capacity of institutions to provide malaria diagnosis and treatment 

services, and curative care for sick children in malarious areas. Curative care includes performing 

diagnostic tests for malaria according to WHO recommendations in order to provide timely and effective 

treatment to those with positive test results [3]. In the case of severe malaria, the SPA is limited in its ability 

to provide a complete picture of a facility’s capacity to provide proper pre-referral treatment. While 

information is collected on facilities with artesunate injections, little is known about the training of 

providers on the treatment of severe malaria. 

In addition to the reported availability of services, interviewers observe a select number of client-provider 

interactions. For example, an interviewer observes a provider using a mRDT as part of the observation 

protocol that classifies the facility as offering malaria diagnosis and treatment services. This process allows 

for cross checks that validate the self-reported data. In this report, the proportion of facilities that offer 

malaria diagnosis and treatment services, and curative child care services includes those identified through 

provider reports and the services identified during client observation. 

Variable Indicator Numerator Denominator 

Appendix A 

Indicator 

Construction 

Facilities offering 

malaria 

diagnosis/treatment 

services 

Proportion of all 

facilities offering 

malaria 

diagnosis/treatment 

services 

Number facilities 

offering malaria 

diagnosis or treatment 

services 

Total number of facilities Table A.1 

Facilities offering 

curative care for 

sick children 

Proportion of all 

facilities offering 

curative sick child care 

services 

Number facilities 

offering curative sick 

child care services 

Total number of facilities Table A.2 

Facilities offering 

malaria 

diagnosis/treatment 

services or curative 

child care services 

Proportion of all 

facilities offering 

malaria 

diagnosis/treatment 

services or curative 

child care services 

Number facilities 

offering malaria 

diagnosis/treatment 

services or curative sick 

child care services 

Total number of facilities 

3.3.2 Trained personnel 

An essential component of the proper diagnosis and treatment of malaria is the appropriate training of the 

facility staff. Ongoing training for service providers ensures that providers continue to learn about the most 

recent developments about the services they provide. Within the SPA, adequate training is defined as a 

facility having at least one provider of malaria services who reports receiving in-service training during the 

24 months before the survey. The training must have involved structured sessions, and does not include 

individual instruction a provider might have received during routine supervision. The Health Worker 

Questionnaire includes questions about the training of the health service providers. 

Providers were asked if the following topics were included in their in-service training, training updates, or 

refresher trainings: 
17 

• Diagnosis of malaria in children 

• Case management and treatment of malaria in children 

• Performance of malaria microscopy 

• Performance of malaria rapid diagnostic tests (mRDT) 

Variable Indicator Numerator Denominator 

Appendix A 

Indicator 

Construction 

Personnel trained in 

mRDT 

Proportion of facilities 

with personnel trained in 

mRDT among facilities 

offering malaria 

diagnosis/treatment 

services or curative sick 

child care services 

Number of facilities with at 

least one interviewed 

provider who reports 

receiving in-service training 

in malaria mRDT in the 

past 24 months 

Total number of 

facilities offering 

malaria 

diagnosis/treatment 

services or curative 

sick child care 

services 

Table A.3 

Personnel trained in 

microscopy 

Proportion of facilities 

with personnel trained in 

malaria microscopy among 

facilities offering malaria 

diagnosis/treatment 

services or curative sick 

child care services 

Number of facilities with at 

least one interviewed 

provider who reports 

receiving in-service training 

in malaria microscopy in 

the past 24 months 

Total number of 

facilities offering 

malaria 

diagnosis/treatment 

services or curative 

sick child care 

services 

Table A.4 

Personnel trained in 

case 

management/treatment 

of malaria in children 

Proportion of facilities 

with personnel trained in 

case 

management/treatment of 

malaria in children among 

facilities offering malaria 

diagnosis/treatment 

services or curative sick 

child care services 

Number of facilities with at 

least one interviewed 

provider who reports 

receiving in-service training 

in case management and 

treatment of malaria in 

children in the past 24 

months 

Total number of 

facilities offering 

malaria 

diagnosis/treatment 

services or curative 

sick child care 

services 

Table A.5 

Personnel trained in 

mRDT, microscopy, 

or case 

management/treatment 

of malaria in children 

Proportion of facilities 

with personnel trained in 

in mRDT, malaria 

microscopy, or case 

management and treatment 

of malaria in children 

among facilities offering 

malaria 

diagnosis/treatment 

services or curative sick 

child care services 

Number of facilities with at 

least one interviewed 

provider who reports 

receiving in-service training 

in mRDT, malaria 

microscopy, or case 

management/treatment of 

malaria in children in the 

past 24 months 

Total number of 

facilities offering 

malaria 

diagnosis/treatment 

services or curative 

sick child care 

services 

3.3.3 National malaria diagnosis/treatment guidelines and mRDT protocol 

National guidelines for the diagnosis and treatment of malaria, as well as treatment job aids and wall charts, 

are essential components of malaria care in a facility setting. These guidelines serve as visual reminders 

and references for healthcare providers. A facility is categorized as having guidelines for diagnosis and 

treatment of malaria only if the interviewer is shown the guidelines at the facility. This indicator is not based 

on self-report. The Inventory Questionnaire contains the questions asked of the health service providers 

about the availability of national guidelines for diagnosis and treatment of malaria. 

The mRDT protocol refers to the written instructions for performing mRDT. Facilities with an mRDT 

protocol must have a training manual, poster, or job aid for using malaria RDT observed in the facility. 
18 

Variable Indicator Numerator Denominator 

Appendix A 

Indicator 

Construction 

National 

guidelines for 

diagnosis and 

treatment of 

malaria 

Proportion of facilities 

that have national 

guidelines for diagnosis 

and treatment of malaria 

among facilities offering 

malaria 

diagnosis/treatment 

services or curative sick 

child care services 

Number of facilities with 

national guidelines for 

diagnosis and treatment 

of malaria 

Total number of 

facilities offering 

malaria 

diagnosis/treatment 

services or curative sick 

child care services 

Table Appendix 

Table A.6 

Malaria mRDT 

Protocol 

Proportion of facilities 

that have protocol for 

malaria mRDT among 

facilities offering malaria 

diagnosis/treatment 

services or curative sick 

child care services 

Number of facilities with 

protocol for malaria 

mRDT 

Total number of 

facilities offering 

malaria 

diagnosis/treatment 

services or curative sick 

child care services 

Table A.7 

3.3.4 Supplies 

For the proper diagnosis of malaria, health facilities must have adequate supplies available for use. The 

gold standard of laboratory malaria diagnosis is an examination by microscope of blood smears for malaria 

parasites (microscopy). The mRDTs are an alternative to microscopy in situations where high quality 

microscopy services cannot be readily provided. 

A facility that is defined as having adequate microscopy supplies must have a functioning microscope with 

glass slides and the relevant stains for malaria microscopy available somewhere in the facility on the day 

of the survey. Appropriate stains for malaria microscopy include Giemsa, field, or acridine orange stain. A 

facility considered to have with adequate mRDT supplies must have unexpired malaria mRDT kits available 

in the facility. 

 
19 

Variable Indicator Numerator Denominator 

Appendix A 

Indicator 

Construction 

Malaria mRDT 

supplies 

Proportion of facilities 

that have malaria mRDTs 

supplies among facilities 

offering malaria 

diagnosis/treatment 

services or curative sick 

child care services 

Number of facilities 

with malaria mRDT 

supplies 

Total number of facilities 

offering malaria 

diagnosis/treatment 

services or curative sick 

child care services 

Table A.8 

Malaria 

microscopy 

supplies 

Proportion of facilities 

that have malaria 

microscopy supplies 

among facilities offering 

malaria 

diagnosis/treatment 

services or curative sick 

child care services 

Number of facilities 

with malaria 

microscopy supplies 

Total number of facilities 

offering malaria 

diagnosis/treatment 

services or curative sick 

child care services 

Table A.9 

Any malaria 

diagnostics 

supplies 

Proportion of facilities 

that have malaria 

microscopy supplies or 

mRDT supplies among 

facilities offering malaria 

diagnosis/treatment 

services or curative sick 

child care services 

Number of facilities 

with malaria 

microscopy or mRDT 

supplies 

Total number of facilities 

offering malaria 

diagnosis/treatment 

services or curative sick 

child care services 

3.3.5 Diagnostic capacity 

Malaria diagnostic capacity for a facility is defined as having the capacity for microscopy or mRDT (Figure 

1). Microscopy capacity is defined as a facility having a functioning microscope with glass slides and 

relevant stains, in addition to at least one health provider who has received training on microscopy during 

the 24 months before the survey. Similarly, RDT capacity is defined as a facility having unexpired malaria 

mRDT kits, at least one health provider who received mRDT training in the 24 months before the survey, 

and the facility has an instructional protocol for performing a mRDT. 

 
20 

Variable Indicator Numerator Denominator 

Appendix A 

Indicator 

Construction 

Microscopy 

diagnostic capacity 

Proportion of facilities 

that have microscopy 

diagnostic capacity 

among facilities offering 

malaria 

diagnosis/treatment 

services or curative sick 

child care services 

Number of facilities 

with microscopy 

diagnostic capacity 

Total number of facilities 

offering malaria 

diagnosis/treatment 

services or curative sick 

child care services 

Table A.10 

mRDT diagnostic 

capacity 

Proportion of facilities 

that have mRDT 

diagnostic capacity 

among facilities offering 

malaria 

diagnosis/treatment 

services or curative sick 

child care services 

Number of facilities 

with mRDT diagnostic 

capacity 

Total number of facilities 

offering malaria 

diagnosis/treatment 

services or curative sick 

child care services 

Table A.11 

Diagnostic 

capacity 

Proportion of facilities 

that have diagnostic 

capacity (microscopy 

diagnostic capacity or 

mRDT diagnostic 

capacity) among facilities 

offering malaria 

diagnosis/treatment 

services or curative sick 

child care services 

Number of facilities 

with diagnostic 

capacity (microscopy 

diagnostic capacity or 

mRDT diagnostic 

capacity) 

Total number of facilities 

offering malaria 

diagnosis/treatment 

services or curative sick 

child care services 

Table A.12 

Figure 1 Components of diagnostic capacity1

1

‘Blood’ icon by Adrien Coquet of the Noun Project. 
21 

3.3.6 Antimalarial availability 

The universal and continuous availability of antimalarial drugs is a critical component for the delivery of 

malaria treatment in health facilities. In the SPA survey, the person most knowledgeable about storage and 

management of medicines and supplies at the health facilities was asked to show the interviewer the 

following medicines: 

• Artemether Lumefantrine (AL) in (6,12,18, and 24 packs) 

• Injectable Artesunate 

• Artesunate Suppositories/Rectal Artesunate 

• Quinine Tablets 

• Quinine Injection 

Antimalarial medicines must be observed in the health facility, and there needed to be at least one valid 

dose of each medicine available on the day of the interview. The Inventory Questionnaire contains the 

questions asked of the health service providers about the availability of antimalarial drugs in the health 

facility. 

Variable Indicator Numerator Denominator 

Appendix A 

Indicator 

Construction 

ACT availability Proportion of facilities 

with ACTs among 

facilities offering malaria 

diagnosis/treatment 

services or curative sick 

child care services 

Number of facilities 

that have ACTs 

available 

Total number of facilities 

offering malaria 

diagnosis/treatment 

services or curative sick 

child care services 

Table A.13 

3.3.7 Malaria service readiness index 

The malaria service readiness index is an indicator that assesses the ability of a facility to provide the best 

care for the diagnosis and treatment of malaria. The facility must have personnel trained in either mRDT, 

microscopy, or case management and treatment of malaria in children; national guidelines for the diagnosis 

and treatment of malaria; diagnostic capacity (microscopy or mRDT capacity); and unexpired ACTs to be 

classified as malaria service ready (Figure 2). 

Variable Indicator Numerator Denominator 

Appendix A 

Indicator 

Construction 

Malaria service 

readiness 

Proportion of facilities 

who are malaria service 

ready among facilities 

offering malaria 

diagnosis/treatment 

services or curative sick 

child care services 

Number of facilities 

that are malaria 

service ready 

Total number of facilities 

offering malaria 

diagnosis/treatment 

services or curative sick 

child care services 

Table A.14 
22 

Figure 2 Components of malaria service readiness1

1

Mosquito icon by Yanti Anis, training icon by Yuvika Koul, guideline icon by Mahdi Ehsaei, and blood icon by Adrien Coquet of the Noun Project. 

3.4 Indicators from the Demographic and Health Survey (DHS) 

The DHS indicators included in this analysis examine care-seeking, diagnostic testing, and appropriate 

treatment for children with recent fever. 

3.4.1 Care-seeking for fever in children 

The proportion of children under age 5 with fever in the previous 2 weeks for whom advice or treatment 

was sought is an indicator that captures care-seeking behavior for febrile illness in children. Most cases of 

malaria include symptoms of fever, which is a proxy for national-level care-seeking for malaria. In the 

Individual Questionnaire, mothers are asked if their child under age 5 has had a fever in the previous 2 

weeks. If so, they are asked, “Did you seek advice or treatment for the illness from any source?” If yes, they 

are asked, “Where did you seek advice or treatment?” The mother is then asked to list the specific type of 

facilities where they sought care for their child with a fever. Multiple responses for sources of care are 

allowed. Interviewers are instructed to ask “Anywhere else?” after recording the first facility listed to make 

sure that all facilities where treatment was sought are captured. 

 
23 

Variable Indicator Numerator Denominator 

Care-seeking for fever in 

children 

Proportion of children under 

age 5 years with fever in the 

previous 2 weeks for whom 

advice and treatment was 

sought 

Number of children under age 

5 with fever in the previous 2 

weeks for whom advice and 

treatment was sought 

Total number of children under 

age 5 with fever in the 

previous 2 weeks 

3.4.2 Diagnostic testing for children with fever 

The proportion of children under age 5 with fever in the previous 2 weeks who had a finger or heel stick is 

an indicator that measures the extent to which children with fever obtain a malaria diagnostic test. Only a 

minority of fever cases that present to a health facility have evidence of malaria parasitemia when tested 

and should be treated with antimalarial medicines. Adherence to this policy cannot be directly measured 

through household surveys. However, interviewed women with children under age 5 who had a fever in the 

previous 2 weeks before the survey are asked: “At any time during the illness, did the child have blood 

taken from his/her finger or heel for testing?” This information serves as a proxy measure for adherence to 

the policy of conducting diagnostic testing for all suspected malaria cases. Since most malaria-endemic 

countries now have policies that require universal diagnostic testing for malaria before treatment, this is an 

important measure of the appropriateness of care. 

In this report, the denominator for the diagnostic testing for children with fever indicator varies slightly 

from the standard RBM MERG indicator (which is also the standard in the DHS and MIS reports) that 

examines children under age 5 with fever in the previous 2 weeks who have had a finger or heel stick [33]. 

