Open Access Research article

Obstacles to prompt and effective malaria treatment lead to low community-coverage in two rural districts of Tanzania

Manuel W Hetzel124*, Brigit Obrist1, Christian Lengeler1, June J Msechu2, Rose Nathan2, Angel Dillip2, Ahmed M Makemba2, Christopher Mshana2, Alexander Schulze3 and Hassan Mshinda2

Author Affiliations

1 Dept. of Public Health and Epidemiology, Swiss Tropical Institute, P.O. Box, CH-4002 Basel, Switzerland

2 Ifakara Health Institute, P.O. Box 53, Ifakara, Tanzania

3 Novartis Foundation for Sustainable Development, WRO-1002.11.56, CH-4002 Basel, Switzerland

4 Papua New Guinea Institute of Medical Research, P.O. Box 60, Goroka, EHP 441, Papua New Guinea

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BMC Public Health 2008, 8:317  doi:10.1186/1471-2458-8-317

Published: 16 September 2008



Malaria is still a leading child killer in sub-Saharan Africa. Yet, access to prompt and effective malaria treatment, a mainstay of any malaria control strategy, is sub-optimal in many settings. Little is known about obstacles to treatment and community-effectiveness of case-management strategies. This research quantified treatment seeking behaviour and access to treatment in a highly endemic rural Tanzanian community. The aim was to provide a better understanding of obstacles to treatment access in order to develop practical and cost-effective interventions.


We conducted community-based treatment-seeking surveys including 226 recent fever episodes in 2004 and 2005. The local Demographic Surveillance System provided additional household information. A census of drug retailers and health facilities provided data on availability and location of treatment sources.


After intensive health education, the biomedical concept of malaria has largely been adopted by the community. 87.5% (78.2–93.8) of the fever cases in children and 80.7% (68.1–90.0) in adults were treated with one of the recommended antimalarials (at the time SP, amodiaquine or quinine). However, only 22.5% (13.9–33.2) of the children and 10.5% (4.0–21.5) of the adults received prompt and appropriate antimalarial treatment. Health facility attendance increased the odds of receiving an antimalarial (OR = 7.7) but did not have an influence on correct dosage. The exemption system for under-fives in public health facilities was not functioning and drug expenditures for children were as high in health facilities as with private retailers.


A clear preference for modern medicine was reflected in the frequent use of antimalarials. Yet, quality of case-management was far from satisfactory as was the functioning of the exemption mechanism for the main risk group. Private drug retailers played a central role by complementing existing formal health services in delivering antimalarial treatment. Health system factors like these need to be tackled urgently in order to translate the high efficacy of newly introduced artemisinin-based combination therapy (ACT) into equitable community-effectiveness and health-impact.