Majority of the facilities still use syndromic approach in the diagnosis of malaria. This finding is not surprising as this had been previously reported from many endemic countries . Using a syndromic approach in diagnosis of malaria means increased likelihood of unnecessary prescribing of antimalarials , because some other febrile illnesses that are not malaria might have been treated as malaria. Also the use of, laboratory diagnosis (RDTs and microscopy) was low in this study. The low use of microscopy at 39.2% for diagnosis in this study is similar to the findings of a previous study in Nigeria where a study based on an audit of 665 patients' records from public and private hospitals found that 45% of patients had diagnostic blood slides . Laboratory diagnosis can improve rational provision of malaria treatment service as it has been found that prescribing anti-malarials only after laboratory confirmation reduced the total number of prescriptions by 68% in Malawi .
The level of awareness of RDTs by all the providers was not high enough for such an item of enormous utility as RDTs. This calls for the employment of means of creating awareness about RDTs among health workers. If people do not know about a new product and the likely benefits that could accrue from its use, they are not likely to use it and this may lead to market failure. Doctors, CHEWs and laboratory technologists were more likely to be aware of RDTs than nurses. This is not unusual for the laboratory technologists since their main job is to conduct tests. The respondents in urban areas and in public facilities were more likely to be aware of RDTs. The reason for this may be that more attention has been paid to public facilities by government and partner agencies in recent times to improve the case management of malaria in Nigeria.
If more than half of the respondents said RDTs were ever available at their facility of work, and yet the rate of use is low, it then becomes a cause for concern and a threat to the current effort to improve the case management of malaria. Some health workers gave the unreliability of RDTs as a reason for not utilizing available RDT kits. This suggests they do not trust the results despite the fact that RDTs have been found to have a sensitivity of 90.6% and a specificity of 95.9% in Nigeria [9, 10]. It has been noted that health workers still treat for malaria even when RDT result is negative . However, most of the health workers who are still using RDTs tend to be satisfied with the results they get. It is possible that poor technique, or even poor preservation of the RDT kits could give rise to poor results which made some health workers to say they stopped using RDTs because it was not reliable. Heat-stability has been noted to be a major concern for some RDTs, especially under field conditions and the health workers may have been exposed to different brands of RDTs including those with health stability problems .
Interestingly, RDTs were more available in the rural facilities than urban facilities, a finding that favours the scaling-up of RDTs since a majority of Nigerians live in rural areas. However, the fact that the government was the source of RDTs for only 3 facilities is worrisome. How does W.H.O. intend to promote the RDT use if the government is obviously lacking any interest? This is further confirmed by the fact that the source of information on RDTs was never through formal training sessions promoted by government, as it should be. Although RDTs are still new in Nigeria and currently there are no policies in place on its usage in the diagnosis of malaria except for that from W.H.O, government should play a lead role and make RDTs available to more public facilities.
A majority of the health workers preferred RDTs to blood film microscopy which is a positive finding as this will encourage their use of RDTs. Some of the limitations of the use of RDTs as noted by the health workers included the lack of skills to use it. This is likely to affect the results of RDTs, a fact that has been raised by some authors [23, 24]. An intervention area to improve this will be to conduct training and re-training of health workers on the use of RDTs. A positive finding however, is that health workers in both public and private facilities know RDT could be affected by temperature and humidity. This is good for quality control although a good number in the public facilities are not aware of this..
The supply of RDT kits to health facilities in Enugu State has been rather erratic and most RDTs are still purchased in the open market. This could lead to purchase of fake kits if the market is not properly regulated as evidence has shown that the drugs in the Nigerian market may be ineffective, counterfeit or expired .
Surprisingly, the drug of choice for the treatment of uncomplicated malaria in the study areas was ACT. This is particularly a positive development in the push to improve the case management of malaria in Nigeria. However, this finding contrasts with a Nigerian survey of malaria control practices that showed that less than a fifth of the primary and secondary health facilities used the recommended ACT  and that monotherapies such as Chloroquine, SP, Quinine, Artesunate and Dihydroartemisinin were still widely used for treatment of malaria .
ACTs especially the recommended first-line types in the national treatment policy (Artemether-Lumefantrine (AL) and Artesunate+Amodiaquine (AA) were readily found in public facilities in diverse trade names. However, it will be noted that as a matter of policy, ACTs are supplied free of charge to children who are under 5 years in public health facilities in Enugu, Nigeria  and this may have accounted for the large presence of ACT in these facilities. The Nigerian malaria control programme also delivered 4.5 million courses of ACT in 2006 and 9 million in 2007 . ACTs can also be purchased over the counter without a prescription, and can be dispensed by a non medical personnel. In Nigeria, pregnant women and children receive free SP and ACTs respectively from all public health facilities; however this does not apply to private facilities. In the private sector charges are fixed by the owners of the facilities while in government facilities there are often specified fees for services.
The study shows that ACTs were still not readily available in private facilities but were more available in both types of facilities than RDTs. This calls for strategies to ensure that both ACTs and RDTs are made available to private health care providers at a subsidized rate in form of public private partnership. But in doing this, there is need for sustainable monitoring systems as monitoring and influencing the quality of private services is recognized as a key component of effective malaria treatment 
However, the fact that ACTs are readily available (and not RDTs) and are used and considering the fact that most health workers still employ syndromic approach for the diagnosis of malaria, it then means that some patients will be treated with ACTs without laboratory diagnosis. Parasitological diagnosis of malaria is an important parameter leading to the appropriate use of anti-malarial drugs. Improper and abusive use of ACTs without proper diagnosis will have a direct clinical and economic impact [6, 29, 30]. This therefore calls for interventions at policy and programmatic levels to improve treatment provision. And one obvious intervention will be ensuring that providers stocked adequate doses of RDTs and ACTs and subsequently used them so as to decrease unnecessary treatment and reduce societal costs of malaria.
We did not review the brands of RDTs found in these facilities and we acknowledge this to be a limitation of the study. Further studies should audit the type of RDTs in these facilities as they vary greatly in effectiveness. The sampled facilities may not be a representative sample for the whole country and therefore the results may not be representative of the country. Nevertheless, we believe that this is a representative sample of all health facilities in the area of study and the state and therefore a good starting point in understanding the tremendous gap existing between the optimal, W.H.O. promoted policies of RDTs and ACTs and the real application in practice.