The RBM MERG indicator denominator is defined as the “Total number of children under age 5 who had 

a fever in the previous 2 weeks.” In this report, the denominator is defined as “Total number of children 

under age 5 who had a fever in the previous 2 weeks who sought advice or treatment” which includes formal 

and non-formal sources. Adding the specification that the child must have sought advice and treatment for 

fever allows the indicator to be more comparable to the indicator from the SPA data (those who sought care 

at a facility and received a diagnostic test). In addition, the indicator in this report does not exclude 

traditional healers, shops, or other non-formal places for seeking care. 

Variable Indicator Numerator Denominator 

Diagnostic testing for 

children with fever 

Proportion of children under 

age 5 with fever in the 

previous 2 weeks who had a 

finger or heel stick 

Number of children under age 

5 with fever in the previous 2 

weeks who had a finger or 

heel stick 

Total number of children under 

age 5 who had a fever in the 

previous 2 weeks who sought 

advice and treatment 

3.4.3 Appropriate treatment with ACT 

The proportion receiving artemisinin-based combination therapy (ACT) treatment among children under 

age 5 with fever in the previous 2 weeks who received any antimalarial drug is an indicator that assesses 

the proportion of antimalarial treatment received by children under age 5 that is in accordance with the 

national malaria treatment policy. ACT is the WHO-recommended first-line antimalarial drug for the 
24 

treatment of uncomplicated malaria. This policy has been recommended in most countries in Sub-Saharan 

Africa since 2006. Understanding which antimalarial drugs are available and prescribed to children is an 

important component for monitoring access to effective treatment. 

For each child who had a fever or cough in the 2 weeks before the survey, mothers are asked in the 

Individual Questionnaire: “At any time during the illness, did the child take any drugs for the illness?” and, 

if yes, “What drugs did the child take?” Respondents are asked the question “Any other drugs?” to identify 

all drugs given to the child. 

Similar to the previous indicator, for this report the denominator for ACT treatment for fever in children 

indicator varies slightly from the standard RBM MERG indicator (which is also the standard in the DHS 

and MIS reports) [33]. The RBM MERG indicator denominator is defined as the “Total number of children 

under age 5 with fever in the previous 2 weeks who received any antimalarial drug” while for this report, 

the denominator is defined as “Total number of children under age 5 with fever in the previous 2 weeks 

who sought treatment and took an antimalarial drug.” Adding the specification that the child must have 

sought advice and treatment for fever allows the indicator to be more comparable to the indicator from the 

SPA data (those who sought care at a facility and received an antimalarial drug). 

Variable Indicator Numerator Denominator 

ACT treatment for fever 

in children 

Proportion receiving ACT 

treatment among children 

under age 5 with fever in the 

previous 2 weeks who 

received any antimalarial drug 

Number of children under age 

5 with fever in the previous 2 

weeks who received an ACT 

Total number of children under 

age 5 with fever in the 

previous 2 weeks who received 

any antimalarial drug
25 

4 RESULTS 

4.1 Malawi 

4.1.1 Service availability 

In the 2015-16 Malawi DHS, advice and treatment was sought for 67% of the children with fever in the 2 

weeks before the survey (Table 4). Most children with recent fever for whom care was sought received 

advice and treatment from a formal health provider (61%). Among those seeking advice and treatment, 39% 

of children were taken to a government health center, 8% to a government hospital, 7% to a government 

health post or mobile clinic, 5% to a private facility, and 4% to a faith-based facility. Only 6% sought advice 

or treatment from a source not sampled in the SPA (Table 4). 

In the 2013-14 Malawi SPA, 97% of facilities in Malawi offered malaria diagnosis/treatment services or 

curative care for sick children. Among the facilities sampled, 100% of government hospitals and health 

centers, 99% of faith-based facilities, 96% of private facilities, and 81% of government health posts or 

mobile clinics offered malaria diagnosis/treatment services or curative care for sick children (Table 4). 

Comparison of the DHS data on the source of advice or treatment for children with fever with SPA data on 

availability of malaria services by facility type in Malawi shows that government health centers had the 

highest utilization for seeking advice and treatment for fever in Malawi (39%) and that 100% of the 

government health centers offer malaria diagnosis/treatment services or curative care for sick children 

(Table 4). 

Table 4 Source of advice or treatment for children with fever and availability of malaria services by 

facilities in Malawi

2015-16 Malawi DHS 2013-14 Malawi SPA

Facility type 

Percentage for 

whom advice or 

treatment was 

sought 

Number of children 

under age 5 with a 

fever 

Facilities 

offering malaria 

diagnosis/treat

ment services 

Facilities 

offering 

curative 

care for 

sick 

children 

Facilities offering 

malaria 

diagnosis/treatment 

services or curative 

care for sick 

children 

Total 

number 

of 

facilities 

Government 

hospital 8 4,774 100 100 100 48 

Government health 

center 39 4,774 99 100 100 339 

Government health 

post or mobile 

clinic 

7 4,774 76 74 81 85 

Private facility 5 4,774 96 90 96 342 

Christian health 

association/mission/ 

faith-based 

4 4,774 99 99 99 163 

Any other source 6 4,774 n/a n/a n/a n/a 

Total 67 4,774 96 94 97 977 

 
26 

4.1.2 Trained personnel 

In the 2015-16 Malawi DHS, 69% of children with a recent fever for whom treatment was sought had blood 

taken from a finger or heel, presumably for malaria testing (Table 5). After disaggregating for facility type, 

87% of children who went to a faith-based organization, 84% of children to a government hospital, 76% of 

children to a government health center, 68% to a private facility, and 57% to a government health post or 

mobile clinic had blood taken from a finger or heel for testing. Only 11% of children who went to a source 

not sampled in the SPA survey had blood taken from a finger or heel for testing. 

The 2013-14 Malawi SPA found that 50% of facilities had at least one staff member trained in mRDT, 40% 

in microscopy, 38% in case management and treatment of malaria in children, and 54% trained in mRDT, 

microscopy, and case management and treatment of malaria in children (Table 5). By facility type, the 

percentage of facilities with at least one staff member trained in mRDT ranges from 82% of government 

hospitals to 34% of private facilities. Personnel trained in microscopy ranges from 72% of government 

hospitals to 26% of government health posts or mobile clinics. Similarly, the percentage of facilities with 

staff trained in case management and treatment of malaria in children ranges from 54% of government 

hospitals to 25% of government health posts or mobile clinics. The composite indicator that examined 

personnel trained in mRDT, microscopy, and case management and treatment of malaria in children ranged 

from 84% of government hospitals to 39% of private facilities (Table 5). 

A comparison of diagnostic testing data from the DHS and malaria training of personnel by facility type 

from the SPA shows that 84% of children in Malawi who went to a government hospital had blood taken 

from a finger or heel for testing. Likewise, 84% of government hospitals had at least one person trained in 

mRDT, microscopy, or case management and treatment of malaria in children (Figure 3). Febrile children 

were most likely to have blood taken from a finger or heel for testing if they were taken to faith-based 

facilities for care (87%), although only slightly more than half of these facilities (58%) had at least one 

person trained in mRDT, microscopy, or case management and treatment of malaria in children (Figure 3). 

A scatterplot of children who had blood taken from a finger or heel for testing and personnel trained in 

mRDT, microscopy, or case management and treatment of malaria in children by facility type shows a 

positive association between the two measures with an R2

 of 0.55 (Figure 3). 

 
27 

Table 5 Diagnosis of fever and malaria training of personnel by facilities in Malawi

2015-16 Malawi DHS 2013-14 Malawi SPA

Percentage 

who had 

blood taken 

from a 

finger or 

heel for 

testing

Number of 

children 

under age 5 

with a fever 

who sought 

treatment

Among facilities offering malaria diagnosis/treatment services or curative sick child care 

services 

Facility type 

Personnel 

trained in 

mRDT 

Personnel 

trained in 

microscopy 

Personnel 

trained in 

case 

management/

treatment of 

malaria in 

children 

Personnel trained 

in mRDT, 

microscopy, or 

case management 

and treatment of 

malaria in children 

Total number of 

facilities 

Government 

hospital 84 372 82 72 54 84 48 

Government 

health center 76 1,843 60 48 46 65 338 

Government 

health post or 

mobile clinic 

57 330 36 26 25 41 68 

Private facility 68 232 34 28 29 39 330 

Christian 

health 

association/ 

mission/faithbased 

87 188 55 44 40 58 162 

Any other 

source 11 278 n/a n/a n/a n/a n/a 

Total 69 3,200 50 40 38 54 947 

Figure 3 Diagnosis of fever by malaria training of personnel in Malawi

Government hospital

Government health 

center

Government health 

post or mobile clinic Private facility

Christian 

health 

association/

mission/faithbased

R2 = 0.5525

0

10

20

30

40

50

60

70

80

90

100

0 10 20 30 40 50 60 70 80 90 100

Percentage of personnel trained in mRDT, microscopy, or case 

management/treatment of malaria in children

Percentage of children under age 5 with fever who sought advice or treatment

who had blood taken from a finger or heel for testing
28 

4.1.3 National guidelines 

In the 2013-14 Malawi SPA, 64% of facilities had national guidelines for the diagnosis and treatment of 

malaria and 60% of facilities had a malaria mRDT protocol available. By facility type, the percentage of 

facilities with national guidelines for the diagnosis and treatment of malaria ranged from 82% of 

government hospitals to 51% of private facilities. Similarly, facilities with a malaria mRDT protocol ranged 

from 88% of government hospitals to 46% of private facilities (Table 6). 

Comparing diagnostic testing of children from the DHS and availability of national malaria guidelines or a 

mRDT protocol by facility type in Malawi from the SPA, 84% of children who went to a government 

hospital had blood taken from a finger or heel for testing, while 88% of government hospitals had a malaria 

mRDT protocol and 82% had national guidelines for the diagnosis and treatment of malaria. Febrile children 

were most likely to have blood taken from a finger or heel for testing if they were taken to faith-based 

facilities for care (87%). However, 70% of the facilities had national guidelines for the diagnosis and 

treatment of malaria and 68% of the facilities had a malaria mRDT protocol. Private facilities were least 

likely to have national guidelines for the diagnosis and treatment of malaria (51%) and malaria mRDT 

protocol (46%), although 68% of children who sought care at a private facility had blood taken from a 

finger or heel for testing. The coefficient of determination (R2

) of percentage of febrile children who had 

blood taken from a finger or heel for testing and percentage of facilities that had national guidelines for 

diagnosis and treatment of malaria by facility type shows a positive association between the two measures 

with an R2

 of 0.52 (Figure 4). Similarly, children who had blood taken from a finger or heel for testing and 

a malaria mRDT protocol by facility type shows a positive association between the two measures with an 

R2

 of 0.56 (Figure 5). 

Table 6 Diagnosis of fever and availability of national malaria guidelines/protocol by facilities in Malawi

2015-16 Malawi DHS 2013-14 Malawi SPA

Percentage who had 

blood taken from a 

finger or heel for 

testing 

Number of children 

under age 5 with a 

fever who sought 

treatment 

 Among facilities offering malaria 

diagnosis/treatment services or curative sick child 

care services 

Facility type 

National guidelines 

for diagnosis and 

treatment of malaria 

Malaria 

mRDT 

Protocol 

Total 

number of 

facilities 

Government hospital 84 372 82 88 48 

Government health center 76 1,843 71 69 338 

Government health post or 

mobile clinic 57 330 60 53 68 

Private facility 68 232 51 46 330 

Christian health 

association/mission/faithbased 87 188 70 68 162 

Any other source 11 278 n/a n/a n/a 

Total 69 3,200 64 60 947 
29 

Figure 4 Diagnosis of fever by availability of national malaria guidelines for diagnosis/treatment in Malawi

Figure 5 Diagnosis of fever by availability of malaria RDT protocol in Malawi

Government hospital

Government 

health center

Government health 

post or mobile clinic

Private Facility

Christian health 

association/mission/

faith-based

R2 = 0.5157

0

10

20

30

40

50

60

70

80

90

100

0 10 20 30 40 50 60 70 80 90 100

Percentage of facilities with guidelines for diagnosis and/or 

treatment of malaria

Percentage of children under age 5 with fever who sought advice or treatment

who had blood taken from a finger or heel for testing

Government 

hospital

Government health 

center

Government health 

post or mobile 

clinic

Private facility

Christian health 

association/

mission/faith-based

R2 = 0.5577

0

10

20

30

40

50

60

70

80

90

100

0 10 20 30 40 50 60 70 80 90 100

Percentage of facilities with malaria RDT protocol

Percentage of children under age 5 with fever who sought

advice or treatment

who had blood taken from a finger or heel for testing
30 

4.1.4 Supplies 

In Malawi, 88% of facilities had mRDT supplies, 14% had malaria microscopy supplies, and 88% had any 

malaria diagnostic supplies (mRDT and/or microscopy) (Table 7). By facility type, the percentage of 

facilities with malaria mRDT supplies ranged from 98% in government hospital and faith-based facilities 

to 76% of private facilities. The percentage of facilities with malaria microscopy supplies ranged from 60% 

of government hospitals to 3% of government health posts or mobile clinics. The percentage of facilities 

with any malaria diagnostic supplies ranged from 98% of government hospitals and faith-based facilities to 

77% of private facilities (Table 7). 

Comparing diagnostic testing and availability of malaria diagnostic supplies by facility type in Malawi, 

87% of children who went to a faith-based facility had blood taken from a finger or heel for testing. Among 

faith-based facilities, 98% had adequate mRDT supplies while only 25% had adequate microscopy supplies. 

A total of 84% of children who attended government hospitals had blood taken from a finger or heel for 

testing. Among government hospitals, 98% had adequate mRDT supplies and 60% had adequate 

microscopy supplies. Few government health centers or government health posts or mobile clinics had 

adequate malaria microscopy supplies (5% and 3%, respectively), although malaria mRDT supplies were 

available at 95% of government health centers and 80% of government health posts or mobile clinics. 

Malaria diagnostic supplies were the least frequently available in private facilities (77%), although 68% of 

children attending a private facility reported having blood taken from a finger or heel for testing. As 

expected, there is a strong association (R2

=0.79) between diagnostic testing among febrile children seeking 

treatment at specific facility types and malaria diagnostic supplies available at the facility type (Figure 6). 

Table 7 Diagnosis of fever and availability of malaria diagnostic supplies by facilities in Malawi

2015-16 Malawi DHS 2013-14 Malawi SPA

Percentage 

who had 

blood taken 

from a 

finger or 

heel for 

testing

Number of 

children under 

age 5 with a 

fever who 

sought 

treatment

Among facilities offering malaria diagnosis/treatment services or curative sick 

child care services 

Facility type 

Malaria 

mRDT 

supplies 

Malaria 

microscopy 

supplies 

Any malaria 

diagnostic 

supplies 

Total number of facilities 

Government hospital 84 372 98 60 98 48 

Government health 

center 76 1,843 95 5 95 338 

Government health 

post or mobile clinic 57 330 80 3 80 68 

Private facility 68 232 76 13 77 330 

Christian health 

association/mission/ 

faith-based 

87 188 98 25 98 162 

Any other source 11 278 n/a n/a n/a n/a 

Total 69 3,200 88 14 88 947 
31 

Figure 6 Diagnosis of fever by availability of malaria diagnostic supplies in Malawi

4.1.5 Diagnostic capacity 

In Malawi, 7% of facilities had microscopy diagnostic capacity, 32% of facilities had mRDT diagnostic 

capacity, and 34% had malaria diagnostic capacity (microscopy diagnostic capacity and mRDT diagnostic 

capacity) (Table 8). By facility type, microscopy diagnostic capacity ranges from 40% of government 

hospitals to 1% of government health post or mobile clinics. The mRDT diagnostic capacity ranges from 

72% of government hospitals to 17% of private facilities. Overall diagnostic capacity by facility ranges 

from 76% of government hospitals to 19% of private facilities (Table 8). 

