Treated before tested: presumptive antimalarial treatment across public, community and private providers, a nationally representative analysis of febrile children in the 2024–25 Uganda Malaria Indicator Survey

Abstract Background WHO recommends parasitological confirmation of suspected malaria before treatment, and Uganda adopted this policy more than a decade ago. Recent, nationally representative evidence on presumptive treatment by sector of care is lacking. Methods Children under 5 years of age with caregiver-reported fever in the preceding 2 weeks in the 2024–25 Uganda Malaria Indicator Survey were analysed. Care seeking, blood taken for testing and antimalarial receipt were estimated among all febrile children. The primary outcome was presumptive treatment, defined as receipt of an antimalarial without blood collection for a malaria diagnostic test during the episode. Survey weighted modified Poisson regression estimated adjusted prevalence ratios (aPR) by sector of care, adjusting for child age, residence, maternal education, household wealth and region. Results Of 6352 children under 5 years of age, 2080 had reported fever. Care was sought for 84.8%, blood was taken from 57.2% and an antimalarial was given to 65.7%; treatment exceeded testing by 8.5 percentage points [95% confidence interval (CI) 5.2 to 11.8]. Presumptive treatment occurred in 22.0% of febrile children (95% CI 19.6 to 24.4): 4.8% in the public sector, 7.7% among community health workers, 21.3% in private formal facilities, the most common source of care, and 52.1% in drug retail. Relative to the public sector, presumptive treatment was more prevalent in private formal facilities (aPR 4.64, 95% CI 2.95 to 7.29) and drug retail (aPR 9.93, 95% CI 6.32 to 15.59). It was more prevalent in children aged 2 to 4 years than in infants, less prevalent in children of mothers with secondary education, and varied by region. One quarter of presumptive treatment occurred in children for whom no care was sought outside the home. Conclusions Reported testing before antimalarial treatment varied along a continuum: highest in public facilities and among community health workers, intermediate in private formal facilities and very low in drug retail outlets. Sector of care was the strongest measured correlate of presumptive treatment, although cross-sectional, caregiver-reported data cannot establish why sectors differ. Private formal facilities and treatment at home, in addition to drug shops, deserve attention in extending diagnostic testing.