Decline in malaria test positivity rates following capacity building and archiving of malaria rapid diagnostic test cassettes in Oyo State, Nigeria: a retrospective review of records

Abstract

Background

The malaria test positivity rate (TPR) is a key indicator for evaluating the effectiveness of malaria interventions. In Nigeria, routine data from January to June 2021 reported consistently high TPRs, ranging from 73 to 82%, while Oyo State reported TPRs of 70% to 74% during the same period. These figures were inconsistent with malaria therapeutic efficacy studies conducted between October 2009 and November 2010, which reported a much lower TPR of 35%. This discrepancy raised concerns about data quality, increased malaria incidence, or inaccuracies in malaria diagnosis.

Methods

This study assessed the effect of two interventions aimed at improving the accuracy of TPR data using secondary quantitative data from the National District Health Information System (NDHIS) for both Primary Healthcare Facilities (PHFs) and Secondary Health Facilities (SHFs). The interventions included (1) facility-level audits of used malaria Rapid Diagnostic Test (RDT) cassettes archived at 733 PHFs, initiated in September 2021, and (2) a 10-day basic malaria microscopy training (BMMT) for Laboratory Scientists at 17 SHFs, completed in September 2021.

Results

At PHFs, the RDT positivity rate declined from 71% in October 2021 to 53% in December 2022. A period review from January to September revealed a decrease in TPR from 62 to 53% in 2022, compared to no difference in TPR for the same period in 2021 with an average TPR of 77%. A paired t-test comparing the mean TPR for each period showed a statistically significant decline of 19.56 (t = 18.081, p < 0.01, CI (17.06–22.05). At SHFs, microscopy-based TPR decreased from 40% in October 2021 to 18% in December 2022. A review of January to September 2021 showed a TPR decline from 53 to 50%, while in 2022, TPR decreased from 25 to 18%. A paired t-test revealed a statistically significant decline of 19.33 in mean TPR at SHFs (t = 8.14, p < 0.01, CI 13.86–24.81).

Conclusion

This study highlights the critical role of auditing used RDT cassettes and recommends scaling up this approach in PHFs. It also underscores the value of basic malaria microscopy training in improving the quality and accuracy of microscopy-based diagnosis. One limitation of this study is the absence of comparative data from other states in Nigeria where the interventions were not implemented.

Background

Malaria, a persistent global public health challenge, has significantly impacted sub-Saharan Africa, with Nigeria, bearing a substantial burden of the disease [1]. The disease imposes considerable socioeconomic burden, affecting productivity and leading to increased healthcare expenditures as well as high morbidity and mortality [2]. According to the World Health Organization (WHO), in the year 2023, there were an estimated 249 million cases of malaria and an estimated 608,000 malaria deaths worldwide. Nigeria alone accounted for 27% of malaria cases globally and 31% of malaria-attributable deaths in 2022 [3]. Approximately 97% of Nigeria’s population is at risk of malaria with children under 5 years (CU5) and pregnant women more susceptible [4].

In 2010, the National Malaria Elimination Programme adopted a policy shift from presumptive treatment to parasite-based diagnosis, as recommended by the WHO [5]. Malaria microscopy and the use of Rapid Diagnostic Test (RDTs) kits were approved as methods for testing suspected malaria before treatment [6]. Prompt malaria diagnosis, either by microscopy which remains the gold standard for diagnosis [7], or malaria RDTs is crucial for effective disease management and robust malaria surveillance [8]. The choice of the malaria diagnosis technique depends on health facility level and staff skill level, infrastructural capacity, patient caseload, epidemiology of malaria, and the possible use of microscopy for the diagnosis of other diseases [8]. In low-resource settings such as Nigeria, Primary Healthcare Facilities (PHFs) rely on RDT for malaria diagnosis, while secondary and tertiary healthcare facilities use both RDT and malaria microscopy based on staff skill level and infrastructural capacity.

Parasite-based diagnostic testing significantly reduces illness and death by enabling health providers to swiftly distinguish between malarial and non-malarial fevers, selecting the most appropriate treatment. It improves the overall management of patients with febrile illnesses and may help reduce the emergence and spread of drug resistance. Parasitological diagnosis ensures that treatment is targeted at those with malaria and allows for accurate recording of the number of confirmed malaria cases, which is useful for assessing the impact of malaria control interventions.

