Malaria is the major cause of illness in Cameroon, responsible for 40 percent of medical consultations. For this reason, the Head of State along with his African Union peers in April 2000 and 2006 undertook to achieve universal access to malaria control interventions, including effective treatment (10;12). Uneven distribution of health services, especially in rural areas, and high poverty rates make health care and drugs inaccessible or unaffordable (14;16). Therefore, the World Health Organization recommends building comprehensive mechanisms grounded on relevant social and community organizations, including the private sector, to improve access to care for vulnerable populations (22;23). Accordingly, the strategic plan to fight malaria in Cameroon, endorsed by the National Committee to Roll Back Malaria, recommends home-based management of malaria (HMM) to improve access and reduce delays in treatment (12).

In the Central African Republic (CAR) malaria is a major public health problem and hampers socioeconomic development. It accounts for 40 percent of complaints and 10 percent of deaths in health facilities (15;17). Pregnant women, who make up 4 percent of the population, and children under 5 years of age, who represent 17.3 percent, are the groups most vulnerable to malaria owing to their low levels of immunity.

Malaria in Ethiopia is one of the leading causes of death (21.8 percent), consultation in outpatient departments (17.8 percent) and hospital admissions (14.1 percent) (2;14). To overcome this problem, the Malaria Control Program (Federal Ministry of Health) has designed a community-based malaria treatment approach that played key roles in malaria epidemic control and community mobilization as well as vector control operations. In this approach, Community Health Workers (CHWs) and Village Malaria Workers, volunteers selected by community and trained on malaria diagnosis and treatment as well as indoor residual spray for few days (16). However, sustainability of this approach has been a challenge to the malaria control program. Thus, institutional arrangements in which every Kebele (the smallest administrative unit of 5,000 people) has a health post staffed by two Health Extension Workers (HEW) as part of the country's health system is a breakthrough to strengthen malaria control. A study has shown that more than half of the patients with fever visit CHWs and private health facility services (4).

Malaria is a major cause of morbidity and mortality in Mozambique. Approximately 6 million cases are reported each year. Malaria accounts for approximately 40 percent of all outpatient visits and 60 percent of pediatric hospital admissions. It is the leading cause of death among children admitted to pediatric services. Malaria transmission takes place year round with a seasonal peak extending from December to April. More than 18.5 million people in Mozambique are considered to be at-risk of malaria, including an estimated 3.6 million children less than 5 years old and almost 1 million pregnant women (13). The Presidential Malaria Initiative (PMI) -supported Malaria Indicator Survey, conducted in 2007, found the national prevalence of malaria parasitemia among children 6 to 59 months old to be 38.5 percent, with a range by province from 60.4 percent in Nampula to less than 10 percent in Maputo. Among pregnant women, the parasite prevalence was 16.3 percent, with 30.1 percent of women in their first pregnancy demonstrating parasites on blood slides (11).

The World Health Organization (WHO) since June 1998 has advocated for the use of artemisinin-based combination therapies (ACTs) in countries where Plasmodium falciparum malaria is resistant to traditional antimalarial therapies such as chloroquine, sulfadoxine-pyrimethamine, and amodiaquine (19;22). In 2006, WHO released evidence-based guidelines for the treatment of malaria backed by findings from various scientific studies (21). During the period between 2002 and 2006, all the five East African states Tanzania, Kenya, Uganda, Rwanda, and Burundi changed their national antimalarial treatment policies to use ACTs as first-line treatments for uncomplicated falciparum malaria and commenced with deployment of the drugs in the state-managed health facilities (12–15). To scale up the use of ACTs in the East African region to combat malaria and speed up progress toward the sixth Millennium Development Goal, a combination of delivery, financial, and governance arrangements tailored to national or subnational contexts needs to be considered.