A nationwide study of community- versus facility-based management of malaria in Sierra Leone from 2019 to 2023

SETTING A nationwide analysis in Sierra Leone using routine DHIS2 surveillance data, 2019–2023. OBJECTIVES To compare community-based and health facility–based malaria case management among people presenting with fever in Sierra Leone from 2019 to 2023, in terms of 1) suspected malaria cases, 2) testing by microscopy or rapid diagnostic tests, and 3) timely initiation of artemisinin-based combination therapy (ACT) within 24 h of reported fever onset, stratified by service level and age. METHOD Observational, cross-sectional, comparative analysis of routinely collected national surveillance data. RESULTS A total of 16.4 million fever cases were reported, of which 90% were managed at health facilities and 10% by community health workers. Overall, 15.8 million cases were tested for malaria, and 10.0 million were confirmed. Timely initiation of ACT within 24 h of reported fever onset was higher among community-managed cases (72.1%) compared with facility-managed cases (61.8%) (risk ratio 1.7, 95% confidence interval: 1.16–1.19), including children under 5 years. CONCLUSION Community-based malaria case management was associated with higher reported timeliness of ACT initiation compared with facility-based care. However, these findings should be interpreted cautiously, given that it is an observational design and the reliance on routinely collected surveillance data.