Several government and non-government funded interventions have been carried out and are still ongoing toward the elimination of malaria in Nigeria, including in Oyo State. However, despite these efforts, the malaria Test Positivity Rate (TPR) remains persistently high in Nigeria’s routine data, raising questions about its accuracy. The malaria TPR is used to assess the effectiveness of malaria interventions. However, over the years, this rate has remained high in routine data from National Health Management Information System (NHMIS)/District health Information System (DHIS2) across Nigeria ranging from 73%–82% between January and June 2021 and 70%–74% between January and June 2021 in Oyo State. The high TPR was inconsistent with other data triangulated from the country’s malaria therapeutic efficacy studies between October 2009 and November 2010 which reported a test positivity rate of 35% [9], suggesting that the high TPR may reflect poor data quality and inaccurate malaria diagnosis.

Discrepancies with other data sources such as household survey data, hospital based primary survey data suggest potential issues with data quality and the accuracy of malaria diagnosis. The elevated TPR has been inconsistent with studies that explored malaria incidence in health facilities of 35% [10], 55% [11] and 54% [12], indicating a need for this study.

Factors contributing to high TPR include suboptimal data management, poor documentation of test results, inadequate infrastructure, limited access to diagnostic tools, and gaps in healthcare delivery systems. Furthermore, the ability to accurately conduct and interpret RDT results continues to pose a challenge [7].

To address these issues effectively, it is crucial to explore practical facility-level approaches that can contribute to the reduction of malaria test positivity rates; therefore, measures were introduced to improve the accuracy of TPR data generated. The decision to commence archiving of used RDT was made by the Oyo State malaria case management committee after careful consideration of the persistently elevated TPR despite several interventions. The two measures were (1) facility-level audits of archived RDT cassettes introduced to Primary Healthcare Facilities (PHFs) in September 2021 to address suboptimal data management (ranging from data entry errors to data falsification), and the challenge of accuracy of conduct and interpretation of the result and (2) a capacity building exercise through a 10-day basic malaria microscopy training (BMMT) at Secondary Healthcare Facilities (SHFs), which was completed in September 2021.

Although some studies explored the use of vector control interventions as a means to reduce malaria TPR, which include the use of long-lasting insecticidal nets (LLIN) and indoor residual house spraying (IRS) [13, 14], the impact of RDT accuracy on the malaria TPR [15] and relationships between age, sex, season and socioeconomic factors and the malaria TPR [16, 17], based on review of literature, this is the first study looking specifically into data accuracy involving auditing of archived RDT cassettes and the influence of capacity building efforts on TPR in Nigeria and sub-Saharan Africa. While there is a paucity of research exploring suboptimal data management and capacity-building impacts on TPR within this region, similar studies in Asia [18, 19] have explored the critical role of data accuracy and capacity-building in malaria elimination efforts. This study aimed to evaluate the impact of RDT cassette archiving and BMMT on reducing malaria TPR. Specifically, it sought to determine the effect of these two interventions on the accuracy of reported TPR in both primary and secondary healthcare facilities in Oyo State, Nigeria.

Methods

Study area

The study was carried out in Oyo State, located in Southwestern Nigeria. Known as the “Pace Setter state”. Oyo State has Ibadan as its capital city and comprises 33 Local Government Areas (LGAs) classified into urban, semi-urban, and rural (see Table 1). Oyo State has an estimated population of approximately 9.5 million people in 2022 [1], primarily of the Yoruba ethnic group, alongside minority groups like Hausa, Fulani, and Igbo. Majority of the population engages in agriculture, trading, and other occupations, often residing in high-density urban areas.

Table 1 Description of the regions in Oyo state

The climate in Oyo State is tropical, characterized by two distinct seasons: rainy season (April to October) and dry season (November to March), with annual rainfall averaging around 1088 mm [20]. High humidity levels, especially during the rainy season, create favourable conditions for mosquito breeding, which facilitates the transmission of malaria [21].

Health facilities in Oyo State are stratified into three levels:

• Tertiary care: Includes teaching hospitals and specialized facilities

• Secondary care: Comprises general hospitals in various LGAs, offering services such as inpatient care and emergency management.

• Primary care: Involves primary health centres (PHCs) and health posts providing essential services.