When comparing diagnosis of fever and malaria diagnostic capacity by facility type in Malawi, 87% of 

children who visited a faith-based facility had blood taken from a finger or heel for testing, although only 

43% of faith-based facilities have full diagnostic capacity. Among children for whom treatment was sought 

at government hospitals, 84% had blood taken from a finger or heel for testing, although only 40% of 

government hospitals had microscopy capacity and 72% had mRDT diagnostic capacity. No facility had a 

greater microscopy diagnostic capacity than mRDT diagnostic capacity. Government health posts or mobile 

clinics and private facilities had the lowest diagnostic capacity (20% and 19% respectively). There is a 

positive association (R2

=0.58) between diagnostic testing among febrile children seeking treatment at 

specific facility types and facilities that have diagnostic capacity (Figure 7). 

 

Government hospital

Government health 

center

Government health 

post or mobile clinic

Private facility

Christian 

health 

association/

mission/

faith-based

R2 = 0.7897

0

10

20

30

40

50

60

70

80

90

100

0 10 20 30 40 50 60 70 80 90 100

Percentage of facilities with any malaria diagnostic 

supplies

Percentage of children under age 5 with fever who sought advice or treatment

who had blood taken from a finger or heel for testing
32 

Table 8 Diagnosis of fever and malaria diagnostic capacity by facilities in Malawi

2015-16 Malawi DHS 2013-14 Malawi SPA

Percentage 

who had 

blood taken 

from a 

finger or 

heel for 

testing

Number of 

children under 

age 5 with a 

fever who 

sought 

treatment

Among facilities offering malaria diagnosis/treatment services or curative sick 

child care services 

Facility type 

Microscopy 

diagnostic 

capacity 

mRDT 

diagnostic 

capacity 

Diagnostic 

capacity Total number of facilities 

Government hospital 84 372 40 72 76 48 

Government health 

center 76 1,843 3 41 41 338 

Government health 

post or mobile clinic 57 330 1 20 20 68 

Private facility 68 232 4 17 19 330 

Christian health 

association/mission/ 

faith-based 

87 188 15 38 43 162 

Any other source 11 278 n/a n/a n/a n/a 

Total 69 3,200 7 32 34 947 

Figure 7 Diagnosis of fever by malaria diagnostic capacity in Malawi

4.1.6 ACT availability 

Among children under age 5 with a fever who sought treatment and took an antimalarial drug, 93% of 

children received an ACT. By facility type, receipt of ACT varies from 97% of children for whom treatment 

was sought and an antimalarial was prescribed at a government health post/mobile clinic, 95% at a 

government hospital, 94% at a government health center, 91% at a faith-based clinic, 85% at a source not 

sampled in the SPA, to 75% at a private facility. Other less frequently prescribed drugs for children who 

sought treatment for fever included injectable quinine (4%), followed by oral quinine (2%), injectable 

artesunate (1%), and artesunate suppository (0.2%). 

Government hospital

Government health 

center

Government health 

post or mobile clinic Private facility

Christian 

health 

association/

mission/

faith-based

R2 = 0.578

0

10

20

30

40

50

60

70

80

90

100

0 10 20 30 40 50 60 70 80 90 100

Percentage of facilities with diagnostic capacity

Percentage of children under age 5 with fever who sought advice or treatment

who had blood taken from a finger or heel for testing
33 

In an examination of the 2013-14 Malawi SPA, 92% of facilities had an ACT drug in stock on the day of 

the survey (Table 9). This means that the ACT drug was observed in the health facility, and there was at 

least one valid dose available on the day of the interview. By facility type, 100% of government hospitals 

and 99% of government health centers and faith-based organizations had ACTs available in stock. However, 

only 82% of private facilities and 81% of government health posts or mobile clinics had ACT in stock. 

(Table 9). 

In a comparison of the type of antimalarial drug used and availability of antimalarial drugs by facilities in 

Malawi, more than 90% of children who went to a government hospital, government health center, or a 

faith-based facility who took an antimalarial drug received an ACT. This concurs with the data from the 

facility level in that greater than 99% of these facilities had availability of ACTs on the day of the survey. 

Data from the DHS showed that 97% of children who went to a government health post who took an 

antimalarial drug received an ACT. However, according to the 2013-14 SPA, 81% of government health 

posts had ACT in stock on the day of the survey. Injectable quinine and oral quinine were well stocked in 

facilities, although they are rarely used because they are not the recommended first-line treatment drugs for 

children under age 5. 
34 

Table 9 Type of antimalarial drug used and availability of antimalarial drugs by facilities in Malawi

2015-16 Malawi DHS 2013-14 Malawi SPA

Among facilities offering malaria diagnosis/treatment services or curative sick 

child care services 

Facility type ACT Injectable artesunate Artesunate suppository (rectal) Oral quinine Injectable quinine 

Number of 

children 

with fever 

who sought 

treatment 

and took an 

antimalarial 

drugs 

Any 

ACT 

Injectable 

artesunate 

Artesunate 

suppository 

(rectal) 

Oral 

quinine 

Injectable 

quinine 

Total number of 

facilities 

Government hospital 95 2 0 0 4 194 100 4 0 86 98 48 Government health center 94 0 0 2 4 942 99 1 0 67 99 338 Government health post or mobile clinic 

97 1 0 1 1 196 81 0 0 49 69 68 

Private facility 77 8 0 9 9 105 82 6 3 74 79 330 

Christian health association/mission/faith-based 

91 1 1 5 13 123 99 4 1 83 95 162 

Any other source 85 0 2 3 2 44 n/a n/a n/a n/a n/a n/a Total 93 1 0 2 4 1,583 92 3 1 72 89 947 
35 

4.1.7 Service readiness 

The components of the malaria service readiness index include facility personnel trained in mRDT, 

microscopy, case management and treatment of malaria in children, national guidelines for diagnosis and 

treatment, proper supplies for diagnosing malaria, and ACTs available on site. Among facilities in Malawi 

that offer malaria diagnosis/treatment services or curative care for sick children, 25% have all the 

components to be considered malaria service ready (Table 10). By facility type, the percentage of facilities 

considered malaria service ready ranges from 60% for government hospitals to 12% for private facilities. 

Across all facilities, the lowest component of the malaria service readiness index was the diagnostic 

capacity. 

In comparisons of the source of advice or treatment for children with fever to the components of the malaria 

service readiness index, 39% of children with a fever were taken to a government health center, although 

only 32% of government health centers are considered malaria service ready. Among government health 

centers, 99% have ACTs available and 71% have national guidelines for the diagnosis and treatment of 

malaria available at the facility, which are components of service readiness. The major barrier to service 

readiness in Malawi appears to be the low diagnostic capacity (41%). Among government hospitals, 60% 

are malaria service ready, although only 8% of children sought care for a fever at a government hospital. 

Table 10 Source of advice or treatment for children with fever and components of malaria service 

readiness by facilities in Malawi

2015-16 Malawi DHS 2013-14 Malawi SPA

Percentage 

for whom 

advice or 

treatment 

was sought 

Number 

of 

children 

under 

age 5 

with a 

fever 

Among facilities offering malaria diagnosis/treatment services or curative sick child 

care services 

Facility type 

 Personnel 

trained in 

mRDT, 

microscopy 

or case 

management 

treatment of 

malaria in 

children 

National 

guidelines 

for diagnosis 

and 

treatment of 

malaria 

Diagnostic 

capacity 

ACTs 

available 

Malaria 

service 

readiness 

index 

Total number 

of facilities 

Government hospital 8 4,774 84 82 76 100 60 48 

Government health 

center 39 4,774 65 71 41 99 32 338 

Government health 

post or mobile clinic 7 4,774 41 61 20 71 15 68 

Private facility 5 4,774 39 51 19 82 12 330 

Christian health 

association/mission/ 

faith-based 

4 4,774 58 70 43 99 33 162 

Any other source 6 4,774 n/a n/a n/a n/a n/a n/a 

Total 67 4,774 54 64 34 92 25 947 

4.1.8 Malaria endemicity 

To explore if malaria service readiness varies by the level of malaria transmission, the components of 

malaria service readiness were examined by endemicity level in Malawi. Facilities were stratified into two 

equal frequency groups (lower and higher malaria risk categories). The lower malaria risk category for 

Malawi included facilities with a PfPR≤10.2% while facilities with a higher malaria risk had a PfPR≥10.3%. 

All components of malaria service readiness (trained personnel, guidelines, diagnostic capacity, and 
36 

available ACTs) were higher in areas of higher malaria transmission as compared to the lower malaria 

transmission areas. When examining malaria service readiness by facilities and malaria endemicity, 

government hospitals, government health centers, government health posts or mobile clinics, and private 

facilities had greater malaria service readiness in locations with higher malaria endemicity, while only faithbased organizations had higher malaria service readiness in locations with lower malaria endemicity (Table 

11). 

Table 11 Malaria service readiness by malaria endemicity and facility in Malawi

 2013-14 Malawi SPA

Facility type 

 Personnel 

trained in 

mRDT, 

microscopy, 

or case 

management/ 

treatment of 

malaria in 

children 

National 

guidelines 

for diagnosis 

and 

treatment of 

malaria 

Diagnostic 

capacity 

ACTs 

available 

Malaria 

service 

readiness 

index 

Total number of facilities 

offering malaria 

diagnosis/treatment 

services or curative sick 

child care services 

Government 

hospital 

PfPR≤ 10.2% 78 78 78 100 56 33 

PfPR≥10.3% 89 85 74 100 63 26 

Government 

health center 

PfPR≤ 10.2% 61 68 41 100 27 150 

PfPR≥10.3% 69 74 42 99 36 188 

Government 

health post or 

mobile clinic 

PfPR≤ 10.2% 35 55 7 74 3 30 

PfPR≥10.3% 46 65 30 86 24 39 

Private facility 

PfPR≤ 10.2% 35 51 18 81 10 177 

PfPR≥10.3% 43 51 21 83 13 153 

Christian health 

association/ 

mission/faithbased 

PfPR≤ 10.2% 57 75 48 99 40 71 

PfPR≥10.3% 58 67 40 99 27 90 

Total 

PfPR≤ 10.2% 49 62 33 90 22 451 

PfPR≥10.3% 58 65 36 93 28 497 

4.2 Senegal 

4.2.1 Service availability 

In the 2016 Senegal Continuous DHS, advice or treatment was sought for 50% of the children with fever 

in the 2 weeks before the survey (Table 12). Most children with recent fever for whom care was sought, 

received advice or treatment from a formal health provider (47%). Among those seeking advice or 

treatment, 32% of children were taken to a government health post or mobile clinic, 9% to a private facility, 
37 

5% to a government hospital or health center, and 3% to a government health hut. Only 3% sought advice 

or treatment from a source not sampled in the SPA survey (Table 12). 

In the 2016 Senegal Continuous SPA, 99% of facilities in Senegal offered malaria diagnosis/treatment 

services or curative care for sick children. Among the facilities sampled, 100% of government hospitals, 

health centers, government health posts or mobile clinics offer malaria diagnosis/treatment services or 

curative care for sick children. Similarly, 98% of government health huts and private facilities offered 

malaria diagnosis/treatment services or curative care for sick children (Table 12). 

Comparison of DHS data on the source of advice or treatment for children with fever with SPA data on the 

availability of malaria services by facility type in Senegal shows that government health posts or mobile 

clinics had the highest utilization for seeking advice or treatment for fever in Senegal (32%) and that 100% 

of government health posts or mobile clinics offer malaria diagnosis/treatment services or curative care for 

sick children (Table 12). 

Table 12 Source of advice or treatment for children with fever and availability of malaria services by 

facilities in Senegal

2016 Senegal Continuous DHS 2016 Senegal Continuous SPA

Facility type 

Percentage for 

whom advice or 

treatment was 

sought 

Number of children 

under age 5 with a 

fever 

Facilities 

offering malaria 

diagnosis/treat

ment services 

Facilities 

offering 

curative 

care for 

sick 

children 

Facilities offering 

malaria 

diagnosis/treatment 

services or curative 

care for sick 

children 

Total 

number 

of 

facilities 

Government 

hospital or health 

center 

5 692 100 96 100 29 

Government health 

post or mobile 

clinic 

32 692 100 100 100 252 

Government health 

hut 3 692 91 94 98 87 

Private facility 9 692 97 80 98 72 

Any other source 3 692 n/a n/a n/a n/a 

Total 50 692 98 95 99 439 

4.2.2 Trained personnel 

In the 2016 Senegal Continuous DHS, 26% of children with a recent fever for whom treatment was sought 

had blood taken from a finger or heel, presumably for malaria testing (Table 13). Disaggregating by facility 

type, 36% of children who visited a government health hut, 34% of children who went to a government 

hospital or health center, 29% of children who went to a government health post, and 11% who went to a 

private facility had blood taken from a finger or heel for testing. The percentage of children who went to a 

source not sampled in the SPA had blood taken from a finger or heel for testing is not shown due to the low 

number of children who visited another type of provider. 

The 2016 Senegal Continuous SPA found that 65% of facilities had at least one person trained in mRDT, 

88% in microscopy, 63% in case management and treatment of malaria in children, and 88% trained in 

mRDT, microscopy, or case management and treatment of malaria in children (Table 13). By facility type, 

the percentage of facilities with at least one person trained in mRDT ranges from 80% of government health 

posts or mobile clinics to 36% of the private facilities. Having at least one person trained in microscopy 
38 

ranges from 96% in government health posts or mobile clinics to 64% in private clinics. Similarly, the 

percentage of facilities with at least one staff member trained in case management and treatment of malaria 

in children ranges from 79% of government health posts or mobile clinics to 34% of health huts. The 

composite indicator that examines personnel trained in mRDT, microscopy, or case management and 

treatment of malaria in children ranges from 96% in government health posts or mobile clinics to 64% in 

the private facilities (Table 13). 

A comparison of diagnostic testing data from the DHS and malaria training of personnel by facility type 

from the SPA shows that 36% of children in Senegal who went to a government health hut had blood taken 

from a finger or heel for testing while 84% of government health huts had at least one person trained in 

mRDT, microscopy, or case management and treatment of malaria in children (Figure 8). Ninety-six percent 

of government health posts or mobile clinics had at least one individual trained in mRDT, microscopy, or 

case management and treatment of malaria in children, while only 29% of children who sought care at 

government health post had blood taken from a finger or heel for testing. A scatterplot of the percentage of 

febrile children who had blood taken from a finger or heel for testing and percentage of facilities with 

personnel trained in mRDT, microscopy, or case management and treatment of malaria in children by 

facility type shows a positive association between the two measures with an R2

 of 0.61 (Figure 8). 

