Summary Objectives Acknowledging that mothers are often the primary caregivers at the household level, malaria control efforts have emphasized educating women in its early recognition. This fails to consider the context in which knowledge will be transformed into action, as women lack decision-making responsibility and financial resources. We examine the knowledge and power dynamics of provider–patient interactions and the implications for malaria treatment of educating mothers during consultations. Methods We conducted in-depth interviews in Tanga, Tanzania, with 79 household participants over 2 years to explore knowledge and perceptions of febrile illness, its treatment and prevention. We also interviewed 55 clinicians at government and private healthcare facilities about their patients’ knowledge and treatment-seeking behaviour. We analysed our data using a grounded theory approach. Results Informants had good knowledge of malaria aetiology, symptoms and treatment. Healthcare workers reported that mothers were able to give them sufficient information about their child for accurate diagnosis. However, health staff continued to see mothers who present ‘late’ as uneducated, intellectually incapable and lazy. Whilst evidence shows that decisions about treatment do not rest with mothers, but with male family members, it is women who continue to be blamed and targeted by health education. Conclusions Aggressive didactic teaching methods used by health staff may be disempowering those already equipped with knowledge, yet unable to control treatment decisions within the household. This may lead to further delays in presentation at a healthcare facility. We propose a rethinking of health education that is context-sensitive, acknowledges class and gendered power relations, and targets men as well as women.