According to the State Ministry of Health, Oyo State has over 1,200 health facilities: including 4 tertiary hospitals, 43 secondary hospitals, and approximately 766 PHCs, with the rest being private hospitals [22]. The incidence of malaria in Oyo State is seasonal, with higher cases recorded during the rainy season (April to October) due to increased mosquito breeding in stagnant water pools created by rainfall [23]. According to the 2021 Malaria Indicator Survey, malaria prevalence in Southwestern Nigeria, including Oyo State, peaks at over 30% during this period, emphasizing the importance of seasonal malaria control interventions [24].

Study design

A retrospective study of malaria data on DHIS 2.

Study population

The study population are fever cases who presented in all the 733 primary healthcare facilities in Oyo state offering malaria treatment services and 17 selected secondary healthcare facilities.

All health facilities report their routine malaria data monthly on the National Health Management Information System (NHMIS) and District Health Information System (DHIS2). The DHIS 2 is an open-source web-based platform that collects routine health facility aggregate data of health facility service delivery data on malaria, family planning services, immunization. These data were extracted from the health facilities’ National Health Management Information System tools. The malaria data captured included the number of patients who presented with fever at the health facilities, the number of patients tested with rapid diagnostic tests, the number of patients tested with malaria microscopy, and the number of patients tested with parasitological confirmation of malaria disaggregated for RDT and microscopy.

Sampling technique

All primary health facilities that reported malaria service delivery data on DHIS 2 were included in the study. A purposive selection of the secondary facilities was done using the criteria: Health facilities with functional microscope and medical laboratory scientist trained on basic malaria microscopy.

Summary of interventions

Two approaches were introduced to improve the accuracy of malaria Test Positivity Rate (TPR) data for both primary healthcare centres (PHCs) and secondary health facilities (SHFs). In September 2021, a capacity-building exercise was implemented at secondary health facilities with medical laboratory scientists in 17 selected secondary health facilities trained on a 10-day basic malaria microscopy course with a focus on malaria parasite identification, speciation, and quantification. The training focused on parasite detection, which is the ability to identify the presence of malaria parasites in blood smears, identify the type of Plasmodium species present in the thin blood film, and perform parasite counting, which is the quantification of Plasmodium parasites present in the blood film per high-power field reported as the number of parasites per microliter of blood.

At the primary health facilities, any patient presenting with fever, is tested using RDT as part of the required diagnostic tests for malaria, according to the national guidelines. Cassettes used are labelled with basic information (patient name, date and time at start and end of the test). Following this, the test is conducted by pricking patient’s finger and blood is collected using a capillary tube for testing using a malaria rapid test kit. Results are obtained after a certain number of minutes ranging from 15–20 min and following specific manufacturer’s instructions [25]. The result indicates a positive test when both the control and test lines are shown, while a negative result will only show the control line. In September 2021, the malaria case management committee implemented an intervention to improve the accuracy of reported test positivity rates, defined as the proportion of fever cases testing positive for malaria. Instead of discarding used RDT cassettes immediately, health facilities were instructed to archive them for 1 month in a safety box or a plastic container with lid before disposal. The archiving was done with the aim of auditing the used RDT cassettes by a State or the Local government supervisory team visiting the health facility. Facility-based audits of archived RDT cassettes were conducted at the 733 PHFs. The audit entailed reviewing labelled archived RDT cassettes and comparing with tests negative and positive results recorded in the health facility registers for the same period. This approach enabled the validation of RDT cassettes against facility records and the data submitted to the National Health Management Information System (NHMIS). In situations where disparities were observed between the records in the health facility registers and the archived cassettes, investigation of the record was done by referring to case folders; where deficiencies in making differential diagnosis were observed or non-adherence to malaria test results, capacity building of health facility staff was done. In situations where data misrepresentation was observed, disciplinary measures were meted out on the erring staff.

Data sets

The malaria datasets for 2021 and 2022 for Oyo state accessed from the DHIS 2 website were used in this analysis. Data was downloaded on 6th June 2024 from the DHIS2. There was free access to the required datasets. Permission to use the records was obtained from the Oyo State Ministry of Health, Department of Planning, Research, and Statistics, and authors adhered to all data use guidelines.

Description of study variables

The study variables included number of fever cases, number of fever cases disaggregated by age into under 5 and above 5 years, number of pregnant women presenting with fever, number of fever patients tested with RDT or malaria microscopy, and test positivity rate across the PHFs. The malaria test positivity rate was defined as the number of positive diagnostic tests as a proportion of the total tests performed among febrile patients using the malaria rapid diagnostic test at the PHFs and malaria microscopy at the secondary health facilities.

