In terms of Gross National Product (GNP), Uganda and Indonesia are both low-income countries. Yet the differences between them are considerable: while Indonesia has undergone a rapid growth of industrial development and of GNP per capita in the last decade, Uganda has suffered negative growth rates which have had considerable effect upon health indicators. Infant Mortality Rates (IMR) in Uganda increased from 109 per 1,000 live births in 1970 to 118 in 1991. Over the same period, IMR in Indonesia dropped from 118 to 74 (World Bank 1993). Some health-related indicators comparing the two countries are given in Table 2.

Health conditions in Uganda and Indonesia differ, and thus the use of injections may be expected to vary accordingly. For example, while in Uganda malaria is the most common diagnosis at health facilities, in Indonesia this is acute respiratory infections, with malaria accounting for only 6% of the illness cases reported to government health facilities. With respect to the incidence of AIDS, Uganda has a much higher number of reported cases than Indonesia. There are also differences in other major health-related variables such as fertility rates, immunization coverage, access to formal health care services, and the implementation of an Essential Drugs Programme. Despite important differences between Indonesia and Uganda in health care systems and the health status of the population, both countries share a common feature: a strong preference for injection therapy resulting in high injection prevalence.

Table 2: Health-related indicators comparing Uganda and Indonesia¹⁷

¹⁷Sources: The State of the World's Children. New York: UNICEF, 1989b; The World Drug Situation. Geneva: WHO, 1988; Investing in Health. World Development Report. New York: World Bank, 1993.

The Ugandan context

Uganda is a country badly hit by a deterioration in health services and the disastrous effects of the AIDS epidemic, which have affected injection use and preference considerably. During the 1970s and 1980s, a precipitous decline in the country's economy led to a decrease in government expenditure on health, and to a breakdown of the health care system. Medicine supplies became irregular and many health professionals left the country. Immunization programmes broke down; only the mission health facilities continued functioning reasonably. The scanty and nearly non-functional health care system gave rise to a number of new local solutions. There was a proliferation of private profit-oriented health care providers, such as unlicensed private clinics, drug shops and home providers (Ministry of Health 1987; Whyte 1991). Injection technology and equipment also diffused from the established health care system to the informal system. Recently, this process has been accentuated by educational messages on AIDS which have undermined confidence in injections administered in government facilities (Birungi and Whyte 1993; Birungi 1994a/b). Presently, Uganda's health care system can best be described as having two sectors, the formal and the informal, which are closely articulated, exhibiting symbiotic relationships in terms of drug supplies, equipment and human resources (Whyte 1991).

It is estimated that 72% of the country's population lives over 6 km from a government health centre (UNICEF 1989a). A study conducted in 1990 indicates that the government only provides 21% of all out-patient modern curative services, while the private sector accounts for 66% (NGO facilities, private clinics and others). There also exist regional disparities in the location of health facilities, with over 50% of the hospitals situated in urban areas, while the majority of health centres are situated near trading centres leaving rural areas with limited access. Apart from the deficit in coverage, the content of health care is largely curative, and almost all forms of treatment involve the use of medicines (World Bank 1992).

Country morbidity and mortality figures for 1991, based on records from both in- and out-patients of 20 government and NGO hospitals, indicate that malaria is the number one cause of death, with AIDS coming second, followed by diarrhoea, pneumonia, and anaemia (World Bank 1992). Children under five account for 54% of all hospital deaths from malaria with pneumonia, diarrhoea, and malnutrition causing 55% of the under-five mortality. AIDS is the primary cause of mortality among adults, accounting for 17% of all hospital deaths, followed by tuberculosis, malaria, meningitis, and diarrhoea.

Studies undertaken in the field of drug use invariably underline the popularity of injections among both users and providers (UEDMP 1990; Glenthøj 1991; Whyte 1991; Birungi and Whyte 1993). The studies also mention the high degree of misuse of drugs and injections; this includes under-dosage as well as overuse or inappropriate use (Mburu 1984; Kalyesubula and Minde 1989; Glenthøj 1991; UEDMP 1990, 1992). In Uganda, injectables, needles and syringes can be easily obtained without prescription or legal order, although the Pharmacy and Drug Act of 1970 limits this activity to licensed individuals. The present study reveals that injectionists and individual users buy their injectables and equipment at pharmacies. Within the household, possession of injection equipment is common. This practice is encouraged and facilitated by some medical practitioners and informal providers.

The Indonesian context

A widespread network of public hospitals in towns, health centres (puskesmas) in the villages and smaller towns, and under-five health clinics (posyandu) in the hamlets is operative in the Indonesian archipelago. The system covers a large part of the population, perhaps the only exception being very remote areas. As a consequence, the modern public sector is predominant in Indonesia. While a large informal sector has developed in other South-East Asian countries, this is not the case in Indonesia. However, the private sector is important. Most doctors and midwives employed in the government health facilities also have their own private practices where they see patients. Although this is illegal, many nurses also operate private practices from their homes where they treat patients and administer injections.

Officially, the lower levels of the health care system, including the health centres, are supposed to devote most attention to preventive programmes in accordance with Primary Health Care principles. In reality, most patients come to the government health centres for curative treatment. In the health centres, doctors play a managing role and rarely see patients. It is the nurses who have the primary responsibility for the examination and treatment of patients (Sciortino 1992, 1993). During research carried out in several puskesmas in Central Java, Sciortino observed that patient's treatment basically consisted of the administering of an injection and the prescribing of several pills. About eighty to ninety percent of the patients leave the clinic with a new fluid in their bodies. Hygienic practices are often unsatisfactory.

The generous administering of injections in the puskesmas and posyandu is a widespread practice in many parts of Indonesia. An analysis of health centre prescribing patterns for 4060 patients treated at 18 health centres in East Java and West Kalimantan (MSH 1988) revealed that nearly 50% of infants and children and 75% of patients of five years and over received one or more injections. The highest use of injections was for skin diseases, musculoskeletal complaints, and nutritional and vitamin deficiencies - conditions which, while sometimes quite serious, are generally not medical emergencies nor urgencies which require intravenous or intramuscular therapy. In addition, over 80% of patients with diarrhoeal diseases and acute respiratory illnesses were treated with antibiotics, many of them in injectable form. Non-doctors (i.e. nurses) prescribed injections more frequently than did doctors.

In Indonesia, it is the formal public health sector, and its biomedically-trained personnel in private practices, who administer the bulk of the injections. The informal sector is almost absent. For example, in contrast to other traditional healers in Sri Lanka and India, the Javanese dukun apparently does not provide injections. Injections are considered the domain of biomedically trained practitioners. They are not found in markets, nor do they form part of self-care in Java (Hagenbeek 1994).