Child mortality in Bangladesh – why, when, where and how? A national survey-based analysis

Children under-five years of age are among the vulnerable group mostly affected by morbidity and mortality due to malaria. Insecticide treated nets (ITNs) have proved to be effective in reducing malaria transmission and increasing child survival. Significant investment into scaling up of ITNs has been done but achieving actual utilisation among beneficiaries is still a challenge in malaria endemic regions including Ghana. The study aimed to assess factors influencing utilisation of ITNs among children under-five years in Kpone-On-Sea in Ghana. We used a cross-sectional community survey design to determine the proportion of children under-five years of age sleeping under ITNs and factors influencing utilisation of ITNs among care-givers in Kpone-On-Sea. We randomly sampled 325 care-givers of children under-five years between March and June 2017. Microsoft Excel version 2016 and SPSS were used for data entry and analysis, and further analysis was conducted using STATA version 14 software. Chi-square test was used to test for associations and multiple logistic regression to determine strength of associations. We found that the proportion of children under-five years sleeping under ITNs was 91%. Factors associated with ITN utilisation among children under-five years included caregivers’ level of education (p<0.01), their awareness that children under-five years are most at risk of malaria (P<0.05), knowledge that ITN protect against mosquito bite (P<0.02), knowledge on the importance of ITNs in preventing malaria (P<0.01), ITN ownership (P<0.03), type of ITN owned (p<0.02) and the period within which caregivers utilise ITN (P<0.00). We also found high ownership of ITNs among caregivers, and no difference between caregivers’ knowledge on malaria and its prevention. These data improved the current knowledge of ITNs utilisation among caregivers of children under-five years and offer opportunities to conduct further studies in other regions of Ghana.

Purpose: This study aims at assessing the nutritional status of children under-five years of age with acute diarrhoea, determine the prevalence of malnutrition and identifying factors associated with undernutrition among children under 5 years old in Ohangwena Region, Namibia.Methods: Cross-sectional, non-interventional study was conducted. A structured questionnaire was administered through face to face interviews. A total of 530 children under-five years from 530 households were included in this study. The nutritional index was measured based on Child Growth Standards proposed by WHO. The anthropometric measures used included mid-upper arm circumference (MUAC) and weight-for-age Z score (WAZ). Logistic regression was applied to determine the factors associated with the prevalence of malnutrition.Results: The overall prevalence of diarrhoea among the children under-five years was 24%, of these, 77% were suffering from malnutrition. Malnutrition prevalence was observed to be significantly associated with a child suffering from diarrhoea (p < .05) and children aged between 12-23 months p .001. Equally, the highest prevalence of malnutrition 29.4% [95% CI = 24.65; 34.15] was found amongst children under-five years old with mothers/caregivers aged 18-30 years. The strongest predictor of malnutrition was the mother/caregiver not being an educated recording odds ratio of 20.2.Conclusions: This study identified the need to develop and intensify strategies that may improve nutritional status in children under-five years such as health education, improved literacy, and women empowerment.

Socio-economic status is an important predictor of stunting, however published population based studies on socio-economic inequalities in stunting among children under-five years of age is scarce in Uganda. Data from the 2016 Uganda Demographic and Health Survey was used to identify possible socio-economic inequalities in stunting among 3941 children aged 6-59 months. Multivariate binary logistic regression models were fitted to calculate the odds ratios and their corresponding 95% confidence intervals for stunting by maternal formal education and household wealth index. The overall prevalence of stunting among children was 30.1%. The risk of stunting was higher among children whose mothers had no formal education (OR: 4.35; 95% CI, 2.45-7.71), attained primary (OR: 2.74 95% CI, 1.62-4.63) and secondary level education (OR: 2.30 95% CI, 1.34-3.96) compared to those whose mothers attained tertiary level education. Similarly higher risk of stunting was found among children that lived in the poorest (OR: 1.78 95% CI, 1.23-2.59), poorer (OR: 1.88; 95% CI, (1.28-2.74), middle (OR: 1.91, 95% CI, 1.31-2.77) and richer households (OR: 1.60; 95% CI, 1.10-2.32) compared to those in the richest households. Socio-economic differences in stunting among children under-five years of age were found. Targeting stunting prevention interventions to less affluent mother-child dyads and households might be important in reducing social inequalities in stunting among children under-five years of age in Uganda.

