Objective To evaluate treatment practices for uncomplicated malaria after the policy change from chloroquine to sulfadoxine-pyrimethamine and to artemether-lumefantrine in Zambia. Design Cross sectional survey. Setting Outpatient departments of all government and mission facilities in four districts in Zambia. Participants 944 children with uncomplicated malaria seen by 103 health workers at 94 health facilities. Main outcome measures Antimalarial prescriptions in accordance with national guidelines and influence of factors on health workers' decision to prescribeartemether-lumefantrine. Results Artemether-lumefantrine, sulfadoxine-pyrimethamine, and chloroquine were available, respectively, at 48 (51%), 94 (100%), and 71 (76%) of the 94 facilities. Of 944 children with uncomplicated malaria, only one child (0.1%) received chloroquine. Among children weighing less than 10 kg, sulfadoxine-pyrimethamine was commonly prescribed in accordance with guidelines (439/550, 79.8%). Among the children weighing 10 kg or more, sulfadoxine-pyrimethamine was commonly prescribed (266/394, 68%), whereas recommended artemether-lumefantrine was prescribed for only 42/394 (11%) children. Among children weighing 10 kg or more seen at facilities where artemether-lumefantrine was available, the same pattern was observed: artemether-lumefantrine was prescribed for only 42/192 (22%) children and sulfadoxine-pyrimethamine remained the drug of choice (103/192, 54%). Programmatic activities such as in-service training and provision of job aids did not seem to influence the prescribing of artemether with lumefantrine. Conclusion Although the use of chloroquine for uncomplicated malaria was succesfully discontinued in Zambia, the change of drug policy towards artemether-lumefantrine does not necessarily translate into adequate use of this drug at the point of care.

Background: Zambia was the first African country to change national antimalarial treatment policy to artemisinin-based combination therapy -artemether-lumefantrine. An evaluation during the early implementation phase revealed low readiness of health facilities and health workers to deliver artemether-lumefantrine, and worryingly suboptimal treatment practices. Improvements in the case-management of uncomplicated malaria two years after the initial evaluation and three years after the change of policy in Zambia are reported.