Objective:To establish the appropriateness of malaria case management at health facility level in four districts in Zambia.Methods:This study was a retrospective evaluation of the quality of malaria case management at health facilities in four districts conveniently sampled to represent both urban and rural settings in different epidemiological zones and health facility coverage.The review period was from January to December 2008.The sample included twelve lower level health facilities from four districts.The Pearson Chi-square test was used to identify characteristics which affected the quality of case management.Results:Out of 4891 suspected malaria cases recorded at the 12 health facilities,more than 80%of the patients had a temperature taken to establish their fever status.About 67%(CI_(95)66.1-68.7)were tested for parasitemia by either rapid diagnostic test or microscopy,whereas the remaining22.5%(CI_(95)213.1-23.7)were not subjected to any malaria test.Of the 2247 malaria cases reported(complicated and uncomplicated),71%were parasitologicaily confirmed while 29%were clinically diagnosed(unconfirmed).About 56%.(CI_(95)53.9-58.1)of the malaria cases reported were treated with artemether-lumefantrine(AL),35%(CI_(95)33.1-37.0)with sulphadoxine-pyrimethamine,8%(CI_(95)6.9-9.2)with quinine and 1%did not receive any anti-malarial.Approximately 30%of patients WHO were found negative for malaria parasites were still prescribed an anti-malarial,contrary to the guidelines.There were marked inter-district variations in the proportion of patients in WHOm a diagnostic tool was used,and in the choice of anti-malarials for the treatment of malaria confirmed cases.Association between health worker characteristics and quality of case malaria management showed that nurses performed better than environmental health technicians and clinical officers on the decision whether to use the rapid diagnostic test or not.Gender,in service training on malaria,years of residence in the district and length of service of the health worker at the facility were not associated with diagnostic and treatment choices.Conclusions:Malaria case management was characterised by poor adherence to treatment guidelines.The non-adherence was mainly in leans of:inconsistent use of confirmatory tests(rapid diagnostic test or microscopy)for malaria;prescribing anti-malarials which are not recommended(e.g.sulphadoxine-pyrimethamine)and prescribing anti-malarials to cases testing negative.Innovative approaches are required to improve health worker adherence to diagnosis and treatment guidelines. Objective: To establish the appropriateness of malaria case management at health facility level in four districts in Zambia. Methods: This study was a retrospective evaluation of the quality of malaria case management at health facilities in four districts conveniently sampled to represent both urban and rural settings in different epidemiological zones and health facility coverage. The review period was from January to December 2008. The sample included twelve lower level health facilities from four districts. The Pearson Chi-square test was used to identify characteristics which affected the quality of case management. Results: Out of 4891 suspected malaria cases recorded at the 12 health facilities, more than 80% of the patients had a temperature taken to establish their fever status. About 67% (CI_ (95) 66.1-68.7) were tested for parasitemia by either rapid diagnostic test or microscopy, while the remaining 22.5% (CI_ (95) 213.1-23.7) were not subjected to any malaria test. Of the 2247 malaria cases r Of the malaria cases reported were treated with artemether-lumefantrine (AL), 71% were parasitologicaily confirmed confirmed while 29% were clinically diagnosed (unconfirmed). About 56%. (CI_ 35% (CI_ (95) 33.1-37.0) with sulphadoxine-pyrimethamine, 8% (CI_ (95) 6.9-9.2) with quinine and 1% did not receive any anti-malarial.Approximately 30% of patients WHO were found negative for malaria parasites were still prescribed an anti-malarial, contrary to the guidelines. These were marked inter-district variations in the proportion of patients in WHOm a diagnostic tool was used, and in the choice of anti-malarials for the treatment of malaria confirmed cases .Association between health worker characteristics and quality of case malaria management showed that nurses performed better than environmental health technicians and clinical officers on the decision whether to use the rapid diagnostic test or not .Gender, in service training on malaria, years of residence in the district and length of service of the health worker at the facility were not associated with diagnostic and treatment choices. Conclusions: Malaria case management was characterised by poor adherence to treatment guidelines. The non-adherence was mainly in leans of: inconsistent use of confirmatory tests (rapid diagnostic test or microscopy) for malaria; prescribing anti-malarials which are not recommended (egsulphadoxine-pyrimethamine) and prescribing anti-malarials to cases testing negative. Innovative approaches are required to improve health worker adherence to diagnosis and treatment guidelines.