Malnutrition is a major public health concern among tribal communities, where children face higher risk due to socio-economic disadvantages, poor healthcare access, and inadequate diets. Despite government programs, it persists, necessitating a focused assessment of its determinants. This study aimed to evaluate the nutritional status and its determinants among Koraga tribal children. A community-based cross-sectional study was conducted among children under-five years of age belonging to the Koraga community, a particularly vulnerable tribal group (PVTG) in southern Karnataka, India. Anthropometric measurements were taken, and data on socio-demographic characteristics, maternal and child health, and environmental conditions were collected using a structured proforma. Data analysis was performed using SPSS version 16.0 with logistic regression identifying factors associated with malnutrition. Among the 180 children included in the study, the median [interquartile range (IQR)] age of the children was 36 months (22.25, 46.00), and 52.2% were female. Low birth weight was reported in 40.2% of children, and 9.9% were currently anaemic. The study found a high prevalence of malnutrition among children under-five years of age, with 81.1% being stunted, 78.3% wasted, and 80.6% underweight. Multivariable analysis identified access to safe drinking water, maternal factors, nutritional factors, and dietary factors as significant contributors to undernutrition in this vulnerable population. The findings highlight the urgent need for targeted nutrition and health interventions in this PVTG. Strengthening maternal care, child feeding practices, sanitation, and healthcare access is essential to reduce malnutrition. A multi-sectoral approach is essential to break the cycle of undernutrition and improve overall child health outcomes.

BACKGROUND: Globally, malnutrition accounts for at least half of all childhood deaths. Managing malnutrition in the community settings involves identifying malnutrition using a universally validated screening tool and implementing appropriate interventions according to the degree of malnutrition. The aim of this study was to estimate prevalence and associated factors that result in malnutrition among children under-five years of age in Thatta and Sujawal districts in Sindh province, Pakistan. METHODS: A cross-sectional survey was conducted between May and August 2014. A total of 3964 children under-five years were enrolled in the study. The WHO growth standards height-for-age Z-scores (HAZ), weight-for-height Z-scores (WHZ) and weight-for-age Z-scores (WAZ) were used to measure stunting, wasting and underweight. A structured questionnaire was used to collect data on socioeconomic conditions, family size, maternal education, parity and child morbidity. Multivariable logistic regression was used to determine the risk factors for malnutrition. RESULTS: The prevalence of stunting, wasting and underweight were 48.2% (95% CI: 47.1–50.3), 16.2% (95% CI: 15.5–17.9), and 39.5% (95% CI: 38.4–41.5), respectively. Stunting was slightly higher (51%) in boys than in girls (45%) (p < 0.001). The proportion of wasting (p = 0.039) and underweight (p = 0.206) was not significantly different between boys and girls. Fifty percent children in the poorest households were stunted as compared to 42% in the wealthiest households. Children in the poorest households were two times more likely to be wasted (20.6%) than children in the wealthiest households (10.3%) (OR 2.33, CI 1.69–3.21, p < 0.001). A similar relationship was observed between household wealth and underweight in children (43.8% in poorest and 28.8% in wealthiest households (OR 2.18, CI 1.72–2.77, p < 0.001). Household wealth was significantly associated with stunting, wasting and underweight. Diarrhea was associated with underweight. Factors such as mother’s education, parity and family size were not associated with malnutrition in our study area. CONCLUSIONS: The findings of our study revealed that malnutrition was widespread among the children under-five years of age. The food/nutrient based interventions together with improved hygiene practices and household wealth should be targeted to improve malnutrition situation in the study area and in the country.

