How Presumptive Treatment Undermines Care-Seeking and Why Point-of-Care Testing Changes Everything
In community health work, we often treat “building trust” as a checkbox on a project plan. In reality, trust develops slowly. I learned this vividly during recent ZAFI-related PhD fieldwork in Batu, Ethiopia.
Trust can shorten the time between the onset of symptoms and seeking care. In communities where Health Extension Workers (HEWs) are perceived as trusted healthcare providers, families often seek advice on the first day of a child’s illness. Where trust is fragile, caregivers describe a different pathway: trying home remedies first, waiting to see whether symptoms improve, or consulting neighbors. Visiting a health post often occurs only when a child stops playing or eating.
A few months ago, we held a co-creation workshop for the project. That event paved the way for subsequent ZAFI activities. When I returned to Batu for data collection, the community was at ease—thanks in large part to the visible presence of local HEWs and community opinion leaders who had participated in the workshop and helped facilitate my entry into the community and the research activities.
In Batu, febrile illness is not a hidden problem waiting to be uncovered by researchers. It is an everyday reality—the “default illness” that community members expect to live with. Working in a community where fever is viewed as a permanent and unavoidable feature of life underscores the threat it poses. People want solutions, yet the health system has not yet convincingly provided them.
Caring for Many with Little Support
One observation that emerged repeatedly was the link between high fertility, household responsibilities, and health-seeking behavior. One participant recounted the following experience:
“Walking through a neighborhood, I heard coughing. I entered a house and found a two-year-old lying on the floor, coughing repeatedly and burning with fever. I asked the mother why the child had not been taken to a health facility. She replied, ‘I have two children under three, and I am pregnant, as you can see. My husband is away. I am waiting for him to come back so he can look after the other child.”
This story illustrates that care-seeking is not simply a matter of knowledge, cost, or physical access. It is shaped by family structure, caregiving responsibilities, and the availability of social support. Without someone to watch a healthy sibling, a mother may be unable to take a sick child to a clinic, however much she wants to.
When a Negative Test Offers No Answer
The problem does not end when families reach the clinic door. Study participants consistently described knowing what to expect from a health facility visit—and being let down. When a mother waits for hours only to be told that her child’s malaria test is negative, and the facility has no alternative diagnosis or medicines to offer, she feels failed. Out of desperation, she may visit a private clinic and purchase antimalarial medicines anyway.
This pattern has serious clinical consequences. Children with fever, including those suffering from zoonotic acute febrile illness, may receive antimalarial treatment without appropriate diagnostic assessment, resulting in misdiagnosis and delayed management of the underlying conditions. When alternatives are unavailable at frontline facilities, “default malaria” becomes a crutch. We are failing these children not because we lack scientific knowledge, but because communities lack access to it.
“To cure the disease, we must first accurately see it. Systemic blindness is not a lack of science; it is a lack of access.” Health Extension Worker (Field Interview, 2026)
Bringing Care to the Doorstep
These two issues—overburdened families and under-resourced health systems—reinforce one another. Caregivers are encouraged to travel to health facilities, only to receive a negative malaria test result and no viable alternative.
Caregivers in Batu are not passive recipients of illness. They actively manage illness through a combination of home remedies, medicines purchased from drug shops, and treatment or advice from traditional health, depending on their perceptions of the illness and the resource availability to them. They do not expect the health system to replace their existing care strategies. Rather, they want it to provide solutions when those strategies are insufficient.
The solution, although challenging in resource-constrained settings such as Batu, is clear: we must bring health services closer to communities. Rapid, technology-supported point-of-care diagnostics for febrile illness—capable of identifying a wider range of causes—could enable appropriate treatment. Such technologies have the potential to reduce diagnostic delays, minimize inappropriate use of antimalarial drugs, improve detection of zoonotic infections, and ultimately strengthen community trust in the health system.