Table 13 Diagnosis of fever and malaria training of personnel by facilities in Senegal

2016 Senegal Continuous 

DHS 2016 Senegal Continuous SPA

Percentage 

who had 

blood taken 

from a 

finger or 

heel for 

testing 

Number of 

children 

under age 5 

with a fever 

who sought 

treatment 

 Among facilities offering malaria diagnosis/treatment services or curative sick child care 

services 

Facility type 

Personnel 

trained in 

mRDT 

Personnel 

trained in 

microscopy 

Personnel 

trained in 

case 

management 

and 

treatment of 

malaria in 

children 

Personnel trained 

in mRDT, 

microscopy, 

or case 

management/treat

ment of malaria in 

children 

Total number of 

facilities 

Government 

hospital 34 32 62 86 63 86 29 

Government 

health post or 

mobile clinic 

29 223 80 96 79 96 252 

Government 

health hut 36 23 42 84 34 84 85 

Private facility 11 60 36 64 36 64 70 

Any other 

source * 10 n/a n/a n/a n/a n/a 

Total 26 345 65 88 63 88 436 

Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 
39 

Figure 8 Diagnosis of fever by malaria training of personnel in Senegal

4.2.3 National guidelines 

In the 2016 Senegal Continuous SPA, 87% of facilities had national guidelines for the diagnosis and 

treatment of malaria, and 82% of facilities had a malaria mRDT protocol available. By facility type, the 

percentage of facilities with national guidelines for diagnosis and treatment of malaria ranged from 94% at 

government health post or mobile clinics to 72% at private facilities. Facilities with a malaria mRDT 

protocol ranged from 93% of government hospitals or health centers to 61% of government health posts 

(Table 14). 

Comparing diagnostic testing of children from the DHS and availability of national malaria guidelines or a 

mRDT protocol by facility type in Senegal from the SPA, 36% of febrile children taken to a government 

health hut had blood taken from a finger or heel for testing, although only 76% of government health huts 

had national guidelines for diagnosis and treatment of malaria and 61% had malaria RDT protocol. The 

coefficient of determination (R2

) of percentage of febrile children who had blood taken from a finger or 

heel for testing and percentage of facilities that had national guidelines for diagnosis and treatment of 

malaria by facility type shows a weak positive association between the two measures with an R2

 of 0.25 

(Figure 9). Similarly, the percentage of children who had blood taken from a finger or heel for testing and 

percentage of facilities with malaria RDT protocol by facility type shows a weak positive association 

between the two measures with an R2

 of 0.04 (Figure 10). 

 

Government hospital or health center

Government health post or 

mobile clinic

Government 

health hut

Private facility

R2 = 0.6086

0

10

20

30

40

50

60

70

80

90

100

0 10 20 30 40 50 60 70 80 90 100

Percentage of personnel trained in mRDT, microscopy, or case 

management/treatment of malaria in children

Percentage of children under age 5 with fever who sought advice or treatment

who had blood taken from a finger or heel for testing
40 

Table 14 Diagnosis of fever and availability of national malaria guidelines/protocol by facilities in Senegal

2016 Senegal Continuous DHS 2016 Senegal Continuous SPA

Percentage who had blood 

taken from a finger or heel 

for testing 

Number of children under 

age 5 with a fever who 

sought treatment 

Among facilities offering malaria diagnosis/treatment 

services or curative sick child care services 

Facility type 

National guidelines 

for diagnosis and 

treatment of malaria 

Malaria 

mRDT 

Protocol 

Total 

number of 

facilities 

Government 

hospital or health 

center 

34 32 91 93 29 

Government health 

post or mobile 

clinic 

39 223 94 91 252 

Government health 

hut 36 23 76 61 85 

Private facility 11 60 72 69 70 

Any other source * 10 n/a n/a n/a 

Total 26 345 87 82 436 

Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 

Figure 9 Diagnosis of fever by availability of national malaria guidelines for diagnosis/treatment in 

Senegal

Government hospital 

or health center Government health 

post or mobile clinic

Government health 

hut Private facility

R2 = 0.2479

0

10

20

30

40

50

60

70

80

90

100

0 10 20 30 40 50 60 70 80 90 100

Percentage of facilities with guidelines for diagnosis and/or 

treatment of malaria

Percentage of children under age 5 with fever who sought advice or treatment

who had blood taken from a finger or heel for testing
41 

Figure 10 Diagnosis of fever by availability of malaria RDT protocol in Senegal

4.2.4 Supplies 

In Senegal, 90% of facilities had mRDT supplies, 10% had malaria microscopy supplies, and 91% had any 

malaria diagnostic supplies (mRDT and/or microscopy) (Table 15). By facility type, the percentage of 

facilities with malaria mRDT supplies ranges from 98% in government hospital, health centers, health posts, 

or mobile clinics to 75% in government health huts and private facilities. The percentage of facilities with 

malaria microscopy supplies ranges from 81% of government hospitals or health centers to 0% of 

government health huts. The percentage of facilities with any malaria diagnostic supplies ranges from 98% 

of government hospitals and faith-based facilities, to 100% of government hospitals or health centers to 

75% of government health huts (Table 15). 

In comparisons of diagnostic testing and availability of malaria diagnostic supplies by facility type in 

Senegal, 36% of children who went to a government health hut had blood taken from a finger or heel for 

testing. Among the government health huts, 75% had adequate mRDT supplies while none had adequate 

microscopy supplies. Government hospitals, health centers, health posts, or mobile clinics had a very high 

percentage of facilities with an availability of diagnostic supplies, although few children had blood taken 

from a finger or heel for testing when going to these facilities. In Senegal there is a weak association 

(R2

=0.1) between diagnostic testing among febrile children seeking treatment at specific facility types and 

malaria diagnostic supplies available at the facility type (Figure 11). 

Government hospital

Government health 

center

Government 

clinic/dispensary

Private facility

R2 = 0.0421

0

10

20

30

40

50

60

70

80

90

100

0 10 20 30 40 50 60 70 80 90 100

Percentage of facilities with RDT protocol

Percentage of children under age 5 with fever who sought advice or treatment

who had blood taken from a finger or heel for testing
42 

Table 15 Diagnosis of fever and availability of malaria diagnostic supplies by facilities in Senegal

2016 Senegal Continuous 

DHS 2016 Senegal Continuous SPA

Percentage 

who had 

blood taken 

from a 

finger or 

heel for 

testing 

Number of 

children under 

age 5 with a 

fever who 

sought 

treatment 

Among facilities offering malaria diagnosis/treatment services or curative sick 

child care services 

Facility type 

Malaria 

mRDT 

supplies 

Malaria 

microscopy 

supplies 

Any malaria 

diagnostic 

supplies 

Total number of facilities 

Government hospital 

or health center 34 32 98 81 100 29 

Government health 

post or mobile clinic 39 223 98 3 98 252 

Government health 

hut 36 23 75 0 75 85 

Private facility 11 60 75 27 78 70 

Any other source * 10 n/a n/a n/a n/a 

Total 26 345 90 10 91 436 

Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 

Figure 11 Diagnosis of fever by availability of malaria diagnostic supplies in Senegal

4.2.5 Diagnostic capacity 

In Senegal, 9% of facilities had microscopy diagnostic capacity, 56% had mRDT diagnostic capacity, and 

60% had malaria diagnostic capacity (microscopy diagnostic capacity and mRDT diagnostic capacity) 

(Table 16). By facility type, microscopy diagnostic capacity ranges from 74% of government hospitals and 

Government hospital Government health 

center

Government health 

post or mobile clinic

Private facility

R2 = 0.0985

0

10

20

30

40

50

60

70

80

90

100

0 10 20 30 40 50 60 70 80 90 100

Percentage of facilities with any malaria diagnostic supplies

Percentage of children under age 5 with fever who sought advice or treatment

who had blood taken from a finger or heel for testing
43 

health centers to 0% of government health huts. The mRDT diagnostic capacity ranges from 73% of 

government health posts or mobile clinics to 28% of government health huts and private facilities. Overall 

diagnostic capacity by facility ranges from 82% of government hospitals and health centers to 28% of 

government health huts (Table 16). 

When comparing the diagnosis of fever and malaria diagnostic capacity by facility type in Senegal, 36% of 

children who went to a government health hut had blood taken from a finger or heel for testing, although 

only 28% of government health huts have full diagnostic capacity. Among children for whom treatment 

was sought at government hospitals or health centers, 34% had blood taken from a finger or heel for testing 

Government hospitals or health centers also had a high percentage of facilities with both microscopy (74%) 

and mRDT diagnostic capacity (60%). All facilities (except government hospitals or health centers) had 

higher mRDT diagnostic capacity than microscopy diagnostic capacity. There is a weak positive association 

(R2

=0.04) between diagnostic testing among febrile children seeking treatment at specific facility types and 

facilities with diagnostic capacity (Figure 12). 

Table 16 Diagnosis of fever and malaria diagnostic capacity by facilities in Senegal

2016 Senegal Continuous DHS 2016 Senegal Continuous DHS

Percentage 

who had 

blood taken 

from a finger 

or heel for 

testing 

Number of 

children under 

age 5 with a 

fever who 

sought 

treatment 

Among facilities offering malaria diagnosis/treatment services or curative 

sick child care services 

Facility type 

Microscopy 

diagnostic 

capacity 

mRDT 

diagnostic 

capacity 

Diagnostic 

capacity 

Total number of 

facilities 

Government hospital 

or health center 34 32 74 60 82 29 

Government health 

post or mobile clinic 39 223 1 73 74 252 

Government health hut 36 23 0 28 28 85 

Private facility 11 60 20 28 42 70 

Any other source * 10 n/a n/a n/a n/a 

Total 26 345 9 56 60 436 

Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 
44 

Figure 12 Diagnosis of fever by malaria diagnostic capacity in Senegal

4.2.6 ACT availability 

Among children under age 5 with a fever who sought treatment and took an antimalarial drug, 30% of 

children received an ACT. The percentage of children who received an injectable artesunate, artesunate 

suppository, oral quinine, and injectable quinine are not shown due to fewer than 25 unweighted cases of 

children who attended the specific health facilities among children with fever who took an antimalarial 

drug. 

In examining the 2016 Senegal Continuous SPA, 69% of facilities had an ACT drug in stock on the day of 

the survey (Table 17). This means that the ACT drug was observed in the health facility, and there was at 

least one valid dose available at the day of the interview. By facility type, 96% of government health posts 

or mobile clinics, and 90% of government hospitals or health centers had ACTs available in stock. However, 

only 63% of government health huts and 48% of private facilities had ACTs available in stock. In Senegal, 

66% of facilities had injectable quinine available on the day of the survey. Less common drugs available 

included oral quinine and injectable artesunate (1%) (Table 17). 

Due to low numbers of children with fever who sought treatment and took an antimalarial drug, it is not 

possible to compare the type of antimalarial drug used and the availability of antimalarial drugs by facilities 

in Senegal. 

Government hospital or health center Government health 

post or mobile 

clinic

Government health hut

Private facility

R2 = 0.0395

0

10

20

30

40

50

60

70

80

90

100

0 10 20 30 40 50 60 70 80 90 100

Percentage of facilities with diagnostic capacity

Percentage of children under age 5 with fever who sought advice or treatment

who had blood taken from a finger or heel for testing
45 

Table 17 Type of antimalarial drug used and availability of antimalarial drugs by facilities in Senegal

2016 Senegal Continuous DHS 2016 Senegal Continuous SPA

Among facilities offering malaria diagnosis/treatment services or curative sick 

child care services 

Facility type ACT Injectable artesunate Artesunate suppository (rectal) Oral quinine Injectable quinine 

Number of 

children with 

fever who 

took an 

antimalarial 

drugs 

Any 

ACT 

Injectable 

artesunate 

Artesunate 

suppository 

(rectal) 

Oral 

quinine 

Injectable 

quinine 

Total number of 

facilities 

Government hospital or health center 

* * * * * 5 90 5 0 5 91 29 

Government health post or mobile clinic 

* * * * * 18 96 1 0 1 88 252 

Government health hut * * * * * 1 63 0 0 0 0 85 

Private facility * * * * * 9 48 2 0 0 54 70 

Any other source * * * * * 0 n/a n/a n/a n/a n/a n/a 

Total 30 0 0 0 0 33 69 1 0 1 66 435 

Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 
46 

4.2.7 Service readiness 

Components of the malaria service readiness index include the facilities having personnel trained in mRDT, 

microscopy, or case management and treatment of malaria in children, national guidelines for diagnosis and 

treatment, proper supplies to diagnosis malaria, and ACTs available on site. Among facilities in Malawi that 

offer malaria diagnosis/treatment services or curative care for sick children, 49% have all the components 

to be considered malaria service ready (Table 18). By facility type, the percentage of facilities considered 

malaria service ready ranges from 77% of government hospitals or health centers to 21% of government 

health huts. Across all facilities, the lowest component of the malaria service readiness index was the 

diagnostic capacity. 

Comparing the source of advice or treatment for children with fever to the components of the malaria 

service readiness index, 32% of children with a fever were taken to a government health post or mobile 

clinic, although only 69% of government health centers are considered malaria service ready. Among 

government health posts or mobile clinics, 96% have ACTs available and personnel trained in mRDT, 

microscopy, or case management and treatment of malaria in children in the past 24 months, and 94% have 

national guidelines for diagnosis and treatment of malaria. Although the government health posts or mobile 

clinics in Senegal are performing poorly, only 74% of facilities have diagnostic capacity. Among 

government hospitals or health centers, 77% are malaria service ready, but only 5% of children are seeking 

care at a government hospital or health center for fever. 

Table 18 Source of advice or treatment for children with fever and components of malaria service 

readiness by facilities in Senegal

2016 Senegal 

Continuous DHS 2016 Senegal Continuous SPA

Percentage 

for whom 

advice or 

treatment 

was 

sought 

Number 

of 

children 

under age 

5 with a 

fever

Among facilities offering malaria diagnosis/treatment services or curative sick child 

care services 

Facility type 

 Personnel 

trained in 

mRDT, 

microscopy, 

or case 

management 

and 

treatment of 

malaria in 

children 

National 

guidelines 

for 

diagnosis/tr

eatment of 

malaria 

Diagnostic 

capacity 

ACTs 

available 

Malaria 

service 

readiness 

index 

Total number 

of facilities 

Government 

hospital or health 

center 

5 692 86 91 82 90 77 29 

Government 

health post or 

mobile clinic 

32 692 96 94 74 96 69 252 

Government 

health hut 3 692 84 76 28 63 21 85 

Private facility 9 692 64 72 42 48 26 70 

Any other source 3 692 n/a n/a n/a n/a n/a n/a 

Total 50 692 88 87 60 69 49 436 

4.2.8 Malaria endemicity 

To explore if malaria service readiness varies by level of malaria transmission, the components of malaria 

service readiness were examined by endemicity level in Senegal. Facilities were stratified into two equal 

frequency groups (lower and higher malaria risk categories). The lower malaria risk category for Senegal 
47 

included facilities with a PfPR≤ 2.4% and those with a higher malaria risk had a PfPR≥2.5%. Across all 

components of malaria service readiness (trained personnel, guidelines, diagnostic capacity, and availability 

of ACTs), malaria service readiness components are slightly higher in areas of lower malaria transmission 

as compared to the higher malaria transmission areas. When examining malaria service readiness by 

facilities and malaria endemicity, government hospitals, health centers, and health huts had a higher malaria 

service readiness in locations with higher malaria endemicity, while only private facilities had higher 

malaria service readiness in locations with lower malaria endemicity (Table 19). 