Background: The nutritional status of children is one of the major indicators of child survival and a proxy indicator for the general health of the population. Malnutrition is a significant public health issue in the majority of developing nations and is particularly prevalent among children under five years of age. Mortality and morbidity among children under-five years of age are influence by nutritional status. The context of Nepal, more than one-third (36%) of children under-five years of age stunted or too short for their age. 10% of children wasted (too thin for height), a sign of acute malnutrition. 27% of children underweight or too thin for their age. These children had greater risk of severe acute malnutrition and death. Objective: Study’s objective was to assess the nutritional status of under-five year’s children and factors associated with malnutrition. Method: A descriptive cross-sectional study conducted in Kolati Bhumlu of Kavrepalanchok district of Nepal. A total of 115 under-five year’schildren and their mothers were included in study. Statistical Package for the Social Sciences (SPSS) version16 was used to analyze the data. Result: The prevalence of underweight was found to be 28.7% according to the classification of malnutrition based on Z- score .Similarly, the prevalence of wasting was found to be 18.3% and the prevalence of stunting was found to be 29.6%. According to Gomez’s malnutrition classification (NCHS/WHO as standard) for Weight for age (underweight) 3.5% children were severely malnourished. According to Water-low’s classification, regarding the height for age (stunting) 9.6% children were severely malnourished. Regarding MUAC measurement 7.8% children had severe malnutrition. The Gender of the child was associated with stunting. Conclusion: In the study population, the high prevalence of malnutrition especially stunting among under-five years children. Taking weight, height, age, and mid- upper arm circumference (MUAC) measurements of malnourished children more than three-fifths of them were below -2SD and nearly one-fourths were below -3SD which needs intervention.

BackgroundVital registration data outlining causes of deaths (CoD) are important for a sustainable health system, targeted interventions and other relevant policies. There is data paucity on vital registration systems in developing countries. We assessed the leading causes and proportions of under-five deaths, and particularly those related to pneumococcal infections in Yaoundé, Cameroon, using hospital registration data.MethodsA retrospective case-finding observational study design was used to access and identify data on 817 death cases in children under-five years of age recorded in health facilities in Yaoundé, within the period January 1, 2006 and December 31, 2012. Patients’ files were randomly selected and needed information including demographic data, date of admission, clinical and laboratory diagnosis, principal and/or underlying causes of death were abstracted into structured case report forms. The International Classification of Diseases and Clinical Modifications 10th revision (ICD-10-CM) codes (ICD10Data.com 2017 edition) were used to classify the different CoD, retrospectively. Ascertainment of CoD was based on medical report and estimates were done using the Kaplan-Meier procedure and descriptive statistics.ResultsOf the 817 death records assessed, malaria was the leading CoD and was responsible for 17.5% of cases. Meningitis was the second largest CoD with 11.0%; followed by sepsis (10.0%), Streptococcus pneumoniae infections (8.3%), malnutrition (8.3%), gastro-enteritis / diarrhoea (6.2%), anaemia (6.1%) and HIV (3.5%), respectively.ConclusionThe main CoD in this population are either treatable or vaccine-preventable; a trend consistent with previous reports across developing countries. Besides, the health effects from non-communicable infections should not be neglected. Therefore, scaling-up measures to reduce causes of under-five deaths will demand sustainable efforts to enhance both treatment and disease prevention strategies, to avoid a decline in the progress towards reducing under-five deaths by 2/3 from the 1990 baseline.

Acute respiratory infection (ARI) and diarrhea are major public health concerns among children under-five years of age. Somalia has one of the highest under-five mortality rates in sub-Saharan Africa, with diarrhea and ARI accounting for most deaths. No national studies have explicitly assessed the determinants of diarrhea and ARI among children in urban and rural settings. This study aimed to assess the prevalence and determinants of diarrhea and ARI among children under-five in urban and rural Somalia. We analyzed nationally representative data from the 2020 Somali Health and Demographic Survey (SHDS) of 7732 under-five-year-old children with complete responses to the variables studied. Descriptive analyses were used to summarize the respondents' characteristics. Multiple logistic regression was used to assess the determinants of diarrhea and ARI. We present our findings as adjusted odds ratios with a 95% confidence interval (95% CI), and a p-value < 0.05 was considered significant. We employed sample weights, stratification, and clustering to account for the sampling design of the SHDS. We adhered to the STROBE checklist for manuscript reporting. The prevalence of ARI was 10.7% and 12.2% in urban and rural areas, respectively, whereas that of diarrhea was 8.8% and 11.0%, respectively. Residence in the North-West, child age of 0-23 months, prelacteal feeding, maternal age of 15-24 and 25-34 years, no media exposure, and belonging to a poor wealth index were significantly associated with higher odds of diarrhea and ARI among under-fives. Being the first child in birth order, average size at birth, institutional delivery, antenatal care visits, and improved sources of drinking water and sanitation facilities were significantly associated with lower odds of diarrhea and ARI among children aged under-five years in an urban-rural setting in this study. Diarrhea and ARI morbidity in children are significant health challenges in urban and rural areas of Somalia. Public health interventions aimed at high-risk regions, young mothers, impoverished households, home deliveries, and unsanitary use of drinking water and sanitation facilities are crucial for reducing the burden of diarrhea and ARI in children under-five years of age in Somalia.

