At the turn of this new century and after much debate, the malaria community reckoned with failing first line therapies and moved to a global recommendation for deployment of an artemisinin-based combination therapy (ACT) to treat infections due to Plasmodium falciparum. No one said it was going to be easy. This series in the Malaria Journal reports longitudinal snapshots of how the core pillar of malaria elimination of ensuring universal access to malaria diagnosis and treatment is faring-it is safe to say "not so well". Core issues that must be addressed to ensure universal access to diagnosis and treatment, and achieve elimination, include lack of access to these essential services for those with malaria and the lack of a common effective service delivery approach to ensure high quality diagnosis and treatment, especially in the private sector which provides the bulk of malaria case management services in many settings. The barriers to universal access to high quality diagnosis and treatment for malaria will need to be addressed if malaria elimination is to remain a real possibility in the foreseeable future.