Presumptive malaria treatment and malaria outcomes in Ghana from 2016 to 2025

Abstract Background Ghana requires parasitological confirmation of suspected malaria before antimalarial treatment, yet some patients are treated without a positive test. We described trends in presumptive malaria treatment from 2016 to 2025 and its association with malaria outcomes. Methods We conducted an ecological panel analysis of annual malaria case management indicators reported through the District Health Information Management System 2 for all 16 regions (160 region-years). The presumptive malaria treatment (PMT) rate was the percentage of treated uncomplicated cases without a positive test. We compared 2016–2020 with 2021–2025 and used two-way fixed-effects panel regression to relate PMT to confirmed incidence and admission, mortality, and case fatality rates, with bootstrap inference and a 2018–2025 sensitivity analysis. Results The national PMT rate fell from 33.5% in 2016 (not-tested component only) to 3.6% in 2025, with a temporary rise to 8.2% in 2024. All regions improved, and Greater Accra had the highest rate in 2021–2025 (11.3%). The under-five share of malaria admissions fell from 48.0% to 27.9%, while their share of deaths stayed near half. Within regions, each percentage-point rise in PMT was associated with 2.28 fewer confirmed cases per 1,000 population (95% CI − 3.84 to − 0.71; bootstrap p = 0.028), with no statistically significant association with admission, mortality, or case fatality rates. Conclusions Presumptive malaria treatment declined in every region, although Greater Accra and northern regions kept the highest rates and the national rate rebounded in 2024. Confirmed malaria incidence is best interpreted alongside not-tested and test-negative treatment rates.