Prevalence of injection use at the household level
The study confirms that injections are very popular in both countries. Prevalence of injection use in the past two weeks is quite high in all of the areas studied in the two countries under consideration. The highest two week prevalence rate is found in Lombok (Indonesia) where 45% of the households report that at least one member of the household has received an injection in the past two weeks; in Lebak this is 42%. Taking the total research population as the denominator, it could be established that in Lebak 10% of all household members had been injected in the past two weeks, and in Lombok 12%. In Uganda, the rates for injection use at the household level were somewhat lower than in Indonesia. Here, during the confined two week period, 30% of the households in Ankole and 25% in Busoga report having received at least one injection. During the initial visit, the reported injection use in the past two weeks was somewhat higher in both areas, especially in Busoga.
Most injections are given for therapeutic reasons. Intravenous drips are not very common. Immunizations do not account for the bulk of the injections in children, in fact, they are not reported very frequently (accounting for 6 to 15% of the households who had received an injection in Uganda and 3 to 4% of individuals receiving an injection in Indonesia). Contraceptive injections are only reported in Lebak (1%).
In Indonesia, it could be established that the very young constitute a high risk group for receiving injections. In Lebak, 18% of the total research population of children under five received an injection in the past two weeks, in Lombok this percentage is even higher: 22%. The percentage of children under five injected is twice as high as the average injection rate (between 10 (Lebak) and 12% (Lombok)). Since most immunizations occur in this age group, the data should be corrected for this factor. However, only a slight percentage of all injections are immunizations in both districts. The data of injected persons in Indonesia indicates that there is no sex difference in injection use.
With regard to injection prevalence rates between the urban, suburban and rural areas, no differences could be established in Indonesia between the various communities. This may be explained by the fact that public health services are widespread, even in the rural areas. In Busoga, Uganda, injection use prevalence is highest in the semi-rural and urban areas and lowest in the remote areas. Since most of the injections were given by private or non-formal providers or at home, this is probably not related to the availability of public health services. In Ankole, no urban-rural differences were found.
The bulk of the injections received at the household level in Indonesia originate from the public sector. Over half of the injected persons receive their injections in the so called puskesmas (health centre). The share of the private health services (both formal and informal) is much smaller. In Lebak, 10% of all injections were received in doctor's private practices and 19% in a nurse's private practice. In Lombok, private practices of doctors are more popular: 20% of all injections had been given there, while only 1% of the injections come from a nurse operating a private practice. Only a small number of injections in Indonesia is given at home and by non-medically trained personnel. It can be concluded that, as most nurses with an (illegal) private practice also work in the puskesmas, injection use in Indonesia is very much a part of the official, government health care system. The injection equipment used in the puskesmas originates partly from the Ministry of Health supplies, and is supplemented by purchases from pharmacies and wholesalers.
In Uganda, the picture that emerges from the data of the study is totally different. Only a minority of the injections is given in the government health facilities: 35% in Busoga and 23% in Ankole. Private medical practices are far more popular. They are responsible for the bulk of all injections given: in Busoga 36% and in Ankole even 47% of all injections are received there. Most striking, however, is the fact that many injections are given by non-formal providers or at home (by family members). In Busoga, 11% of the injections have been received at a non-formal facility (in Ankole this percentage is 15%) and 17% at home (in Ankole 16%). This reflects the fact that in Uganda public facilities are often mistrusted and held responsible for the spread of the AIDS-epidemic. The distribution channels for the injection equipment reflect this situation: injectionists and customers buy their syringes and needles over the counter from pharmacies. The government and NGO clinics largely depend upon foreign donations distributed through the UEDMP-kits and other institutions.
In both countries, households report a high burden of illness. In Uganda, some 70% of households in both regions have had one or more sick members in the past two weeks. In Indonesia, prevalence of illness ranges from 80 (Lebak) to 70% (Lombok). Over one fifth of all subjects in Lebak and Lombok claimed to have suffered an illness episode in the past two weeks. While there are no differences between illness rates in Lebak than in Lombok, the level of health seeking behaviour and the injection rates of the household members are higher in Lombok. Help is more often sought and more patients who seek medical attention are being injected (62 against 59% in Lebak). Injection rates per health facility, especially in Lombok, are very high. It can be calculated from the household survey that in Lebak, of all visits to formal health facilities, between 40 to 56% end in one or more injections; in Lombok these percentages are between 70 and 83%.
Prevalence of injection use at the level of health facilities
The study also investigated injection use at the level of health facilities. In Uganda prescriptions of 30 consecutive patients in formal health facilities (14 in Busoga, 12 in Ankole) were recorded. Injection rates are fairly high in both regions: between six to seven out of every ten patients received an injection. In Busoga, 68% of the prescriptions contained at least one injection against 60% in Ankole.
In Indonesia, patients - mainly in public health facilities - were interviewed about their complaints and about treatment given. In Lebak, 71% of the patients interviewed in public health centres had been injected. Therefore, of every ten patients treated seven received an injection. In Lombok, the mean injection rate in public health facilities is even higher: 87%. Almost nine out of ten visits here end with one or more injections being given.