Fever is defined as axillary temperature of > or = 37.5 at the time of visit to the health facility or reported experience of fever by clients within 24 h prior to presentation at the health facility.

The average TPR was calculated for all the PHFs in the state for each of the study months.

The data were summarized into regions based on information obtained from the Department of Health Planning, Research and Statistics of the Oyo State Ministry of Health.

Data analysis

A secondary data analysis was conducted for malaria data extracted from DHIS 2 from January 2021 to December 2022. The primary outcome variables were the RDT TPR at the 733 public primary healthcare facilities and microscopy TPR for 17 secondary health facilities.

SPSS version 21 was used to perform the analysis. A descriptive analysis of the data obtained was performed, Frequency tables were used to show the distribution of key socio-demographic variables. Descriptive statistics of percentage, frequency, mean, and standard deviation were used to summarize the sociodemographic variables.

Considering the seasonal nature of malaria, a comparison of malaria data for the same period in 2021 and 2022 was done. A paired t-test was used to compare group means between the malaria test positivity rate in from January to September 2021 before intervention using the facility-based audits and similar period in 2022 after the intervention. An association was considered statistically significant if the p-value was less than 0.05.

At the secondary health facilities, the average TPR was reported across the 17 selected SHFs. These health facilities had at least one medical laboratory scientist who had been trained in basic malaria microscopy and were performing malaria microscopy from October 2021–December 2022. Paired t-tests were performed to compare the mean TPR for each period from January–September 2021 and January –September 2022.

Results

Over the period of January 2021 to December 2022, as shown in Table 2, A total of 849,960 patients visited the primary health facilities with complaints of fever ranging from 23,968 in March 2021 to 50,599 in July 2021 across all the PHCs in the 33 LGAs of Oyo state. At the PHCs, among patients with suspected malaria, 839,830 (99%) had a diagnostic test performed, and of these, 821,626 (97.8%) were tested using RDT. Overall, 540,392 (65.8%) of those tested for malaria were positive, with malaria RDT TPRs ranging from 51 to 82% across the 33 LGAs, with an average TPR of 65.5%, SD ± 10.57.

Table 2 Number of persons with fever, proportion of fever cases tested and test positivity rates from January 2021 to December 2022 across PHFs in Oyo State

Over the same period, the persons less than 5 years presenting with fever were 226,507 (27%) and those greater than 5 years including pregnant women were 623,453 (73%) as shown in Table 3. The average TPR for children less than 5 years was 64% SD ± 12.05, while for persons greater than 5 years including pregnant women was 66%, SD ± 9.90.

Table 3 Number of persons with fever and test positivity rate from January 2021 to December 2022 disaggregated by age in the PHCs in Oyo State

The Malaria RDT TPR data in the PHCs across the LGAs over the study period were summarized across the region in Table 4. This revealed that in the urban areas, the average TPR was 65%, SD ± 10.58, that in the semi-urban areas was 63%, SD ± 9.81, and the rural areas was 70%, SD ± 11.85 across the PHCs in the 33 LGAs.

Table 4 Average test positivity rate in PHFs across urban, semi urban and rural regions in Oyo State from January 2021 to December 2022

A consistent decline in the state malaria RDT positivity rate was observed at PHCs, dropping from 71% in October 2021 to 53% in December 2022 as seen in Fig. 1. A review of data from January to September 2021 showed no consistent decline in TPR from January to September, with an average TPR of 77% ± 2.72. In comparison, during the same period in 2022, the TPR decreased from 62% in January to 53% in September, with an average TPR of 58% ± 3.61, as illustrated in Fig. 2. A paired t-test revealed a statistically significant decline of 19.56 (t = 18.08 p < 0.01 CI (17.06–22.05) in the mean TPR for the reviewed period from January to September of both years at the PHFs.

Fig. 1

Malaria RDT test positivity rate across primary health facilities from January 2021–December 2022

Fig. 2

Malaria microscopy test positivity rate across 17 selected secondary health facilities from January 2021 to December 2022

Table 5 showed that at the 17 selected secondary health facilities, from January 2021 to December 2022, there were a total of 102,096 patients with complaints of fever. Among patients suspected to have malaria, 99,906(98%) had a diagnostic test performed, and 57,566 (56%) of these patients were tested using malaria microscopy. Overall, 17,692 of those tested for malaria using malaria microscopy were positive, and the average TPR was 33.5% ± 10.33. Additionally, the average TPR of children younger than 5 years over the same period was 36.0% ± 13.0, and for children older than 5 years, the average TPR was 32.9% ± 9.90.

