In many clinics across the Democratic Republic of Congo, diagnosing malaria can take just a few minutes. A drop of blood from a finger prick is placed on a rapid diagnostic test.
If a line appears, malaria parasites are present. If not, the patient should receive care for another illness.
But new research published recently in Malaria Journal suggests that, in practice, a negative result does not always prevent antimalarial treatment from being prescribed.
The study, conducted under Breakthrough ACTION, a Johns Hopkins Center for Communication Programs-led project that closed in 2025, found that health providers often continue to treat fevers as malaria even when the rapid test is negative.
The Johns Hopkins Bloomberg School of Public Health research team used Deki Readers, battery-powered devices that automatically read malaria tests and upload the results to a cloud database. These devices are not widely used in routine care but were deployed for this study to allow researchers to compare what the tests actually showed with what was reported through the national health system based on how each patient was treated.
The comparison revealed a clear gap. Routine reports recorded far more malaria cases than the Deki Readers registered, particularly during the dry season when malaria transmission is naturally lower. This suggests that providers gave antimalarial medication to feverish patients, even when rapid tests were negative.
One concern is that treating all fevers as malaria could contribute to resistance to antimalarial drugs, making it harder to treat patients in the future. “We need to understand health workers’ concerns if we want to increase confidence in test results while still providing care for the patient in front of them,” says Kathryn Sugg, who led the work when she was at CCP.
Those seeking care may themselves complicate the picture. Many patients expect malaria treatment when they come in with a fever, and some express distrust if the test comes back negative.
In rural areas, where access to health care is limited, families may travel long distances for a clinic visit. For them, leaving without medicine can feel like leaving without help.
“Patients can insist on treatment, and health workers may feel that patients will not be satisfied with their care if they leave without it,” Sugg says. This tension shapes how care is delivered on the ground.
Seasonal patterns of malaria transmission also play a role. During the rainy season, transmission is high and test results are more likely to match the clinical presumption that all fevers are malaria. But in the dry season, when mosquitoes are scarce, the study found the gap between reported and actual cases was widest. Researchers say this suggests that providers’ decision-making may outweigh objective test results, particularly when the actual risk of malaria is low.
Sugg says she hopes the findings can inform better training and supervision for providers. Interventions could include reinforcing trust in rapid diagnostic tests by clearly communicating their real-world accuracy, improving diagnostics for other causes of fever, and offering more precise guidance on when to prescribe antimalarials. She emphasized that the goal is not to penalize providers for erring on the side of caution, but to support decisions that both protect patients and reduce unnecessary drug use.
“The study underscores the complexity of malaria care in real-world settings,” she says. “While rapid diagnostic tests are a powerful tool, human factors including provider judgment, patient expectations, and the overall care-seeking context continue to shape treatment. Addressing these factors could help ensure that antimalarial medicines remain effective for the patients who truly need them.”
“Positive tests are all alike, every negative test is negative in its own way: lack of confidence in negative malaria rapid diagnostic tests in the Democratic Republic of the Congo” was written by Sugg, Florence W. Mpata, Michael D. Humes, Dédé Aliango Marachto, Radha Rajan and Peter J. Winch.
Breakthrough ACTION was funded by the United States Agency for International Development (USAID and the U.S. President’s Malaria Initiative.