Table 19 Malaria service readiness by malaria endemicity and facility in Senegal

 2016 Senegal Continuous SPA

Facility type 

 Personnel 

trained in 

mRDT, 

microscopy, or 

case 

management 

and treatment 

of malaria in 

children 

National 

guidelines 

for diagnosis 

and 

treatment of 

malaria 

Diagnostic 

capacity 

ACTs 

available 

Malaria 

service 

readiness 

index 

Total number of facilities 

offering malaria 

diagnosis/treatment 

services or curative sick 

child care services 

Government 

hospital 

PfPR≤ 2.4% 83 89 77 92 71 16 

PfPR≥2.5% 90 94 87 87 84 13 

Government 

health center 

PfPR≤ 2.4% 96 94 74 94 68 134 

PfPR≥2.5% 97 94 73 98 70 118 

Government 

health hut 

PfPR≤ 2.4% 80 74 23 69 19 41 

PfPR≥2.5% 88 77 32 57 22 45 

Private facility 

PfPR≤ 2.4% 80 77 45 64 35 28 

PfPR≥2.5% 54 68 39 38 20 42 

Total 

PfPR≤ 2.4% 90 88 61 85 55 219 

PfPR≥2.5% 86 86 59 78 52 217 

4.3 Tanzania 

4.3.1 Service availability 

In the 2015-16 Tanzania DHS-MIS, advice or treatment was sought for 81% of the children with fever in 

the 2 weeks before the survey (Table 20). Among children with recent fever for whom care was sought, 

41% received advice or treatment from a formal health provider. Among febrile children seeking advice or 

treatment, 19% were taken to a government clinic or dispensary, 8% to a private facility, 6% to a government 

health center, 4% to a government hospital, and 4% to a mission or faith-based facility. The majority (54%) 

of children who sought advice or treatment were taken to a non-health facility provider such as an ADDO 

or a pharmacy (Table 20). 
48 

In the 2014-15 Tanzania SPA, 99% of facilities in Tanzania offered malaria diagnosis/treatment services or 

curative care for sick children. Among the facilities sampled, 100% of government health centers, 

government clinic or dispensaries, and mission or faith-based facilities, 99% of government hospitals, and 

96% of private facilities offered malaria diagnosis/treatment services or curative care for sick children 

(Table 20). 

Comparison DHS data on the source of advice or treatment for children with fever with SPA data on 

availability of malaria services by facility type in Tanzania shows that government clinic or dispensaries 

had the highest utilization for seeking advice or treatment for fever in Tanzania (19%), and that 100% of 

these same government clinic or dispensaries offer malaria diagnosis/treatment services or curative care for 

sick children (Table 20). 

Table 20 Source of advice or treatment for children with fever and availability of malaria services by 

facilities in Tanzania

2015-16 Tanzania DHS-MIS 2014-15 Tanzania SPA

Facility type 

Percentage for 

whom advice or 

treatment was 

sought 

Number of children 

under age 5 with a 

fever 

Facilities 

offering malaria 

diagnosis/treat

ment services 

Facilities 

offering 

curative 

care for 

sick 

children 

Facilities offering 

malaria 

diagnosis/treatment 

services or curative 

care for sick 

children 

Total 

number 

of 

facilities 

Government 

hospital 4 1,706 99 98 99 25 

Government health 

center 6 1,706 100 100 100 88 

Government 

clinic/dispensary 19 1,706 100 99 100 764 

Private facility 8 1,706 96 91 96 162 

Mission/faith-based 4 1,706 100 97 100 148 

Any other source 54 1,706 n/a n/a n/a n/a 

Total 81 1,706 99 98 99 1,187 

4.3.2 Trained personnel 

In the 2015-16 Tanzania DHS-MIS, 42% of children with a recent fever for whom treatment was sought 

had blood taken from a finger or heel, presumably for malaria testing (Table 21). Disaggregating by facility 

type, blood from a finger was taken from 80% of children who went to a faith-based organization, 79% of 

children in a private facility, 73% of children in a government hospital, 62% in a government health center, 

and 54% in a government clinic or dispensary. Only 25% of children who went to an informal source not 

sampled in the SPA survey had blood taken from a finger or heel for testing. 

The 2014-15 Tanzania SPA found that 40% of facilities had at least one personnel trained in mRDT, 36% 

in microscopy, and 47% in mRDT, microscopy, and case management and treatment of malaria in children 

(Table 21). By facility type, the percentage of facilities with at least one personnel trained in mRDT ranges 

from 66% of government health centers to 26% of private facilities. At least one personnel trained in 

microscopy ranges from 66% of government health centers to 25% of private facilities. Similarly, the 

percentage of facilities with staff trained in case management and treatment of malaria in children ranges 

from 64% of government health centers to 24% of private facilities. The composite indicator that examined 

at least one personnel trained in mRDT, microscopy, and case management and treatment of malaria in 

children ranges from 74% of government health centers to 27% of private facilities (Table 21). 
49 

A comparison of diagnostic testing data from the DHS and malaria training of personnel by facility type 

from the SPA shows that 73% of children in Tanzania who went to a government hospital had blood taken 

from a finger or heel for testing, while 67% of government hospitals had at least one personnel trained in 

mRDT, microscopy, or case management and treatment of malaria in children (Figure 13). Faith-based 

facilities had the highest percentage of children who had blood taken from a finger or heel for testing (80%), 

although only slightly less than half of the facilities (47%) had at least one personnel trained in mRDT, 

microscopy, or case management and treatment of malaria in children (Figure 13). A scatterplot of children 

who had blood taken from a finger or heel for testing and personnel trained in mRDT, microscopy, or case 

management/treatment of malaria in children by facility type shows a weak negative association between 

the two measures with an R2

 of 0.14 (Figure 13). 

Table 21 Diagnosis of fever and malaria training of personnel by facilities in Tanzania

2015-16 Tanzania DHSMIS 2014-15 Tanzania SPA

Percentage 

who had 

blood taken 

from a 

finger or 

heel for 

testing

Number of 

children 

under age 5 

with a fever 

who sought 

treatment

Among facilities offering malaria diagnosis/treatment services or curative sick child care 

services 

Facility type 

Personnel 

trained in 

mRDT 

Personnel 

trained in 

microscopy 

Personnel 

trained in 

case 

management 

and 

treatment of 

malaria in 

children 

Personnel trained 

in mRDT, 

microscopy, or 

case management 

and treatment of 

malaria in children 

Total number of 

facilities 

Government 

hospital 73 61 56 62 59 67 24 

Government 

health center 62 95 66 66 64 74 88 

Government 

clinic/ 

dispensary 

54 312 41 34 34 47 761 

Private facility 79 130 26 25 24 27 156 

Mission/faithbased 80 64 36 38 39 48 147 

Any other 

source 25 738 n/a n/a n/a n/a n/a 

Total 42 1,385 40 36 36 47 1,177 
50 

Figure 13 Diagnosis of fever by malaria training of personnel in Tanzania

4.3.3 National guidelines 

In the 2014-15 Tanzania SPA, 62% of facilities had national guidelines for diagnosis and treatment of 

malaria and 64% of facilities had a malaria mRDT protocol available. By facility type, the percentage of 

facilities with national guidelines for diagnosis and treatment of malaria ranged from 65% of government 

clinics or dispensaries to 43% of private facilities. Facilities with a malaria mRDT protocol ranged from 

90% of government hospitals to 54% of mission or faith-based facilities (Table 22). 

In a comparison of diagnostic testing of children from the DHS and the availability of national malaria 

guidelines and an mRDT protocol by facility type in Tanzania from the SPA, 80% of children who went to 

a mission or faith-based facility had blood taken from a finger or heel for testing, while only 60% of mission 

or faith-based facilities had national guidelines for the diagnosis and treatment of malaria and 54% had an 

mRDT protocol. The coefficient of determination (R2

) of the percentage of febrile children who had blood 

taken from a finger or heel for testing and the percentage of facilities that had national guidelines for 

diagnosis and treatment of malaria by facility type shows a moderate negative association between the two 

measures with an R2

 of 0.45 (Figure 14). Similarly, children who had blood taken from a finger or heel for 

testing and mRDT protocol by facility type shows a weak negative association between the two measures 

with an R2

 of 0.11 (Figure 15). 

Government hospital

Government health 

center

Government clinic/

dispensary

Private facility

Mission/faith-based

R2 = 0.1364

0

10

20

30

40

50

60

70

80

90

100

0 10 20 30 40 50 60 70 80 90 100

Percentage of personnel trained in mRDT, microscopy, or case 

management/treatment of malaria in children

Percentage of children under age 5 with fever who sought advice or treatment

who had blood taken from a finger or heel for testing
51 

Table 22 Diagnosis of fever and availability of national malaria guidelines/protocol by facilities in 

Tanzania

2015-16 Tanzania DHS-MIS 2014-15 Tanzania SPA

Percentage who had 

blood taken from a 

finger or heel for 

testing

Number of 

children under 

age 5 with a 

fever who sought 

treatment

Among facilities offering malaria diagnosis/treatment services or 

curative sick child care services

Facility type 

National guidelines 

for diagnosis and 

treatment of malaria 

Malaria 

mRDT 

Protocol 

Total number of facilities 

Government 

hospital 73 61 48 90 24 

Government 

health center 62 95 61 80 88 

Government 

clinic/dispensary 54 312 65 65 761 

Private facility 79 130 43 55 156 

Mission/faithbased 80 64 60 54 147 

Any other source 25 738 n/a n/a n/a 

Total 42 1,385 62 64 1,177 

Figure 14 Diagnosis of fever by availability of national malaria guidelines for diagnosis/treatment in 

Tanzania

Government hospital

Government health 

center

Government clinic/dispensary

Private facility

Mission/faith-based

R2 = 0.446

0

10

20

30

40

50

60

70

80

90

100

0 10 20 30 40 50 60 70 80 90 100

Guidelines for diagnosis and treatment of malaria

Percentage of children under age 5 with fever who sought advice or treatment

who had blood taken from a finger or heel for testing
52 

Figure 15 Diagnosis of fever by availability of malaria RDT protocol in Tanzania

4.3.4 Supplies 

In Tanzania, 81% of facilities had mRDT supplies, 17% had malaria microscopy supplies, and 84% had any 

malaria diagnostic supplies (mRDT and/or microscopy) (Table 23). By facility type, the percentage of 

facilities with mRDT supplies ranges from 94% for government hospitals to 63% for the private facilities. 

The percentage of facilities with malaria microscopy supplies ranges from 55% of government hospitals to 

5% of government clinics or dispensaries. The percentage of facilities with any malaria diagnostic supplies 

ranges from 99% of government hospitals to 100% of government hospitals and 74% of private facilities 

(Table 23). 

Comparing diagnostic testing and availability of malaria diagnostic supplies by facility type in Tanzania, 

80% of children who went to a mission or faith-based facility had blood taken from a finger or heel for 

testing. Among the mission or faith-based facilities, 72% had adequate mRDT supplies, while 38% had 

adequate microscopy supplies. Government hospitals had a very high percentage of facilities with an 

availability of diagnostic supplies, although a smaller percentage of children had blood taken from a finger 

or heel for testing when being seen at these facilities. In Tanzania, there is a weak negative association 

(R2

=0.11) between diagnostic testing among febrile children seeking treatment at specific facility types and 

the malaria diagnostic supplies available at the facility type (Figure 16). 

Government hospital

Government health 

center

Government 

clinic/dispensary

Private facility

Mission/faith-based

R2 = 0.1088

0

10

20

30

40

50

60

70

80

90

100

0 10 20 30 40 50 60 70 80 90 100

Percentage of facilities with malaria RDT protocol

Percentage of children under age 5 with fever who sought advice or treatment

who had blood taken from a finger or heel for testing
53 

Table 23 Diagnosis of fever and availability of malaria diagnostic supplies by facilities in Tanzania

2015-16 Tanzania DHS-MIS 2014-15 Tanzania SPA

Percentage 

who had 

blood taken 

from a 

finger or 

heel for 

testing 

Number of 

children under 

age 5 with a 

fever who 

sought 

treatment 

Among facilities offering malaria diagnosis/treatment services or curative sick 

child care services 

Facility type 

Malaria 

mRDT 

supplies 

Malaria 

microscopy 

supplies 

Any malaria 

diagnostic 

supplies 

Total number of facilities 

Government hospital 73 61 94 55 99 24 

Government health 

center 62 95 93 45 96 88 

Government 

clinic/dispensary 54 312 84 5 84 761 

Private facility 79 130 63 38 74 156 

Mission/faith-based 80 64 72 39 82 147 

Any other source 25 738 n/a n/a n/a n/a 

Total 42 1,385 81 17 84 1,177 

Figure 16 Diagnosis of fever by availability of malaria diagnostic supplies in Tanzania

4.3.5 Diagnostic capacity 

In Tanzania, 7% of facilities had microscopy diagnostic capacity, 26% had mRDT diagnostic capacity, and 

28% had malaria diagnostic capacity (microscopy diagnostic capacity and mRDT diagnostic capacity) 

(Table 24). By facility type, microscopy diagnostic capacity ranges from 43% of government hospitals to 

Government health center Government hospital

Government 

clinic/dispensary

Private facility

Mission/faith-based

R2 = 0.106

0

10

20

30

40

50

60

70

80

90

100

0 10 20 30 40 50 60 70 80 90 100

Percentage of facilities with any malaria diagnostic supplies

Percentage of children under age 5 with fever who sought advice or treatment

who had blood taken from a finger or heel for testing
54 

1% of government clinics or dispensaries. The percentage of facilities that have mRDT diagnostic capacity 

ranges from 51% of government hospitals to 17% of the mission or faith-based facilities. Overall diagnostic 

capacity by facility ranges from 62% of government hospitals to 21% of private facilities and mission or 

faith-based facilities (Table 24). 

When comparing diagnosis of fever and malaria diagnostic capacity by facilities in Tanzania, 80% of 

children who went to a mission or faith-based facility had blood taken from a finger or heel for testing, 

while only 21% of mission or faith-based facilities have full diagnostic capacity. Among children for whom 

treatment was sought at government hospitals, 73% had blood taken from a finger or heel for testing. 