Background : The first five years of life is often regarded as “golden age period” of development. During this period physical, motor, intellectual, emotional, language, and social development proceed rapidly in children. Brain tissues grow fast to reach 80% of adult brain weight. Anemia occuring during this period can affect health, as well as cognitive and physical development in children. This study aimed to determine the effects of birthweight, illness history, dietary pattern, maternal education, and family income on the incidence of anemia in children under-five years of age. Subje ct and Met h od: This was an analytic observational study using case control design. The study was carried out at Karanganyar District, Central Java, from February to April 2017. A sample of 110 subjects was selected for this study, consisting of 35 children under-five years of age with anemia and 75 children of the same age without anemia. The independent variables were birthweight, illness history, dietary pattern, maternal education, and family income. The dependent variable was anemia. The data were collected by a set of questionnaire. Hemoglobin concentration was measured by Hb meter. The data were analyzed by path analysis on Stata 13. Results : Anemia in children under-five was directly affected by illness history (b= 2.50; 95% CI = 1.06 to 3.95; p= 0.001;), dietary pattern (b= -1.89; 95% CI = -3.39 to -0.39; p=0.013;), and birthweight (b= -0.97; 95% CI = -2.07 to 0.13; p= 0.083). Anemia in children under-five was indirectly affected by maternal educational (b=1.09; 95% CI = 0.14 – 2.04; p= 0.024) and family income (b= -0.90; 95% CI = -1.78 to 0.02; p= 0.044). Conclusion : Anemia in children under-five is directly affected by illness history, dietary pattern, and birthweight. It is indirectly affected by maternal educational and family income. K eywords : Anemia, birthweight, illness history, dietary pattern, children under-five Correspondence: Yeni Anggraini. Masters Program in Public Health, Sebelas Maret University, Jl. Ir. Sutami 36 A, Surakarta 57126, Indonesia. Email : yenni.anggrainie@gmaill.com. Mobile : 085712329100 Journal of Maternal and Child Health (2017), 2(3): 200-212 https://doi.org/10.26911/thejmch.2017.02.03.02

This study examined the prevalence of stunting-overweight and socio-demographic determinants among children under-five years of age, as well as associations with infant and young child feeding (IYCF) among children aged 6-23 months. Secondary data analysis based on the Thailand Multiple Indicator Cluster Survey 2015-2016. Cross-national study. Nationally representative sample of children under-five years of age (n 12 313). The prevalence of wasting, stunting, overweight and stunting-overweight was 5·3, 10·5, 10·1 and 1·6 %, respectively. In multivariate analyses, children under 6 months, children from low and middle wealth tertiles, and children living in rural areas were prone to being wasted. Male children, low wealth tertile and a non-Thai speaking household head were positively and children aged 48-59 months and a one-child household were inversely associated with stunting. Children from a low wealth tertile were less likely to be overweight, while older age, male children and children from a one-child household were more likely to be overweight. Stunting-overweight was associated with children aged 24-47 months, male children, mothers having secondary education, a one-child household, a non-Thai speaking household head and an urban area. In terms of IYCF indicators, despite no association with stunting and stunted-overweight children, current breast-feeding and inadequate meal frequency were associated with being wasting, while current breast-feeding and dietary diversity were inversely associated with being overweight. This study revealed the double burden of malnutrition at the individual and population levels among Thai children under-five, which calls for concrete integrated interventions to tackle all forms of malnutrition.