Table 5 Number of persons with fever, number of fever cases tested and test positivity rate from January 2021 to December 2022 in 17 selected secondary health facilities in Oyo State

Furthermore, at the selected secondary health facilities, following the completion of the BMMT in September 2021, the microscopy-based TPR decreased from 40% in October 2021 to 18% in December 2022 as shown in Fig. 2. Further review from Jan 2021 to September 2021 revealed that the TPR decreased from 53 to 50% and an average TPR of 45%, while in the subsequent year Jan 2022 to September 2022, the TPR decreased from 25 to 18% and an average TPR of 25%. A paired t- test demonstrated a statistically significant decline of 19.33 (t = 8.14, p < 0.01 CI 13.86–24.81) in the mean TPR for the reviewed period from January to September of both years at the SHFs.

Discussion

Malaria transmission peaks during the rainy season, with significant variations across different ecological zones in the country [26]. In this study, across the 2 years study period, fever cases peaked at June, July, and August in 2021 and May, June, July in 2022, corresponding to the periods of maximum rainfalls in Oyo state Nigeria. Similarly, malaria cases peaked in these months compared to other months as shown in Table 1. Malaria RDT TPR were almost similar between CU5 and persons ≥ 5 years both in PHCs and secondary health facilities as seen in this study.

Several studies have shown that malaria is more prevalent in rural areas compared to urban areas, hence often described as a disease of the poor. One study attributed this difference to better living conditions and access to healthcare facilities in urban areas [27]. Others have explained the difference in incidence of malaria across regions is attributable to reduced breeding sites for mosquitoes and fewer opportunities of vector contact with humans in urban than the rural regions [28]. This study also shows that in the 2-year study period, test positivity rate was highest in the rural LGAs and least in the semi-urban LGAs. The stratification lacked a clear distinction as factors that characterize very large urban settings reducing malaria transmission intensity (e.g. improved housing, piped water, good sewage system and accessible health care) are found within the semi-urban regions [29]. Additionally, as this is an hospital-based study, the incidence of malaria cannot be well elucidated.

In sub-Saharan Africa, including Nigeria, issues such as limited resources, weak health systems, inadequate training of healthcare workers contribute to data quality and diagnostic inaccuracies. Similarly, in regions like Southeast Asia, such as India under the Malaria Elimination Demonstration Project (MEDP), similar challenges have been reported [18]. These include inconsistent data reporting, suboptimal use of diagnostic tools, and gaps in healthcare worker training. However, MEDP demonstrated success by integrating innovative strategies such as capacity building [30], digital tools for real-time reporting [31], and robust community engagement, which significantly improved data accuracy and diagnostic reliability. This aligns with findings from this study with improved test positivity rates following capacity building on malaria microscopy in secondary health facilities.

The introduction of supervised archiving and facility-level audits of RDT cassettes at PHFs, as well as BMMT for Laboratory Scientists at SHFs, were likely to have contributed to the reduction in the TPR. The sustained decline in RDT positivity from 71% in October 2021 to 53% in December 2022 at PHFs, and the significant decrease in microscopy-based TPR at SHFs from 53 to 18% over the same period, indicates that these measures were successful in improving diagnostic accuracy and data quality.

In this study, the average TPR was higher for RDT (65%) compared to microscopy (34%). This is similar to what has been found in other studies [32]. Several factors are thought to affect the accuracy and sensitivity of RDT, including storage, manufacturing deficiency and performance of the end user [33]. In addition, healthcare workers not being able to accurately conduct the tests using prescribed steps and accuracy in correctly recording test results have been noted as major factors affecting malaria test positivity rates in the field. The inaccuracy of the reported data can sometimes be due to inaccurate data recording, where negative test results are reclassified as positive to justify the administration of artemisinin-based combination therapy (ACT) for the treatment of the patient. In some instances, faint RDT test bands are sometimes misreported as negative or positive, and improper timing in reading test results can lead to false negatives.

