Where and why malaria persists in heterogeneous transmission settings: insights from routine health facility data

Background Malaria distribution in sub-Saharan Africa is becoming increasingly spatially heterogeneous. Pre-elimination areas, high-transmission settings and urban areas with increasing transmission may all coexist within the same country. Effective intervention planning requires identifying high-risk areas and their drivers—an area in which geospatial models can provide valuable insights. Yet these models often assume stationary risk factors across transmission levels and frequently rely on prevalence survey data, which are unreliable in low-transmission settings. This study uses routine public-sector health facility data (ie, DHIS2) to model malaria incidence in Senegal from 2017 to 2021, accounting for transmission levels, and introduces novel fine-scale estimates of reported malaria incidence derived from dasymetric disaggregation. Methods Health facility catchment populations were estimated using a probabilistic approach, allowing individuals to attend multiple facilities based on relative travel time. Malaria incidence per catchment was modelled using high-resolution environmental and socioeconomic covariates within a Bayesian hierarchical modelling framework. Separate models were fitted by season and endemicity-urbanisation level to assess the heterogeneity of risk factors. We adapted dasymetric disaggregation methods from population mapping to redistribute facility-level cases to 1 km pixels. Results Estimated malaria incidence increased from 60 cases per 1000 people in 2017 to 71 cases in 2021. Key risk factors varied across endemicity-urbanisation levels; some factors were uniquely associated with low (eg, distance to roads), moderate (eg, cropland) and high-transmission settings (eg, flooded vegetation). Fine-scale maps represent malaria cases that the public-sector health system routinely reports, rather than the total malaria burden, and revealed potential underdiagnosis in remote areas. Conclusions Our findings emphasise the importance of considering endemicity levels when evaluating malaria risk factors in heterogeneous transmission contexts. As health system data quality continues to improve, this approach offers a scalable alternative for mapping reported malaria incidence, supporting better targeted interventions and the identification of underdiagnosed areas.