Published in PLOS One on 2026-04-30, this study is presented as an attributed evidence briefing. The excerpts below are the original researchers’ words, reproduced under their Creative Commons Attribution licence. Health Signal has selected the abstract and, where needed, opening background paragraphs; the complete methods, results, limitations and references remain in the linked paper.
Original authors: Mastewal Worku Lake, Kassahun Alemu Gelaye, Mulusew Andualem Asemahagn, Kindie Fentahun Muchie, Hailemariam Awoke Engedaw, Muluken Azage Yenesew, Mohammed Hasen Badeso
Source: PLOS One • DOI 10.1371/journal.pone.0348088
Read the complete primary study ↗ · Creative Commons Attribution licence
From the researchers
Abstract
Ethiopia has experienced a marked malaria resurgence in recent years, with the Amhara Region disproportionately affected. Although Ethiopia’s national strategy emphasizes test-before-treat and a public–private mix, implementation fidelity of the malaria test-and-treat guideline during resurgence has not been well characterized. This study assessed fidelity to malaria diagnosis and treatment guidelines in public and private health facilities in the Amhara Region within this resurgence context.
We conducted a convergent parallel mixed-methods study from February to March 2025 in 53 health facilities (38 public, 15 private) in Amhara Region. The facility was the unit of analysis; one provider primarily responsible for malaria case management was interviewed per facility (n = 53). Implementation fidelity was operationalized using Carroll’s framework across three domains: content (adherence to key diagnostic/treatment steps), coverage (proportion of suspected cases tested before treatment, extracted from facility registers), and frequency (self-reported consistency of testing for febrile patients in the preceding month). Domain scores were standardized to 0–100 and averaged with equal weights to form a composite fidelity score; ≥ 75% indicated high fidelity. To explain quantitative patterns, we conducted 32 in-depth interviews and analyzed data using inductive thematic analysis with CFIR-informed interpretation. Quantitative analysis used nonparametric tests and parsimonious multivariable linear regression, with prespecified sensitivity analyses excluding the self-reported frequency domain.
Overall mean implementation fidelity was 64.3% (SD 12.1); 40% of facilities had high fidelity (≥75%), and 13% scored <50%. Public facilities had higher fidelity than private facilities (median 67% [IQR 60–77] vs 63% [IQR 56–70]; Wilcoxon rank-sum p = 0.041). In multivariable analysis, higher fidelity was associated with higher participant responsiveness (β = 3.4, p < 0.001), stronger facilitation strategies (β = 2.8, p < 0.001), and lower perceived intervention complexity (reverse-coded; β = 2.1, p < 0.001). Interviews indicated that fidelity gaps were driven by diagnostic and treatment deviations (including non–species-specific prescribing), inconsistent counseling and follow-up mechanisms, supply constraints, and patient pressure, with challenges more frequently emphasized in private facilities.
Implementation fidelity to Ethiopia’s malaria test-and-treat guideline in Amhara during resurgence was moderate, with lower fidelity in private facilities. Provider responsiveness, facilitation strategies, and lower intervention complexity were identified as factors associated with implementation fidelity. Strengthening supportive supervision and mentorship with explicit inclusion of private facilities, improving supply reliability, and simplifying decision supports may improve adherence during resurgence.
Introduction
Malaria is an infectious disease caused by the Plasmodium parasites [1]. It is an entirely preventable and treatable parasitic disease [2,3]. Globally, an estimated 263 million cases and 597,000 deaths occurred in 2023, with 94% of deaths occurring in sub-Saharan [4,5]. Factors contributing to this resurgence include insecticide resistance, the spread of Anopheles stephensi, climate anomalies, conflict, healthcare system disruptions, and a resources shortages [4,6]. Alarmingly, molecular markers associated with partial artemisinin resistance (e.g., pfk13 R561H, P574L, A675V) have been reported in multiple African countries, including Ethiopia [7].
Reading this evidence
Use the full paper to check the study design, participant selection, comparator and outcome definitions before drawing a practical conclusion. An association does not by itself show cause and effect. A reported performance measure needs its denominator and uncertainty. A finding from a particular facility, sample or time period should retain that scope when it is discussed elsewhere.
This briefing makes the source accessible within the wider technology & industry desk. It does not assess an individual patient or certify a product. When considering relevance to another health system, examine the original authors’ account of context and limitations, then seek local implementation evidence. The related reporting below provides other studies to read alongside this one; it is a topic connection, rather than a claim that their results are directly comparable.
© 2026 Mastewal Worku Lake, Kassahun Alemu Gelaye, Mulusew Andualem Asemahagn, Kindie Fentahun Muchie, Hailemariam Awoke Engedaw, Muluken Azage Yenesew, Mohammed Hasen Badeso. Excerpts reproduced under CC BY. Selection, formatting and contextual notes by Health Signal. The researchers are the authors of the source study, not members of Health Signal’s staff.
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- Evidence brief: Investigating barriers to adherence to antimalarial prescribing guidelines in public healthcare facilities in Arba Minch, South Ethiopia: A qualitative study
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