Government hospitals also had the highest percentage of facilities with both microscopy (43%) and mRDT 

diagnostic capacity (51%). All facilities had higher mRDT diagnostic capacity than microscopy diagnostic 

capacity. There is a weak negative association (R2

=0.06) with diagnostic testing among febrile children 

seeking treatment at specific facility types and facilities with diagnostic capacity (Figure 17). 

Table 24 Diagnosis of fever and malaria diagnostic capacity by facilities in Tanzania

2015-16 Tanzania DHS-MIS 2014-15 Tanzania SPA

Percentage 

who had 

blood taken 

from a finger 

or heel for 

testing 

Number of 

children under 

age 5 with a 

fever who 

sought 

treatment 

Among facilities offering malaria diagnosis/treatment services or curative 

sick child care services 

Facility type 

Microscopy 

Diagnostic 

capacity 

mRDT 

Diagnostic 

capacity 

Diagnostic 

capacity 

Total number of 

facilities 

Government hospital 73 61 43 51 62 24 

Government health 

center 62 95 33 50 57 88 

Government 

clinic/dispensary 54 312 1 26 27 761 

Private facility 79 130 8 18 21 156 

Mission/faith-based 80 64 13 17 21 147 

Any other source 25 738 n/a n/a n/a n/a 

Total 42 1,385 7 26 28 1,177 
55 

Figure 17 Diagnosis of fever by malaria diagnostic capacity in Tanzania

4.3.6 ACT availability 

Among children under age 5 with a fever who sought treatment and took an antimalarial drug, 85% of 

children received an ACT. By facility type, receipt of ACT varies from 96% of children for whom treatment 

was sought and an antimalarial was prescribed at a government clinic or dispensary, 84% at a non-health 

facility, 81% at government health centers, 80% at a government hospital, 75% at a private facility, and 

75% at a mission or faith-based facility. 

In examining the 2014-15 Tanzania SPA, 90% of facilities had an ACT drug in stock on the day of the 

survey (Table 25). This means that the ACT drug was observed in the health facility, and there was at least 

one valid dose available on the day of the interview. By facility type, 94% of government health centers, 

94% of government dispensaries, and 91% of government hospitals had ACTs available in stock. However, 

only 84% of mission or faith-based facilities and 74% of private facilities organizations had ACTs available 

in stock. In Tanzania, 80% of facilities had injectable quinine available on the day of the survey, while 67% 

of facilities had oral quinine. Less common drugs available included injectable artesunate (27% of facilities) 

and artesunate suppository (2%) (Table 25). 

When comparing the type of antimalarial drug used and the availability of antimalarial drugs by facilities 

in Tanzania, more than 96% of children who visited a government clinic or dispensary with a fever received 

an ACT. This concurs with the data from the facility level in that greater than 94% of government clinics 

or dispensaries had availability of ACTs on the day of the survey. 

Government hospital Government health 

center

Government 

clinic/dispensary Private facility

Mission/faith-based

R2 = 0.0609

0

10

20

30

40

50

60

70

80

90

100

0 10 20 30 40 50 60 70 80 90 100

Percentage of facilities with diagnostic capacity

Percentage of children under age 5 with fever who sought advice or treatment

who had blood taken from a finger or heel for testing
56 

Table 25 Type of antimalarial drug used and availability of antimalarial drugs by facilities in Tanzania

2015-16 Tanzania DHS-MIS 2014-15 Tanzania SPA

Among facilities offering malaria diagnosis/treatment services or curative sick 

child care services

Facility type ACT Injectable artesunate Artesunate suppository (rectal) Oral quinine Injectable quinine 

Number of 

children 

with fever 

who took 

an 

antimalarial 

drugs 

Any 

ACT 

Injectable 

artesunate 

Artesunate 

suppository 

(rectal) 

Oral 

quinine 

Injectable 

quinine 

Total number of 

facilities 

Government hospital 80 2 0 4 7 38 91 52 2 73 88 24 Government health center 81 0 0 11 12 58 94 45 3 66 83 88 Government clinic/dispensary 96 0 0 0 2 194 94 24 1 70 83 761 Private facility 75 7 0 2 5 73 74 34 5 52 67 156 Mission/faithbased 75 0 0 7 13 43 84 25 4 64 77 147 Any other source 84 0 0 5 1 447 n/a n/a n/a n/a n/a n/a 

Total 85 1 0 4 3 811 90 27 2 67 80 1,177 
57 

4.3.7 Service readiness 

Components of the malaria service readiness index include the facilities having personnel trained in mRDT, 

microscopy, or case management and treatment of malaria in children, national guidelines for diagnosis and 

treatment, proper supplies to diagnosis malaria, and ACTs available on site. Among facilities in Tanzania 

that offer malaria diagnosis/treatment services or curative care for sick children, 18% have all the 

components to be considered malaria service ready (Table 26). By facility type, the percentage of facilities 

that are considered malaria service ready ranges from 35% of government health centers to 11% of private 

facilities. Across all facilities (except government hospitals), the lowest component of the malaria service 

readiness index that was diagnostic capacity. 

Comparing the source of advice or treatment for children with fever to the components of the malaria 

service readiness index, 19% of children with a fever were taken to a government clinic or dispensary, 

although only 19% of government clinics or dispensaries are considered malaria service ready. Among 

government clinics or dispensaries, 94% have ACTs available and 65% have national guidelines for 

diagnosis and treatment of malaria, two components of service readiness. At the government health centers 

in Tanzania that are performing poorly, only 47% of facilities have personnel trained in mRDT, microscopy, 

or case management and treatment of malaria in children, and 27% have diagnostic capacity. In Tanzania, 

35% of government health centers are malaria service ready, but only 6% of children seek care at a 

government health centers for fever. 

Table 26 Source of advice or treatment for children with fever and components of malaria service 

readiness by facilities in Tanzania

2015-16 Tanzania 

DHS-MIS 2014-15 Tanzania SPA

Percentage 

for whom 

advice or 

treatment 

was 

sought 

Number 

of 

children 

under age 

5 with a 

fever

Among facilities offering malaria diagnosis/treatment services or curative sick child 

care services

Facility type 

 Personnel 

trained in 

mRDT, 

microscopy, 

or case 

management 

and 

treatment of 

malaria in 

children 

National 

guidelines 

for 

diagnosis 

and 

treatment 

of malaria 

Diagnostic 

capacity 

ACTs 

available 

Malaria 

service 

readiness 

index 

Total number 

of facilities 

Government 

hospital 4 1,706 67 48 62 91 33 24 

Government 

health center 6 1,706 74 61 57 94 35 88 

Government 

clinic/dispensary 19 1,706 47 65 27 94 19 761 

Private facility 8 1,706 27 43 21 74 11 156 

Mission/faithbased 4 1,706 48 60 21 84 12 147 

Any other source 54 1,706 n/a n/a n/a n/a n/a n/a 

Total 81 1,706 47 61 28 90 18 1,177 

4.3.8 Malaria endemicity 

We also examined malaria service readiness by endemicity level for each type of facility. The lower malaria 

risk category for Tanzania included facilities with a PfPR≤ 5%, while facilities with a higher malaria risk 

had a PfPR≥5.1%. In general, across all components of malaria service readiness (trained personnel, 
58 

guidelines, diagnostic capacity, and available ACTs), the malaria service component is higher in areas of 

higher malaria transmission when compared to lower malaria transmission areas. When examining malaria 

service readiness by facilities and malaria endemicity, government hospitals, government health centers, 

and government clinics or dispensaries had a higher malaria service readiness in locations with higher 

malaria endemicity, while private facilities and mission or faith-based facilities had higher malaria service 

readiness in locations with lower malaria endemicity (Table 27). 

Table 27 Malaria service readiness by malaria endemicity and facility in Tanzania

 2014-15 Tanzania SPA

Facility type 

 Personnel 

trained in 

mRDT, 

microscopy, or 

case 

management/tre

atment of 

malaria in 

children 

National 

guidelines 

for diagnosis 

and 

treatment of 

malaria 

Diagnostic 

capacity 

ACTs 

available 

Malaria 

service 

readiness 

index 

Total number of facilities 

offering malaria 

diagnosis/treatment 

services or curative sick 

child care services 

Government 

hospital 

PfPR≤ 5% 70 44 63 88 28 12 

PfPR≥5.1% 63 51 61 95 39 12 

Government 

health center 

PfPR≤ 5% 79 59 62 94 34 39 

PfPR≥5.1% 69 63 54 95 37 50 

Government 

clinic/dispensary 

PfPR≤ 5% 44 63 26 95 16 312 

PfPR≥5.1% 49 67 27 94 20 449 

Private facility 

PfPR≤ 5% 30 35 25 75 11 94 

PfPR≥5.1% 24 55 14 72 10 62 

Mission/faithbased 

PfPR≤ 5% 47 73 25 74 14 69 

PfPR≥5.1% 48 49 17 93 10 78 

Total 

PfPR≤ 5% 45 58 29 88 16 526 

PfPR≥5.1% 48 63 27 92 20 651 
59 

5 DISCUSSION AND CONCLUSIONS 

To investigate the gaps between the seeking and provision of malaria services, we examined malaria service 

utilization data in children under age 5 with fever from the household-based DHS surveys and provision of 

care data from the facility-based SPA surveys from Malawi, Senegal, and Tanzania. Here we summarize 

the key results for each component of malaria service readiness by facility and malaria service readiness by 

malaria endemicity, discuss the study limitations, and provide overall conclusions. 

5.1 Key Findings of Malaria Service Readiness Components by Facility 

5.1.1 Trained personnel 

An essential component of the proper diagnosis and treatment of malaria is the adequate training of facility 

staff to provide the required services. Ongoing training for service providers ensures that providers continue 

to learn the latest information about the services they provide. The percentage of facilities with at least one 

personnel member trained in mRDT, microscopy, or case management and treatment of malaria in children 

in the 24 months before the survey ranges from 47% of all facilities in Tanzania to 88% of all facilities in 

Senegal. In all three countries, the lowest level facilities (health center/health post/health clinic) were the 

most commonly utilized facilities for advice and treatment- seeking among children with fever. In Senegal, 

96% of health centers or health post facilities had at least one personnel member trained in the diagnosis 

and treatment of malaria in children in the 24 months before the survey. However, Malawi (65%) and 

Tanzania (74%) had far fewer health centers or health post facilities with at least one person trained in 

malaria diagnosis and treatment. These findings suggest that Malawi and Tanzania should increase the 

number of malaria-specific trainings offered to personnel, especially focusing on the facilities, such as the 

government health centers, where care-seeking for children with fever is most prevalent. Although the 

personnel might have received training in the past (>24 months prior to the survey), malaria policies are 

continually changing. There can be repercussions on the quality of diagnosis and treatment in facilities that 

do not have at least one personnel member trained in updated policies. 

5.1.2 National guidelines 

National guidelines for the diagnosis and treatment of malaria are essential components of malaria care in 

the facility setting. National guidelines serve as references for health care providers on the proper diagnosis 

and treatment of malaria in their country. The percentage of facilities with national guidelines for diagnosis 

and treatment of malaria ranges from 62% of all facilities in Tanzania to 87% of all facilities in Senegal. 

When compared to other facility types, the health posts/health clinics/dispensaries in Senegal and Tanzania 

had the highest percentage of facilities with national guidelines for diagnosis and treatment of malaria. In 

Malawi, however, a higher percentage of hospitals (82%) had national guidelines available than the 

government health centers (71%). 

Similar to the percentage of facilities with at least one trained personnel member, Senegal is performing 

well with almost all health posts (94%) having national guidelines for diagnosis and treatment of malaria 

available at the facility. Unfortunately, the lack of available national guidelines is prevalent across all 

facility types in Malawi and Tanzania. The availability of national guidelines within the health facility is 

essential for staff to be knowledgeable about the guidelines for the diagnosis and treatment of malaria in 
60 

their country. It is imperative for countries to disseminate regular guidelines across all levels of the health 

facility system so that all staff are informed. In addition, across all three countries, private facilities had the 

lowest percentage of facilities with national guidelines available on the day of the interview. Since private 

facilities play a key role in the diagnosis and treatment of malaria, it is vital that they are also aware of the 

national guidelines. 

5.1.3 Diagnostic capacity 

Malaria diagnostic capacity in a facility is defined as having microscopy or mRDT capacity. The percentage 

of facilities with diagnostic capacity ranges from 28% for all facilities in Tanzania to 60% for the facilities 

in Senegal. Across the three countries, government hospitals had the highest percentage of facilities with 

diagnostic capacity. Government hospitals provide a wide array of services and are expected to have strong 

diagnostic capacity. However, most care for children is sought at government health centers/health 

posts/clinics in Malawi and Tanzania, where the diagnostic capacity of these facilities is less than 50%. In 

all three countries, the malaria service readiness indicator was most influenced by a low diagnostic capacity. 

Within the components of microscopy capacity, countries in this analysis had a low percentage of facilities 

with adequate microscopy supplies (a functioning microscope with glass slides and relevant stains). Within 

the components of mRDT capacity, countries had a low percentage of facilities with at least one personnel 

member trained in mRDT. 

Having adequate diagnostic capacity within facilities is a key component to the T3: Test, Treat, and Track

policy implemented by WHO in 2012 [34]. This policy mandates that every suspected malaria case should 

be tested, every confirmed case should be treated with a quality-assured antimalarial medicine, and the 

disease should be tracked through a timely and accurate surveillance system [34]. However, if adequate 

diagnostic supplies are not available in the facility or if personnel are not adequately trained in mRDT or 

microscopy testing, the T3 policy cannot be properly implemented. 

5.1.4 ACT availability 

The universal and continuous availability of antimalarial drugs is a critical component in the delivery of 

malaria treatment in health facilities. The percentage of facilities with unexpired ACTs available on the day 

of the survey ranges from 69% of all facilities in Senegal to 92% of all facilities in Malawi. Examination 

of the most frequently reported source for advice or treatment for fever across all three countries (health 

center or health post) showed that more than 90% of facilities had ACTs available on the day of the survey. 

This is an encouraging finding because children who are positive for malaria can be treated with ACTs 

within the facility where treatment is sought. According to the World Malaria Report, an estimated 409 

million treatment courses of artemisinin-based combination therapy (ACT) were procured by countries in 

2016, which represents an increase from 311 million in 2015 [1]. Of these procurements, 69% were reported 

in the public sector. This is evident in the results of this analysis. Regardless of the source of care, the 

majority of children who are treated with antimalarials are receiving ACTs in comparison to the less 

efficacious monotherapy antimalarial drugs, although these drugs are available in the facility. Across all 

three countries, the private facilities had the lowest percentage of facilities with ACTs available on the day 

of the survey. While many governments do not have control of the stocks of ACTs in the private facilities, 

these facilities play a crucial role in the overall health system and make a significant contribution to the 

treatment of malaria. 
61 

5.1.5 Malaria service readiness 

The malaria service readiness index is an indicator that measures the ability of a facility to provide the best 

care for the diagnosis and treatment of malaria. The facility must have personnel trained in either mRDT, 

microscopy, or case management and treatment of malaria in children, national guidelines for diagnosis and 

treatment of malaria, diagnostic capacity (microscopy or mRDT capacity), and unexpired ACTs to be 

classified as malaria service ready. The percentage of facilities classified as malaria service ready ranges 

from 49% of the facilities in Senegal to 18% of the facilities in Tanzania. Despite some countries performing 

well in the individual components of malaria service readiness, a facility must have all four required 

components to be classified as malaria service ready. Overall, among the four components of readiness, the 

diagnostic capacity is the weakest area, followed by personnel training. All three countries perform well in 

the availability of ACTs. Analysis of the most utilized provider type for malaria services revealed that in 

Senegal, 69% of health centers or health posts were classified as malaria service ready, compared with a 

much lower level in Malawi and Tanzania at 32% and 20%, respectively. Across the three countries, 

government hospitals had the highest percentage of facilities classified as malaria service ready, although 

only 10% of children under age 5 with a fever sought advice at a government hospital. 

