This study provides data on the comparative feasibility of microscopy and RDT among outpatients attending government rural primary health care centres located within areas of varying transmission intensities. The study findings indicate that RDT was more feasible than microscopy and prescribers were unlikely to adhere to negative results especially in the microscopy arm.
It is reported here that patients attending HCs with RDT as the method for malaria investigation had a higher probability of getting a parasitological test done regardless of age and transmission setting. Out of 133 clinical and laboratory staffs trained in 30 HCs, 56 were in the RDT arm and they performed the testing of patients during the whole period of study implementation. In the microscopy arm, the staff either had clinical or laboratory roles, although clinicians were able to prepare usable thick smears. Microscopy was the sole responsibility of the laboratory assistants. This meant that the RDT diagnostic services were not interrupted even if the laboratory assistants were away on leave. Performing RDT takes a much shorter time than microscopy. Therefore given a similar time, more patients could be tested in RDT compared to microscopy. RDTs reduced the patient waiting time compared to microscopy and were thus more convenient for health workers and patients. An earlier investigation  also reported a high number of patients tested by RDT. However, that study did not have a microscopy arm and therefore constraining a full comparison with the current findings. In Tanzania, a study that introduced routine use of malaria RDTs only resulted into 35% of patients being tested .
The risk of a febrile patient not getting a malaria diagnostic service was higher in HCs with microscopy and even far higher among patients under-five years of age. The current malaria treatment policy in Uganda and WHO  recommend that malaria case diagnosis be based on parasitological confirmation either by microscopy or RDT. An earlier publication reported a shortage of staff where only 34% of laboratory assistant posts were filled, although only four HCs had functioning laboratories at the time . In order to improve the availability of microscopy services, there is need to functionalize the laboratories and to train and post at least two laboratory assistants at each HC. The low rate of malaria tests done in the microscopy arm adds to previous reports [13–15, 23] regarding the microscopy limitations, signifying the difficulties surrounding its feasibility and scale up of the service.
With routine use of parasitological confirmation of malaria, prescription of AL was reduced by 28.1% between presumptive and microscopy; and by 38% between presumptive and RDT. This benefit was also reported in other studies [21, 24], but it was offset by continued prescription of AL to patients with negative results. Indeed treatment of this "negative syndrome" with AL is a cause for concern in both intervention arms, and it was significantly higher in the microscopy arm in both transmission settings and age groups. This might imply prescribers were unlikely to adhere to negative microscopy results. Prescribing anti-malarials among patients with negative results has also cited [2–4, 9, 21, 22, 25–27]. The behaviour of treating negative patients with AL may reflect the hangover of previous practices of presumptive treatment, doubting accuracy of test methods, patients having been on anti-malarials before, or clinicians not knowing how to treat patients with negative results due to lack of clear guidelines. The continuous prescription of anti-malarials by clinicians disregarding negative test results is likely to impact on the cost-effectiveness of the diagnostic methods, clinical care of patients as well as increasing the costs of diagnosis and that of the overall treatment. Furthermore if negative patients continue receiving anti-malarials, health workers are more likely not to see the need for parasite-based diagnosis and may not be motivated to implement the policy. Therefore, service providers need support and guidelines on how to manage patients with negative results.
In the preparation for the study, RDTs, AL and laboratory supplies were delivered by the study team to the district medical stores. However, AL stock-out occurred in the high transmission setting that resulted into a reduction in the number of outpatient attendance. Subsequently this impacted on the number of patients enrolled in the high transmission setting. RDTs were in-stock throughout the study implementation period. The training of staff for this study took one day. However, other cadres of staff without such skills as HIV testing might require slightly longer period (three to five days). To acquire adequate skills for example in testing malaria with RDT, it is important to make frequent supervisory visits and tapering the number of visits with time. In this study, it was planned to have three diagnostic arms (presumptive, RDT and microscopy). Further research should consider incorporating the arm of RDT plus microscopy.