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The World Health Organization report in 2007, declared that, it will not be possible to achieve national and international health goals without greater investments in health systems. It is a known fact that today, the advancement in science has led to a better understanding of aetiologies and risk factors of most diseases burden in the world. However, the capacity to deliver these innovations to the population that needs them the most is severely handicapped by fragile and poor health systems, particularly in developing countries. The differing diseases burden spectrum between and within countries, underscores the complexity and the need for context specific measures to address disease burdens and major causes of poor ill health in respective societies. Today, malaria continues to be a public health problem and important cause of morbidity and mortality in countries with ongoing transmission. In Tanzania, malaria is among the leading causes of hospital attendance and mortality in prevalent areas. Efficacious interventions to combat malaria have advanced such that endemic regions are seeing a decline in malaria related deaths and morbidity. These gains however, are threatened with the emergency of drugs and insecticide’s resistance, environmental, vectors and hosts’ related challenges. Despite these challenges, malaria is a preventable disease and historically the disease, once prevalent in the North, was successfully eradicated. This provides hope for elimination and possible eradication of malaria in endemic regions in future if efficacious interventions are adopted in scale. The current malaria control strategies in Tanzania can broadly be categorized as; vector control activities which includes use of treated bed nets, indoor residual praying and environmental management; chemoprevention to specific vulnerable groups; and prompt, effective treatment of cases. Health care provision in the country is facing many bottlenecks such as shortage of qualified workforce, lack of appropriate technologies and frequent stock-out of essential medicines. In addition, reports of poor providers’ compliance to treatment recommendations undermine the effectiveness of the health system. Through a phase four platform of effectiveness and safety studies of antimalarials (INESS), we assessed the quality of malaria case management in the study areas. The goal was to understand factors influencing treatment outcomes in real world settings, with focus in diagnostic accuracy and provider’s compliance for malaria treatment. This work involved a pair of cross-sectional health facility surveys that interviewed patients, providers and inventoried health facilities for availability of products related to malaria treatment. Complimentary data were obtained from the IMPACT-Tz project which introduced artemisinin based combination therapy (ACT) in similar study areas, before the national adoption of ACT for malaria treatment. Findings from this work demonstrated that, increased use of malaria rapid tests (RDTs) for routine care reduced over-treatment with ACT during high malaria transmission period from 45.8% in a pre-RDT area to 20.9% in a post-RDT area. Conversely, correct treatment with ACT was higher in the post-RDT area 85.9% as compared to pre-RDT area 58.3%. This implies that, having appropriate technology in place improves targeting of resources and facilitates providers’ compliance. Further assessment on correct dosing revealed that age based dosing were more prone to errors. The proportion of patients receiving correct dosing as per national guideline was lower in middle aged groups; 42% for 9-12 years old and 50% for 3-9 years old patients. Analysis of health facility data from 2002 to 2010 showed that presence of parasitemia at health facility was generally declining to children below 5 and increasing to above 5 years. However, significant intra-group’s differences were observed. While children below age of 2 showed a declining trend, those above 2-5 years had an increasing trend (p

Poor adherence to and inappropriate use of antimalarials leads to ineffective cure and promote development of drug resistance. We assessed quality of malaria case management in two areas with health and demographic surveillance systems in rural Tanzania to ascertain health worker and facility factors that influence correct prescription and correct dosing of an artemisinin based combination therapy (ACT); Artemether-Lumefantrine (ALu). Exit interviews were conducted to all patients attending for initial illness consultation at health facilities. We collected information about health worker’s training, supervision visits and inventoried facility capacity and availability of medical products related to care of malaria patients. Data were double entered in EPI data and analyzed in STATA version 10 We used logistic regression to assess association of different health system factors to correct use of ALu. The outcomes variables were correct treatment, correct dosing and receiving counselling messages, and the predictors were a range of health worker, health facility and patient factors. Total of 1471 patients were included in this analysis. Majority of patients were seen in dispensaries 70.5 %; (95% confidence interval (95%CI): 57.6-80.8) and in public health facilities 80.2% (95%CI: 72.4-86.1). Work experience seems to be a significant predictor of health workers’ compliance to treatment recommendation. Availability of medical products at health facility and patient characteristics are shown to influence correct use of treatment recommendations. The need to develop targeted interventions to address health system bottlenecks that affect quality of care; such as in-availability of medical products is becoming more apparent.