5.2 Key Findings of Malaria Service Readiness by Endemicity 

Previous research has shown a link between health facility readiness to deliver malaria services and malaria 

endemicity [5]. To examine this relationship, we stratified each facility type by high and low endemicity 

(within the country) and compared the malaria service readiness. In general, across all three countries, there 

was higher malaria service readiness in facilities located in the higher malaria endemicity areas of the 

country. The exception was private and faith-based facilities where a higher degree of readiness was 

observed in locations with low malaria endemicity. In all three countries, the greatest difference in malaria 

service readiness by endemicity is seen in government facilities versus private or faith-based organizations. 

Government hospitals, health posts, and health huts all had higher malaria service readiness in areas of 

higher malaria endemicity. This may be due to the targeting of limited resources to facilities that have a 

higher demand for malaria services, although the private and faith-based organizations had higher malaria 

service readiness in places of lower malaria endemicity. This finding could be related to the ease of 

providing supplies to urban settings that also have lower malaria endemicity. This report did not test for 

significant differences between the endemicity of facility types, but this could be explored in an additional 

analysis. 

5.2.1 Study limitations 

One important limitation of this study is the lack of linkages between the facilities in the DHS and SPA 

surveys. Without this linkage, we do not know the service readiness of the exact facilities where the 

caregiver sought advice and treatment for their child with a fever. In this report, the SPA surveys provided 

information on the malaria service readiness of facilities, while the DHS surveys provided information on 

population-level utilization of malaria services in children under age 5 with fever. However, linking these 

two types of data sources can be challenging because the SPA and DHS are independent surveys and were 

not designed to be linked. In addition, DHS clusters are geographically displaced to protect confidentiality 

of the participants [35]. Since linkage of DHS and SPA surveys is not possible with these limitations, this 

report provides a general overview of service readiness of facilities (according to SPA surveys) by specific 

categories of facilities where caregivers sought care for children under age 5 with fever (according to the 
62 

DHS surveys). While harmonizing facility types between DHS and SPA, several types (private hospitals, 

clinics, dispensaries) are sometimes classified into one category, and this suggests that variability in service 

readiness among these facilities may exist. 

Another limitation is that the service readiness of informal health services or private health care providers 

who operate outside a formal facility are not included in this report because the SPA includes only formalsector health facilities. There is evidence of increased use of private healthcare providers and informal 

health care providers, such as pharmacies, for the disbursement of antimalarial drugs. For example, in the 

2015-16 Tanzania DHS-MIS, 54% of children who sought advice or treatment for fever were taken to a 

location categorized as an “other source.” The primary reason that smaller private providers, informal health 

care providers, or CHWs who provide iCCM, are not included in a SPA survey is the absence of an accurate 

sampling frame for these providers. Since many of these providers are not well documented or do not have 

the proper accreditation, the MoH does not have a complete listing that could serve as the basis for a 

sampling frame. In addition, including these types of health care providers in SPA surveys has the potential 

to substantially increase the cost of the survey. Nevertheless, these providers are valuable sources of 

antimalarial drugs for many individuals. 

The SPA has limits with the assessment of case management of severe malaria, because it does not provide 

a complete analysis of a facility’s ability to provide proper pre-referral treatment [29]. Although information 

is collected on availability of artesunate injections, the training of providers on the treatment of severe 

malaria is not assessed. For Tanzania and Malawi, it should also be noted that the survey periods did not 

overlap, and this limited the direct comparability of the SPA and DHS surveys. In Malawi, there was a gap 

of 20 months between the field work of the two surveys, while the surveys in Tanzania were fielded six 

months apart. 

Household survey questions and indicators are also limited. For example, the DHS survey asked questions 

about finger or heel stick, which is a proxy indicator for examination of a malaria diagnosis. In addition, 

the questions about where caregivers sought treatment and those about the drugs taken for treatment are 

multiple response questions, which means that a caregiver could have taken a child to two types of facilities 

for treatment and that both facilities would be captured in the percent distribution of sites visited for advice 

and treatment. 

Finally, there are limitations in terms of sample size. The R2 values in the analysis are limited to four or five 

data points because the facilities had to be grouped to allow for comparability between the DHS and SPA. 

In addition, with low malaria parasitemia, Senegal has very few cases of febrile children. The problem of 

small sample size emerges when the data are further stratified to examine febrile children for whom care 

was sought by health facility type. This should be noted in interpretation of the results. 

5.2.2 Conclusions 

This report investigated the gaps between the seeking and provision of malaria services through the 

examination of malaria service utilization data in children under age 5 with fever from the household-based 

DHS surveys and provision of care data from the facility-based SPA surveys from Malawi, Senegal, and 

Tanzania. By using existing data sources, we are able to further examine health system performance with 

the goal of better targeting of interventions. Further research is needed on the readiness and quality of 
63 

services provided by informal providers in settings where the informal sector is widely used for malaria 

diagnosis and treatment. 

In all three countries, the health center/health post/health clinic was the most utilized type of facility for 

care-seeking among children with fever. However, only 69% of these facilities in Senegal, 32% in Malawi, 

and 19% in Tanzania were classified as malaria service ready (Figure 18). Malaria endemicity appears to 

be a driver of service readiness of health facilities. Overall, facilities located in high endemicity areas were 

found to be better prepared to provide malaria diagnostic and treatment services. 

This report highlights the need for improving the malaria service readiness of facilities in all three countries. 

More effort should be focused on facilities that are commonly used for care, especially in the areas of 

malaria diagnostic capacity and provider training. It is essential for policy makers to consider the malaria 

service readiness of secondary health care facilities when allocating resources and trainings. This is 

particularly important in limited resource settings to ensure that the points of care that are most utilized are 

properly equipped to provide diagnosis and treatment for malaria. 
64 

Figure 18 Summary table of results 
65 

REFERENCES 

1. World Health Organization. 2017. World Malaria Report 2017. Geneva, Switzerland: World 

Health Organization. 

2. World Health Organization. 2015. Global Technical Strategy for Malaria 2016-2030. Geneva: 

Switzerland: World Health Organization. 

3. World Health Organization. 2015. Guidelines for the Treatment of Malaria. 3rd edition. Geneva, 

Switzerland: World Health Organization. 

4. Zhao, J., M. Lama, E. Korenromp, P. Aylward, E. Shargie, S. Filler, R. Komatsu, R. Atun. 2012. 

“Adoption of Rapid Diagnostic Tests for the Diagnosis of Malaria, a Preliminary Analysis of the Global 

Fund Program Data, 2005 to 2010.” PLoS One 7(8): e43549. 

https://doi.org/10.1371/journal.pone.0043549.s001. 

5. Lee, E. H., C. H. Olsen, T. Koehlmoos, P. Masuoka, A. Stewart, J. W. Bennett, and J. Mancuso. 

2017. “A Cross-sectional Study of Malaria Endemicity and Health System Readiness to Deliver Services 

in Kenya, Namibia, and Senegal.” Health Policy and Planning 32(suppl_3): iii75-iii87. 

https://doi.org/10.1093/heapol/czx114. 

6. Zurovac, D., M. Ndhlovu, N. Sipilanyambe, P. Chanda, D. H. Hamer, J. L. Simon, and R. W. 

Snow. 2007. “Paediatric Malaria Case-management with Artemether-lumefantrine in Zambia: A Repeat 

Cross-sectional Study.” Malaria Journal 6(1): 31. https://doi.org/10.1186/1475-2875-6-31. 

7. Namuyinga, R.J., D. Mwandama, D. Moyo, A. Gumbo, P. Troell, M. Kobayashi, M. Shah, et al. 

2017. “Health Worker Adherence to Malaria Treatment Guidelines at Outpatient Health Facilities in 

Southern Malawi Following Implementation of Universal Access to Diagnostic Testing.” Malaria 

Journal 16 (1): 40. https://doi.org/10.1186/s12936-017-1693-3. 

8. Rowe, A. K., G. F. Ponce de León, J. Mihigo, A. C. Santelli, N. P. Miller, P. Van-Dúnem, and J. 

Malar. 2009. “Quality of Malaria Case Management at Outpatient Health Facilities in Angola.” Malaria 

Journal 8(1): 275. http://dx.doi.org/10.1186/1475-2875-8-275. 

9. Njogu, J., W. Akhwale, D. H. Hamer, and D. Zurovac. 2008. “Health Facility and Health Worker 

Readiness to Deliver New National Treatment Policy for Malaria in Kenya.” East African Medical 

Journal 85(5): 213-221. 

10. Steinhardt, L. C., J. Chinkhumba, A. Wolkon, M. Luka, M. Luhanga, J. Sande, J. Oyugi, et al.

2014. “Quality of Malaria Case Management in Malawi: Results from a Nationally Representative Health 

Facility Survey.” PLoS One 9(2): e89050. http://doi.org/10.1371/journal.pone.0089050.

11. Abdelgader, T. M., A. M. Ibrahim, K. A. Elmardi, S. Githinji, D. Zurovac, R. W. Snow, and 

A. M. Noor, et al., 2012. “Progress Towards Implementation of ACT Malaria Case-Management in 

Public Health Facilities in the Republic of Sudan: A Cluster-sample Survey.” BMC Public Health. 12(1): 

11. https://doi.org/10.1186/1471-2458-12-11.
66 

12. Poyer, S., T. Shewchuk, S. Tougher, Y. Ye, ACTwatch Group, A. G. Mann, B. A. Willey, et al. 

2015. “Availability and Price of Malaria Rapid Diagnostic Tests in the Public and Private Health Sectors 

in 2011: Results from 10 Nationally Representative Cross‐sectional Retail Surveys”. Tropical Medicine & 

International Health 20(6): 744-756. https://doi.org/10.1111/tmi.12491. 

13. Noor, A. M., I. A. Rage, B. Moonen, and R. W. Snow. 2009. “Health Service Providers in 

Somalia:Their Readiness to Provide Malaria Case-management.” Malaria Journal 8(1): 100. 

https://doi.org/10.1186/1475-2875-8-100. 

14. ACTwatch Group, H. Kaula, P. Buyungo and J. Opigo. 2017. “Private Sector Role, Readiness 

and Performance for Malaria Case Management in Uganda, 2015.” Malaria Journal. 16(1): 219. 

https://doi.org/10.1186/s12936-017-1824-x. 

15. Kyabayinze, D. J., C. Asiimwe, D. Nakanjako, J. Nabakooza, H. Counihan, and J. K. 

Tibenderana. 2010. “Use of RDTs to Improve Malaria Diagnosis and Fever Case Management at Primary 

Health Care Facilities in Uganda.” Malaria Journal. 9(1): 200. https://doi.org/10.1186/1475-2875-9-200. 

16. Ruizendaal, E., S. Dierickx, K. P. Grietens, H. DFH Schallig, F. Pagnoni, and P. F. Mens, 2014. 

“Success or Failure of Critical Steps in Community Case Management of Malaria with Rapid Diagnostic 

Tests: A Systematic Review.” Malaria Journal 13(1): 229. https://doi.org/10.1186/1475-2875-9-200. 

17. World Health Organization and UNICEF. 2012. WHO/UNICEF Joint Statement: Integrated 

Community Case Management (iCCM) - An Equity-focused Strategy to Improve Access to Essential 

Treatment Services for Children. New York, NY: United Nations Children’s Fund. 

https://www.unicef.org/health/files/iCCM_Joint_Statement_2012.pdf. 

18. Rowe, S. Y., J. M. Kelly, M. A. Olewe, D. G. Kleinbaum, J. E. McGowan Jr, D. A. McFarland , 

R. Rochat, and M. S. Deming. 2007. “Effect of Multiple Interventions on Community Health Workers’ 

Adherence to Clinical Guidelines in Siaya District, Kenya.” Trans R Soc Trop Med Hyg, 101(2): 188-202. 

https://doi.org/10.1016/j.trstmh.2006.02.023. 

19. Mukanga, D., A. B. Tiono, T. Anyorigiya, K. Källander, A. T. Konaté, A. R. Oduro, J. K. 

Tibenderana, et al. 2012. “Integrated Community Case Management of Fever in Children under Five 

Using Rapid Diagnostic Tests and Respiratory Rate Counting:A Multi-country Cluster Randomized 

Trial.” Am J Trop Med Hyg 87(5 Suppl): 21-9. https://doi.org/10.4269/ajtmh.2012.11-0816.. 

20. Zurovac, D., J-O. Guintran, W. Donald, E. Naket, J. Malinga, and G. Taleo. 2015. “Health 

Systems Readiness and Management of Febrile Outpatients under Low Malaria Transmission in 

Vanuatu.” Malaria Journal. 14(1): 489. https://doi.org/10.1186/s12936-015-1017-4. 

21. Kazembe, L. N., I. Kleinschmidt, T. H. Holtz, and B. L. Sharp. 2006. “Spatial Analysis and 

Mapping of Malaria Risk in Malawi Using Point-referenced Prevalence of Infection Data.” International 

Journal of Health Geographics. 5: 41-41. https://doi.org/10.1186/1476-072X-5-41. 

22. USAID. 2018. Malawi Malaria Operational Plan FY 2018. https://www.pmi.gov/docs/defaultsource/default-document-library/malaria-operational-plans/fy-2018/fy-2018-malawi-malaria-operationallan.pdf?sfvrsn=5. 
67 

23. Ministry of Health (Malawi) and ICF International. 2014. Malawi Service Provision Assessment 

2013-14. Lilongwe, Malawi: MoH/Malawi and ICF International. 

https://dhsprogram.com/pubs/pdf/SPA20/SPA20%5BOct-7-2015%5D.pdf. 

24. National Malaria Control Programme. Guidelines for the Treatment of Malaria in Malawi, 2013. 

Lilongwe, Malawi: Government of Malawi, Ministry of Health. 

https://www.severemalaria.org/sites/mmv-smo/files/content/attachments/2017-03-

03/Malawi%202013%20Edition%20of%20Malaria%20Treatment%20Guidelines.pdf. 

25. USAID. 2018. President’s Malaria Initiative, Senegal- Malaria Operational Plan FY 2018. 

https://www.pmi.gov/docs/default-source/default-document-library/malaria-operational-plans/fy-2018/fy2018-senegal-malaria-operational-plan.pdf?sfvrsn=5. 

