In both regions it is evident that many providers, especially private ones, apart from providing a service, are strongly motivated by a desire to make money. In order to attract their clientele an injection has to be provided, because most patients feel they only got their money’s worth if an injection is included in the treatment. The provider survey findings reveal that the provider’s profit motive favours injections which yield more than oral therapy. For instance, comparing malaria treatment at the various health facilities in Busoga, the study findings indicate that 84% of the antimalarial prescriptions at the profit-oriented health facilities are injections as compared to 66% at the non-profit oriented facilities. At one of the private clinics in an urban area, a full treatment course of chloroquine tablets earns a profit of U. Shs. 240 as contrasted with U. Shs. 2000 from injection treatment; over 20% of the profits gained from injection treatment are obtained from the sale of needles and syringes.
In Busoga, some of the providers justify the prescription of injections in that it gives them greater control over the treatment and limits patient non-compliance. Unlike tablets or oral medications which are often administered by the patient, the injection is administered by a health specialist. Providers claim that the majority of patients do not observe times to take medicines and that many skip doses. According to them, there is also a danger of overdosage. This has become the justification of providers for injection prescription as a rule of medical practice in many communities.
Patients often demand injections. In Ankole, this practice is common at non-formal facilities and homes where diagnosis by the patient or patient’s family determines the mode of treatment. In both regions, it is not unusual for patients to indicate to the providers that they had attempted self-medication with tablets prior to visiting the provider. Since tablets proved ineffective, they want an injection. The users also believe that medicine injected into the blood stream does not leave the body as quickly as that administered orally. Oral medicine is often compared to food which enters the digestive system and eventually leaves the body through defecation. For diseases that are transmitted through the blood system, the administration of the treatment into the blood stream is believed to attack the disease directly at the source. In the case of (suspected) malaria, injections are also preferred to chloroquine oral treatment because of the perceived side-effects of the latter form of medication. Chloroquine tablets are said to cause nausea and itching. The tablets are bitter and not palatable and therefore particularly difficult to administer to children. Other patients who had recurrent malarial attacks claimed that these do not respond to tablets. For some, preference for injection is guided by the idea that it cured or provided a source of relief during previous illness. Many patients are thus motivated by the erroneous belief that injectables have higher efficacy than tablets. They do not recognize that failure of tablets to work may be because of improper diagnosis, underdosage, resistance or expired drugs.
The situation can be summarized as follows:
- Patients usually first self medicate with oral therapy.
- Patients have been oriented towards injection use. It is common practice that patients carry a personal needle and syringe, even on index visit to a provider facility.
- Patients tend to solicit for injections from providers guided by local ideas and beliefs of illness and concepts of efficacy of various treatment options.
- The profit motive which tends to be overriding among private providers strengthens this set of preferences. Injections cost more and bring in more money.
- Patients are more than willing to pay for injections, but monetary constraints sometimes limit access to injections.