Background <p>Malaria remains one of the most deadly mosquito-borne parasitic diseases, causing an estimated 263&#xa0;million cases and 597,000 deaths globally in 2023, according to the World Health Organization (WHO) World Malaria Report 2024. Ethiopia remains among the top malaria-endemic countries in sub-Saharan Africa, where the disease continues to pose a substantial public health challenge. Analysing prevalence trends using health-facility data is essential to guide malaria control and prevention efforts, although such data may not capture asymptomatic infections. Therefore, this study aimed to analyse a seven-year trend in malaria prevalence at Pawe General Hospital, located in a malaria-endemic district of northwestern Ethiopia.</p> Methods <p>A retrospective study was conducted using laboratory records collected between 2015 and 2021. All reported malaria cases were reviewed, and data completeness and consistency were verified before analysis. Data were analysed using SPSS version 26. Chi-square (χ²) tests were used to assess associations between malaria prevalence and selected independent variables such as sex, age group, and season. Odds ratios (ORs) were computed to quantify the strength of association between sex and malaria infection, with <i>p</i> &lt; 0.05 considered statistically significant.</p> Results <p>Among 155,669 suspected malaria cases, 11,495 (7.4%, 95% CI: 7.2–7.5%) were microscopically confirmed (mean ± SD: 1,642 ± 434 cases annually). Of these, 90.8%, 6.2%, and 3.0% were caused by <i>Plasmodium falciparum</i>,<i> P. vivax</i>, and mixed infections, respectively. Malaria prevalence fluctuated, showing alternating periods of decline and resurgence during the study period. The prevalence was significantly higher among males (8.8%, 6,178/70,021) than females (6.2%, 5,317/85,648), with males having 1.48 times higher odds of infection (OR = 1.48, 95% CI: 1.43–1.54; <i>p</i> &lt; 0.001). All age groups were affected, with the highest proportions observed among 25–54 and 15–24 year-olds.</p> Conclusion <p>This study demonstrated that malaria remains a major public health problem in the study area, with <i>P. falciparum</i> as the predominant species. The observed resurgence after 2018 highlights the need for strengthened surveillance and further investigation into potential contributing factors such as programmatic gaps, vector resistance, and environmental changes.</p> Clinical trial <p>Not applicable.</p>