(1996; 157 pages)
When ill, Ugandans usually self-medicate with oral therapy first. When this brings no relief, or when a fast cure is desired, patients tend to solicit injections from providers. This preference for injections is guided by local ideas and beliefs of illness and concepts of efficacy of various treatment options. Injections are believed to go directly into the blood stream, unlike oral medications which have to pass the digestive system. Therefore, for diseases that are transmitted through the blood system such as malaria, the administration of injections is preferred. How strongly Ugandans are oriented towards injection use, is demonstrated by the fact that a majority of the households visited in Uganda kept a syringe and needle for injection at home and carry this equipment when visiting a provider, even on index visit (see Chapter 6.2.1). This set of preferences of the general population is strengthened by the profit motive, particularly among private providers. Injections bring in more money, but providers often justify their choice for injectables as a way to limit patient non-compliance in oral therapy.
Popular demand for injections is also enormous in Indonesia, although they are not a first resort. In the household survey it was found that most injections were given on request of the patients or their families (62% of all injected patients in Lebak and 52% in Lombok). Apart from injections, most patients were given oral medication as well. Furthermore, in the exit interviews at health facilities it was shown that the majority of injections had been given on request in Lebak, while the reverse was true for Lombok. The majority of users, when asked why this request for injections had been made, stated that injections were preferred because of their "fast action". The second most stated reason was that it was "customary" to receive injections, followed by reasons such as "injections are more appropriate"; "they are cheaper" and "more effective" and "I forget to take medicine". Not all injections are given on request - they are also part of a routine treatment procedure in health facilities over which customers have little say. In fact, in focus group discussions, mothers explained that it is usually the nurses who decide whether the children are injected or not. When the providers are asked why they give injections, they usually claim that this is because of patient demand. This vicious circle (health workers give injections because they think patients expect them; patients want injections because health workers give them) and the lack of communication between both parties, also demonstrated in this research, keeps the practice of routine administration of injections going.