Health care in malaria endemic areas of Africa is at a crucial tipping point. On the positive side, increased commitment to and funding for malaria control is leading to improved access to effective antimalarial drugs, with over the counter availability and extensive subsidies. However, current efforts do not yet adequately address the need for tools to diagnose malaria accurately and track its incidence. Since presumptive case management leads to dramatic overuse of antimalarial drugs, programmes to improve access will also inevitably lead to further inappropriate treatment for individual patients, increased risk of parasite resistance to antimalarial compounds, and the potential diversion of hundreds of millions of dollars worth of antimalarial drugs to patients who do not actually have malaria. It is vital to make effective antimalarial treatment widely available,1 2 but doing so without equally intensive efforts to improve access to parasite based diagnosis is likely to be counterproductive. Thoughtful implementation of malaria diagnostics has the potential to improve care and resource allocation, with broad public health significance.