Malnutrition affects physical, mental and intellectual development as well asthe morbidity, mortality and physical work ability and the continued consequencesimpact on human performance and survival. It is underlying causes resulted in manydiseases and death for the children under-five years of age. Factors are contributing tothe malnourished children are considered to many and varied.The objective of the cross sectional study is to identify the sociocultural andother factors associated with underweight children age under-five in Preah Vihearprovince. Factors considered socio demographic characteristics of the mothers/closedcaregiver,food relating factors, environment factors, household economic and healthstatus of mother and child. It was a cross sectional study using a modifiedquestionnaire from MICS 2006 and measure of weight and height.Two hundred twenty households with children under-five from 3 sub-districtof Chhaeb, Preah Vihear participated in the study. SPSS (version 16) was used for dataanalysis of frequency, percentage, mean, standard deviation and crosstabulation testedby chi-square test. The result showed that the prevalence of underweight, stunting andwasting children under-five years of age was 77.3%, 60.9% and 61.4%. Most of therespondents were farmers (95.3%) and no education (33.6%) and completed primaryschool (63.7%). From the statistical analysis using Chi-square; factors associate withunderweight children were level of mother’s education, number of timesfeeding/breastfeeding, feeding child extra snacks, children ate carbohydrate, proteinfood, vegetables/fruits, sweets (p&lt;0.05). Moreover, the finding revealed that theenvironment factors (child drinking water treatment) and child health factors (childfever with cough) showed statistical significant with underweight children (p&lt;0.05).In term of food culture, beliefs and prejudice there were no statisticalsignificant different. However, over half the mothers/closed-caregivers thought thatchild ate fish caused parasite and first breast milk caused child diarrhea or sickness dueto their food beliefs. For improving the child nutritional status, health and nutrition andsafe drinking water should be provided to the mothers.

BackgroundSince 2004, the Tanzanian National Voucher Scheme has increased availability and accessibility of insecticide-treated nets (ITNs) to pregnant women and infants by subsidizing the cost of nets purchased. From 2008 to 2010, a mass distribution campaign delivered nine million long-lasting insecticidal nets (LLINs) free-of-charge to children under-five years of age in Tanzania mainland. In 2010 and 2011, a Universal Coverage Campaign (UCC) led by the Ministry of Health and Social Welfare (MoHSW) was implemented to cover all sleeping spaces not yet reached through previous initiatives.MethodsThe UCC was coordinated through a unit within the National Malaria Control Programme. Partners were contracted by the MoHSW to implement different activities in collaboration with local government authorities. Volunteers registered the number of uncovered sleeping spaces in every household in the country. On this basis, LLINs were ordered and delivered to village level, where they were issued over a three-day period in each zone (three regions). Household surveys were conducted in seven districts immediately after the campaign to assess net ownership and use.ResultsThe UCC was chiefly financed by the Global Fund to Fight AIDS, Tuberculosis and Malaria with important contributions from the US President’s Malaria Initiative. A total of 18.2 million LLINs were delivered at an average cost of USD 5.30 per LLIN. Overall, 83% of the expenses were used for LLIN procurement and delivery and 17% for campaign associated activities. Preliminary results of the latest Tanzania HIV Malaria Indicator Survey (2011–12) show that household ownership of at least one ITN increased to 91.5%. ITN use, among children under-five years of age, improved to 72.7% after the campaign. ITN ownership and use data post-campaign indicated high equity across wealth quintiles.ConclusionClose collaboration among the MoHSW, donors, contracted partners, local government authorities and volunteers made it possible to carry out one of the largest LLIN distribution campaigns conducted in Africa to date. Through the strong increase of ITN use, the recent activities of the national ITN programme will likely result in further decline in child mortality rates in Tanzania, helping to achieve Millennium Development Goals 4 and 6.

Knowledge of the causes of child death is important for health-sector planning since they relate to available interventions. Little is known about causes of child death in Bangladesh from the conventional sources since there is no vital registration system and very few deaths are attended by a qualified physician. To determine the cause structure of child deaths, verbal autopsy interviews were conducted in the Bangladesh Demographic and Health Survey (BDHS) 1993/94 national sample. Verbal autopsy is a method of finding out the causes of death based on an interview with the next of kin or other caregivers. Between BDHS 1993/94 and BDHS 1996/97, 1-4-y-old child mortality in Bangladesh declined by about 27.0%. This impressive decline prompted a verbal autopsy study using the BDHS 1996/97 national sample to determine whether the cause structure had changed. The same verbal autopsy instrument and methods to collect the data and the same computer algorithm to assign causes of death were used in both surveys. Comparison of BDHS 1993/94 and 1996/97 cause-specific mortality rates revealed that deaths due to almost all causes had declined, although significantly so only for acute respiratory infections (ARI), persistent diarrhoea and drowning. Deaths due to neonatal tetanus, acute watery diarrhoea and undernutrition had not decreased at all. Despite an impressive decline in deaths due to ARI, this condition remains the most important known cause of death in Bangladeshi children. Neonatal tetanus and measles together account for about 10% of deaths in children under 5 y. Further improvements in child survival are possible by improving access to and quality of available child survival interventions.