26. Agence Nationale de la Statistique et de la Démographie (ANSD) and ICF. 2017. Senegal 

Enquête Démographique et de Santé Continue (EDS-Continue) 2016. Dakar, Sénégal: ANSD and 

Rockville, Maryland, USA: ICF. 

27. Programme National de Lutte contre le Paludisme-Senegal. 2015. Plan Strategique National de 

Lutte contre le Paludisme au Senegal 2016-2020. https://fr.africacheck.org/wpcontent/uploads/2018/04/Senegal-paludisme-PSN-2016-2020-PNLP.pdf. 

28. Dieye, B., M. Affara, L. Sangare, F. Joof, Y. D. Ndiaye, J. F. Gomis, M. Ndiaye, A. Mbaye, et al. 

2016. West Africa International Centers of Excellence for Malaria Research: Drug Resistance Patterns to 

Artemether-Lumefantrine in Senegal, Mali, and The Gambia. Am J Trop Med Hyg. 95(5): 1054-1060. 

https://doi.org/10.4269/ajtmh.16-0053 

29. Linn, A. M., Y. Ndiaye, I. Hennessee, S. Gaye, P. Linn, and M. McLaughlin. 2015. Reduction in 

Symptomatic Malaria Prevalence Through Proactive Community Treatment in Rural Senegal. Trop Med 

Int Health, 20(11): 1438-1446. https://doi.org/10.1111/tmi.12564 

30. National Malaria Control Programme -The United Republic of Tanzania, 2014. National Malaria 

Strategic Plan 2014–2020 2014. 

http://ihi.eprints.org/3314/1/Malaria_Strategic_Plan_Full_Version_02_27_14.pdf. 

31. Zanzibar Malaria Elimination Programme - Revolutionary Government of Zanizbar Ministry of 

Health, 2017. Zanzibar Malaria Elimination Strategic Plan IV 2018/19-2022/23. 

32. National Malaria Control Programme - The United Republic of Tanzania. 2014. National 

Guidelines for Diagnosis and Treatment of Malaria. 

33. Roll Back Malaria Partnership to End Malaria (RBM), 2013. Household Survey Indicators for 

Malaria Control. 

http://www.malariasurveys.org/documents/Household%20Survey%20Indicators%20for%20Malaria%20

Control.pdf. 

34. World Health Organization. 2012. T3: Test. Treat. Track initiative. 

http://www.who.int/malaria/areas/test_treat_track/en/. 
68 

35. Wang, W., R. Winter, L. Mallick, C. Burgert-Brucker, and E. Carter. 2015. The Relationship 

Between the Health Service Environment and Service Utilization: Linking Population Data to Health 

Hacilities Data in Haiti and Malawi. DHS Analytical Studies No. 51. Rockville, Maryland, USA: ICF 

International. https://www.dhsprogram.com/pubs/pdf/AS51/AS51.pdf. 
69 

APPENDIX INDICATOR CONSTRUCTION 
70 

Appendix Table A.1 Facilities offering malaria diagnosis/treatment services 

Definition Numerator/denominator Questionnaire Formula Proportion of all facilities offering malaria diagnosis/treatment services 

Number facilities offering malaria diagnosis/treatment services 

Inventory Questionnaire 

Interviewer observed RDT being conducted: Q1420(6)=1 OR Providers in facility diagnose malaria: Q1702=1 OR Providers in facility prescribe treatment for malaria: Q1710=1 OR Facility had malaria microscopy capacity (all components 1, 2, and 3) 1. Light microscope used and functioning: Q840(1) B=1 AND 

Q840(1)C=1 

AND 2. Glass slides and covers used: Q840(8)B=1 AND 3. Giemsa Stain, Field Stain, or Acridine Orange stain available: 

Q847(1)B=1 OR Q847(2)B=1 OR Q847(3)B=1 

OR Facility had RDT capacity (components 1, 2, or 3)

1. Observed RDT kit (malaria section): Q1706=1 

OR 2. Observed RDT kit (parasitology section): Q843=1 OR 3. Observed malaria rapid diagnostic testing: Q1420(6)=1 

Total number of facilities Total number of facilities interviewed Q006 
71 

Appendix Table A.2 Facilities offering curative child care services 

Definition Numerator/denominator Questionnaire Formula Proportion of all facilities offering curative child care services 

Number facilities offering curative child care services 

Inventory Questionnaire 

Q102(03)=1 And Q1201a!=0 

Total number of facilities Total number of facilities interviewed Q006 

Appendix Table A.3 mRDT training 

Definition Numerator/denominator Questionnaire Formula Proportion of facilities with personnel trained in mRDT among facilities offering malaria diagnosis/treatment services or curative sick child care services 

Number of facilities with at least one interviewed provider who reports receiving in-service training in malaria mRDT in the past 24 months 

Health Worker Questionnaire 

Health worker personally provides child curative care and has received in-service training(components 1 and 2) 1. Health worker personally provides any child curative care 

services: Q302=1 

AND 2. Health worker received in-service training or training updates:

Child health services section of questionnaire 

• Perform malaria RDT test: Q304(4)=1 

OR Malaria section of questionnaire 

• Perform malaria RDT test: Q206(3)=1 

OR Diagnostic services section of questionnaire 

• Malaria RDT: Q703(8)=1 

Total number of facilities offering malaria diagnosis/treatment services or curative sick child care services 

Number of facilities offering malaria diagnosis/treatment services 

or curative sick child care services 
72 

Appendix Table A.4 Microscopy training 

Definition Numerator/denominator Questionnaire Formula Proportion of facilities with personnel trained in malaria microscopy among facilities offering malaria diagnosis/treatment services or curative sick child care services 

Number of facilities with at least one interviewed provider who reports receiving in-service training in malaria microscopy in the past 24 months 

Health Worker Questionnaire 

Health worker personally provides child curative care and has received in-service training(components 1 and 2) 1. Health worker personally provides any child curative care 

services: Q302=1 

AND 2. Health worker received in-service training or training updates:

Child health services section of questionnaire 

• Diagnosis of malaria in children: Q304(3)=1 

OR Malaria section of questionnaire 

• Diagnosing malaria in children: Q206(2)=1 • How to perform malaria microscopy: Q206(8)=1 

o Variable only found in 2014-15 TZ SPA 

OR Diagnostic services section of questionnaire 

• Malaria Microscopy: Q703(7)=1 

Total number of facilities offering malaria diagnosis/treatment services or curative sick child care services 

Number of facilities offering malaria diagnosis/treatment services 

or curative sick child care services 
73 

Appendix Table A.5 Case management and treatment training 

Definition Numerator/denominator Questionnaire Formula Proportion of facilities with personnel trained in case management/treatment of malaria in children among facilities offering malaria diagnosis/treatment services or curative sick child care services 

Number of facilities with at least one interviewed provider who reports receiving in-service training in case management/treatment of malaria in children in the past 24 months 

Health Worker Questionnaire 

Health worker personally provides child curative care and has received in-service training(components 1 and 2) 1. Health worker personally provides any child curative care 

services: Q302=1 

AND 2. Health worker received in-service training or training updates:

Child health services section of questionnaire 

• Case management/treatment of malaria in children: 

Q304(5)=1 

OR Malaria section of questionnaire 

• Case management/treatment of malaria in Children: 

Q206(7)=1 

Total number of facilities offering malaria diagnosis/treatment services or curative sick child care services 

Number of facilities offering malaria diagnosis/treatment services 

or curative sick child care services 
74 

Appendix Table A.6 Diagnosis and treatment of malaria guidelines 

Definition Numerator/denominator Questionnaire Formula Proportion of facilities that have national guidelines for diagnosis and treatment of malaria among facilities offering malaria diagnosis/treatment services or curative sick child care services 

Number of facilities with guidelines for diagnosis/treatment of malaria 

Inventory Questionnaire 

Facility had diagnosis and treatment of malaria guidelines available 

(components 1 or 2)1. Available and observed national guidelines for the diagnosis 

and treatment of malaria: Q1712=1 

OR 2. Available and observed other guidelines for the diagnosis and 

treatment of malaria: Q1714=1 

Total number of facilities offering malaria diagnosis/treatment services or curative sick child care services 

Number of facilities offering malaria diagnosis/treatment services 

or curative sick child care services 

Appendix Table A.7 mRDT protocol 

Definition Numerator/denominator Questionnaire Formula Proportion of facilities that have protocol for malaria mRDT among facilities offering malaria diagnosis/treatment services or curative sick child care services 

Number of facilities with protocol for malaria RDT 

Inventory Questionnaire 

Facility had RDT protocol available (components 1 or 2)

1. Interviewer shown training manual, poster, or job aid for using

malaria RDT (parasitology section): Q846=1 

OR 2. Interviewer shown training manual, poster, or job aid for using

malaria RDT (malaria section): Q1709=1 

Total number of facilities offering malaria diagnosis/treatment services or curative sick child care services 

Number of facilities offering malaria diagnosis/treatment services 

or curative sick child care services 
75 

Appendix Table A.8 mRDT supplies 

Definition Numerator/denominator Questionnaire Formula Proportion of facilities that have malaria mRDTs supplies among facilities offering malaria diagnosis/treatment services or curative sick child care services 

Number of facilities with malaria RDT supplies 

Inventory Questionnaire 

Facility had RDT capacity (components 1, 2, or 3)1. Observed RDT kit (malaria section): Q1706=1 OR 2. Observed RDT kit (parasitology section): Q843=1 OR 3. Observed malaria rapid diagnostic testing: Q1420(6)=1 

Total number of facilities offering malaria diagnosis/treatment services or curative sick child care services 

Number of facilities offering malaria diagnosis/treatment services 

or curative sick child care services 

Appendix Table A.9 Microscopy supplies 

Definition Numerator/denominator Questionnaire Formula Proportion of facilities that have malaria microscopy supplies among facilities offering malaria diagnosis/treatment services or curative sick child care services 

Number of facilities with malaria microscopy supplies 

Inventory Questionnaire 

Facility had malaria microscopy capacity (all components 1,2,and 3)

1. Light microscope used and functioning: Q840(1) A=1 AND 

Q840(1)C=1 

AND 2. Glass slides and covers used: Q840(8)A=1 AND Giemsa Stain, Field Stain, or Acridine Orange stain available: Q847(1)B=1 OR Q847(2)B=1 OR Q847(3)B=1 

Total number of facilities offering malaria diagnosis/treatment services or curative sick child care services 

Number of facilities offering malaria diagnosis/treatment services or 

curative sick child care services 
76 

Appendix Table A.10 Microscopy diagnostic capacity 

Definition Numerator/denominator Questionnaire Formula Proportion of facilities that have microscopy diagnostic capacity among facilities offering malaria diagnosis/treatment services or curative sick child care services 

Number of facilities with microscopy diagnostic capacity 

Inventory Questionnaire 

Malaria microscopy capacity (all components 1 and 2) 

1. Number of facilities with malaria microscopy 

AND 

2. Number of facilities with staff trained in malaria microscopy 

Total number of facilities offering malaria diagnosis/treatment services or curative sick child care services 

Number of facilities offering malaria diagnosis/treatment services or 

curative sick child care services 

Appendix Table A.11 mRDT diagnostic capacity 

Definition Numerator/denominator Questionnaire Formula Proportion of facilities that have mRDT diagnostic capacity among facilities offering malaria diagnosis/treatment services or curative sick child care services 

Number of facilities with mRDT diagnostic capacity 

Inventory Questionnaire 

Malaria RDT capacity (all components 1,2,and 3) 

1. Number of facilities with protocol for malaria RDT 

AND 

2. Number of facilities with malaria RDT 

AND 

3. Number of facilities with staff trained in malaria RDT 

Total number of facilities offering malaria diagnosis/treatment services or curative sick child care services 

Number of facilities offering malaria diagnosis/treatment services or 

curative sick child care services 
77 

Appendix Table A.12 Diagnostic capacity 

Definition Numerator/denominator Questionnaire Formula Proportion of facilities that have diagnostic capacity (microscopy diagnostic capacity or mRDT diagnostic capacity) among facilities offering malaria diagnosis/treatment services or curative sick child care services 

Number of facilities that have diagnostic capacity 

Inventory Questionnaire and Health Provider Questionnaire 

Malaria RDT Capacity (all components 1,2,and 3) 

4. Number of facilities with protocol for malaria RDT 

AND 

5. Number of facilities with malaria RDT 

AND 

6. Number of facilities with staff trained in malaria RDT 

OR Malaria Microscopy Capacity (all components 1 and 2) 

3. Number of facilities with malaria microscopy 

AND 

4. Number of facilities with staff trained in malaria microscopy 

Total number of facilities offering malaria diagnosis/treatment services or curative sick child care services 

Number of facilities offering malaria diagnosis/treatment services or 

curative sick child care services 
78 

Appendix Table A.13 Antimalarial availability 

Definition Numerator/denominator Questionnaire Formula Proportion of facilities with ACTs among facilities offering malaria diagnosis/treatment services or curative sick child care services 

Number of facilities that have ACTs available 

Inventory Questionnaire and Health Provider Questionnaire 

Facility had antimalarial medicines available: Artemether Lumefrantrine (LA) 6 tablets/pack: Q905(1)=1 OR Artemether Lumefrantrine (LA) 12 tablets/pack: Q905(2)=1 OR Artemether Lumefrantrine (LA) 18 tablets/pack: Q905(3)=1 OR Artemether Lumefrantrine (LA) 24 tablets/pack: Q905(4)=1 Malawi and Tanzania included the following drugs in addition to the standard drugs listed above: Artemether – Amodiaquine (ASAQ) 25mg/67.5mg: Q905(10A)=1 OR Artemether – Amodiaquine (ASAQ) 50mg/135mg: Q905(10B)=1 OR Artemether – Amodiaquine (ASAQ) 100mg/270mg: Q905(10C)=1 Senegal included the following drugs from the “Inventory for Case de Santé Questionnaire” in addition to the standard drugs listed above: Artemisinin-Based Combination Therapy [ACT] Adult Artemisinin-Based Combination Therapy [ACT] Child Artemisinin-Based Combination Therapy [ACT] Infant 

Total number of facilities offering malaria diagnosis/treatment services or curative sick child care services 

Number of facilities offering malaria diagnosis/treatment services or 

curative sick child care services 
79 

Appendix Table A.14 Malaria service readiness 

Definition Numerator/denominator Questionnaire Formula Proportion of facilities who are malaria service ready among facilities offering malaria diagnosis/treatment services or curative sick child care services 

Number of facilities that are malaria service ready 

Inventory Questionnaire and Health Provider Questionnaire 

Facility has diagnosis and treatment of malaria guidelines available=TRUE AND Facility has ACTs available=TRUE AND Facility has personnel trained in mRDT, microscopy, or case management/treatment of malaria in children=TRUE AND Facility has diagnostic capacity=TRUE 

Total number of facilities offering malaria diagnosis/treatment services or curative sick child care services 

Number of facilities offering malaria diagnosis/treatment services or 

curative sick child care services