Before the facility audits of RDT, a very high TPR among febrile clients tested for malaria with RDT was noted in the health facilities. These figures, compared to survey data, raise questions about the accuracy of the routinely collected health facility data. For instance, data from Therapeutic Efficacy Study (TES) conducted in Ibadan Oyo reported that the malaria incidence in 2021 was 45.7% [34] compared to health facility test positivity rates of 71% in the same year. Field visits often reveal inaccuracies in documentation and sometimes data falsification. Data falsification may occur when clinical patients are managed with ACT and documented as RDT positive or when negative test results are documented as positive. Several factors have been found to significantly affect the judgement of clinicians when dealing with RDT negative patients, including the provider’s cadre and previous training on other causes of fever [35].

Data falsification of service delivery data from other health interventions has also been noted to be driven by incentives, and system level studies have focused on numbers or targets to assess performance [36]. Some studies have shown inflation of data or overreporting of services provided, in addition to reclassification of cases [35,36,37]. This study showed improvement and a reduction in the test positivity rate because of accurate and improved data capture. Prior to cassette archiving, this study revealed that the average reported TPR at PHCs was 77%, while it reduced to 58% after archiving commenced. This is similar to the malaria TPR of 55% reported in a 2021 hospital-based survey in Ibadan [11].

Despite malaria microscopy being the gold standard for malaria diagnosis, its use is limited by factors such as the sub-optimal skills of health workers, poor quality stains and the infrastructural capacity of health facilities. Malaria diagnosis using microscopy not only detects Plasmodium species but also allows for speciation and parasite density counting. Training malaria microscopists significantly improves the accuracy of malaria microscopy test results. Following BMMT in September 2021, the overall prevalence of malaria in this study using microscopy was 29%. This study revealed a reduction in test positivity rates at the selected facilities after the BMMT training. This finding is consistent with many other studies showing concurrent improvements in the accuracy of malaria microscopy results and training of medical laboratory scientists on malaria microscopy [38,39,40].

The significant decline in TPR observed in both PHFs and SHFs suggests that the interventions not only improved the accuracy of the reported data but may also have enhanced the overall effectiveness of malaria control efforts by reducing the number of false positive test results. This is particularly important in the context of malaria elimination efforts, where accurate data is critical for monitoring progress. Institutionalizing RDT cassette archiving and audits and microscopy training as routine activities, holds significant potential for improving malaria case management reporting. These measures would not only ensure the reliability of reported data but also contribute to informed decision-making and targeted interventions. By embedding these practices into routine healthcare processes, a robust system for accurate data collection and analysis can be established, thereby supporting and accelerating malaria elimination efforts.

The study is a secondary data analysis; while the results suggest a causal relationship between the interventions and the observed decline in TPR, other factors including seasonal malaria trends, or environment conditions may have contributed to the changes in TPR over time. Further studies could investigate the long-term sustainability of the observed improvements in TPR and assess the potential for scaling up these interventions at the national level. However, sustainability may be challenged by factors such as maintaining interventions like RDT cassette archiving and auditing; and BMMT in resource-constrained settings. One limitation of this study is the absence of comparative data from other states in Nigeria where the interventions were not implemented. This lack of comparison limits the ability to conclusively attribute the observed improvements in TPR accuracy solely to the interventions.

Conclusion

The accuracy of reported data is another major concern in the fight against malaria. Factors contributing to data inaccuracy include the reclassification of negative test results as positive. This practice not only skews malaria prevalence statistics but also leads to the inappropriate use of ACT, which can promote drug resistance.

The introduction of facility audits for RDTs has shown promising results in improving data accuracy. This study revealed a significant reduction in the test positivity rate after the implementation of cassette archiving and audits. This reduction indicates that accurate data capture and improved reporting practices can lead to a more realistic understanding of malaria prevalence. Similar improvements were noted in accuracy of reports from malaria microscopy following the basic malaria microscopy training.

Improving the accuracy of malaria diagnosis is critical for effective health service planning and achieving malaria control targets. Training of Medical Laboratory Scientists in malaria microscopy and ensuring adherence to diagnostic protocols can significantly improve the quality of diagnostic results. Continued investment in training, infrastructure, and regular audits will help address the challenges faced in malaria diagnosis. Accurate data is essential for measuring progress, making informed decisions, and ultimately reducing the burden of malaria in Nigeria. By addressing these challenges, Nigeria can make significant strides towards better health outcomes and control of malaria.