In many countries in sub-Saharan Africa, estimates of malaria occurrence used by health planners at all levels are based on data from formal sector health facilities. Since the majority of fever episodes are treated at home and within the community, the burden estimates obtained this way are the tips of the iceberg. A case study from Ghana comparing household data on acute morbidity and treatment-seeking behavior in two districts with health facility data is used as an illustration. For every case of febrile illness seen in the health facilities, there were approximately 4-5 in the community. Many sub-Saharan African countries recommend that all febrile episodes, especially in children, be treated with an antimalarial. Since several countries extend malaria treatment to include the community and the home through public and private, formal and informal sectors, the need for more comprehensive burden estimates becomes urgent.
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