Government recommends the use of reusable equipment only. With the co-sponsorship of big donors such as Danish Red Cross and UNICEF, the Ministry of Health now provides only reusable injection equipment to its units for both curative and immunization services. These are provided together with paraffin, sterilizers, training and logistics for supervision by higher health care managers. Private pharmacies and drugshops act as the significant sources of disposable injection equipment to providers and users.

The reusable equipment observed was mainly plastic. A few glass syringes were also identified in provider facilities and in users’ possession. However, the distinction between reusable and disposable equipment was not made by the majority of providers and users who treat all equipment as reusable. Some providers maintained mat some disposable equipment, especially syringes, may outlive reusables. This removes the boundary of reusable and disposable.

Based on observations at providers facilities an estimated sixty percent of the patients presented with their personal equipment to the clinic. Nearly all the provider facilities sell equipment to patients with injection prescription or at index visit. In one of the urban private clinics, needles were sold to patients at each subsequent visit; these would then be applied to an old syringe which the patient carried along. The rationale was that the syringe offered little chance of transferring contamination as compared to the needles. This contrasted with the semi-rural and remote government health centres which offered only needles for sale to the patient while syringes were provided by the health centre. Government health centres are sometimes provided with more needles than syringes.

Provider facilities in urban areas attending to company patients are paid by the employers for providing treatment. These patients refused to carry along used equipment and requested a new sealed set of needle and syringe for each injection administered. This suggests that many patients would prefer new sterile equipment at each visit but cannot afford it. In contrast, company patients have their medical bills settled by their employers, so they can demand new equipment at each visit.

The mistrust in the effectiveness of ‘communal sterilization’ is evident in both patients and health providers. It is common practice especially among the semi-rural and remote communities for patients to contact the provider for the injectable and then arrange for the injection to be administered at home. In other cases patients present with used equipment on index visit to the provider.

Sterilization/high level disinfection

The methods of sterilization observed in the Busoga study were as follows:

Table 15: Methods of sterilization observed at providers facilities in Busoga Region

Boiling

Sterilization through boiling was used by all providers. No special skill or technology is required for it to be effective. In the semi-rural and remote provider facilities, and in households, cooking pans were used for boiling the equipment. This has contributed to the easy personalization and domestication of the injection equipment. Providers instruct patients to boil the issued equipment prior to visiting their facilities. However, interviews with patients at the provider facilities indicate that boiling was not actually done by many patients. This fact was known to the providers but they continued using the equipment. One itinerant injectionist in a remote community did not even allow the equipment to stay boiling in water for more than one minute before he used it.

The major fuel for sterilization in the semi rural and remote communities is firewood and charcoal.¹³ In government and NGO provider facilities standard sterilizing equipment was utilized. The urban private clinics also possessed standard sterilization equipment, which are in most cases siphoned off from the government health units. This equipment is adaptable to charcoal, paraffin and electric stoves.

¹³ According to the 1991 population census data, over 90% of Uganda’s population depends on firewood and charcoal for cooking.

The frequency of boiling of equipment varies from facility to facility. However, the majority of established provider facilities boil their instruments once a day in the morning before patients start reporting. Some providers complained that the sterilization procedure was rather long, involving the washing of needles and syringes individually. The same equipment is therefore used on multiple patients, especially in the remote provider facilities. In the urban and semi-rural provider facilities where over 60% of the patients come with their syringes and needles, quite a lot of equipment remains unused. These are sterilized again for use the following day. The busy provider facilities such as the hospital, NGO facilities and urban private clinics keep their boilers on throughout the busy hours (10 am - 2 pm). The used needles and syringes are flushed and immersed in the boiling water. Here, it is difficult to distinguish the equipment that has just been immersed in the water from that which has been boiling for the last 20 minutes.

Steam sterilization

This is employed only in those provider facilities offering immunization services under the UNEPI. Portable steam sterilizers issued by UNICEF are utilized. The method is properly applied by the responsible units. From the users’ point of view this sterilizing procedure is more acceptable than other methods employed in public health services - they witness the opening of the sterilizer.

Chemical sterilization/high level disinfection

This method was observed in one private clinic in an urban area. Hypochlorite 10% solution was used. The provider learnt from a medical review that it is effective against HIV and this was the major reason for applying it. The equipment is flushed with the solution before washing with water. This is done to patient owned equipment. The facility-owned equipment is immersed in the solution for hours before boiling. This double sterilization, he says, has not failed the unit in preventing injection abscesses.

With respect to sterilization, the Ugandan situation is rather unique. Sterilization of equipment is not confined to established biomedical institutions; instead the provider facilities normally require the users to sterilize their equipment at home before and after visiting the provider facility. In all communities visited it was clear that the lay person’s standards of sterilization diverged from those stipulated by biomedical experts. For instance, disposable needles and syringes are in most cases handled like reusables, although there are instructions on the packaging for disposable needles and syringes that they are for single use, and that they are only sterile if package is not damaged. Some of the users interpreted single use to mean single illness episode, or that they arc for individual use only and therefore not harmful. Accordingly, there was a problem of disposing equipment. Some people are of the view that things to be destroyed should be only those items which have no use or are beyond repair. Something dirty or contaminated still has value. Others believe that self contamination with personal equipment is not possible. People lack clear understanding about the dangers of unsterile needles and syringes. Besides the general lack of concepts of hygiene and sterilization, many households especially in the remote and semi-rural areas consider family control over the needles and syringes and personal knowledge of the users to be a more significant and determining factor in the safety of injection than actual sterilization procedures. In fact, it is understood that the locus of contamination is outside the household.