BackgroundMaternal and child malnutrition is widely prevalent in low and middle income countries. In Pakistan, widespread food insecurity and malnutrition are the main contributors to poor health, low survival rates and the loss of human capital development. The nutritional status trends among children exhibit a continuous deteriorating with rates of malnutrition exceeding the WHO critical threshold. With the high prevalence of maternal and child malnutrition, it is important to identify effective preventative approaches, especially for reducing stunting in children under-five years of age. The primary aim of this study is to assess the effectiveness of food-based interventions to prevent stunting in children under-five years.MethodsA mixed methods study design will be conducted to evaluate the effectiveness of food-based interventions to prevent stunting among children under-five years in districts Thatta and Sujawal, Sindh Province, Pakistan. The study will include cross sectional surveys, a community-based cluster randomized controlled trial and a process evaluation. The study participants will be pregnant women, lactating mothers and children under-five years. The cross-sectional surveys will be conducted with 7360 study participants at baseline and endline. For the randomized control trial, 5000 participants will be recruited and followed monthly for compliance of food-based supplements, dietary diversity, pregnancy outcomes, and maternal and child morbidity and mortality. Anthropometric measurements and hemoglobin levels will be measured at baseline, quarterly and at endline. The interventions will consist of locally produced lipid-based nutrient supplement (Wawamum) for children 6–23 months, micronutrient powders for children 24–59 months, and wheat soya blends for pregnant and lactating mothers. Government lady health workers will deliver interventions to participants. The effectiveness of the project will be measured in terms of the impact of the proposed interventions on stunting, nutritional status, micronutrient deficiencies, and other key indicators of the participants. The process evaluation will assess the acceptability, feasibility and potential barriers of project implementation through focus group discussions, key informant interviews and household surveys. Data analysis will be conducted using STATA version 12.DiscussionThere is considerable evidence on the effectiveness of food-based interventions in managing stunting in developing countries. However, these studies do not account for the local environmental factors and widespread nutrient deficiencies in Pakistan. These studies are often conducted in controlled environments, where the results cannot be generalized to programs operating under field conditions. The findings of this study will provide sufficient evidence to develop policies and programs aimed to prevent stunting in children 6–59 months and to improve maternal and child health and growth outcomes in poor resource settings.Trial registrationNCT02422953. Registered on April 15, 2015.

BackgroundMalaria is still a disease of global public health importance and children under-five years of age are the most vulnerable to the disease. Nigeria adopted the “test and treat” strategy in the national malaria guidelines as one of the ways to control malaria transmission. The level of adherence to the guidelines is an important indicator for the success or failure of the country’s roadmap to malaria elimination by 2030. This study aimed to assess the fidelity of implementation of the national guidelines on malaria diagnosis for children under-five years and examine its associated moderating factors in health care facilities in Rivers State, Nigeria.MethodsThis was a descriptive, cross-sectional study conducted in Port Harcourt metropolis. Data were collected from 147 public, formal private and informal private health care facilities. The study used a questionnaire developed based on Carroll’s Conceptual Framework for Implementation Fidelity. Frequency, mean and median scores for implementation fidelity and its associated factors were calculated. Associations between fidelity and the measured predictors were examined using Mann Whitney U test, Kruskal Wallis test, and multiple linear regression modelling using robust estimation of errors. Regression results are presented in adjusted coefficient (β) and 95% confidence intervals.ResultsThe median (IQR) score fidelity score for all participants was 65% (43.3, 85). Informal private facilities (proprietary patent medicine vendors) had the lowest fidelity scores (47%) compared to formal private (69%) and public health facilities (79%). Intervention complexity had a statistically significant inverse relationship to implementation fidelity (β = − 1.89 [− 3.42, − 0.34]). Increase in participant responsiveness (β = 8.57 [4.83, 12.32]) and the type of malaria test offered at the facility (e.g., RDT vs. no test, β = 16.90 [6.78, 27.03]; microscopy vs. no test, β = 21.88 [13.60, 30.16]) were positively associated with fidelity score.ConclusionsThis study showed that core elements of the “test and treat” strategy, such as testing all suspected cases with approved diagnostic methods before treatment, are still not fully implemented by health facilities. There is a need for strategies to increase fidelity, especially in the informal private health sector, for malaria elimination programme outcomes to be achieved.