Interviewer(s): Interviewer
Interviewee(s): Respondent

Interviewer: Today is the 20th of March and we are at UHI in the tea room, and we are seated with one of the health workers. Okay, then, um, so tell me about yourself; how old are you madam?

Respondent: I am 35 years old.

Interviewer: And what are your qualifications?

Respondent: I am a Registered Nurse and I came to the Heart Institute, and I am a Study Researcher Nurse.

Interviewer: Okay. And then, um, where did you train from?

Respondent: I did my degree from Mengo School of Nursing and Midwifery.

Interviewer: Okay. Then how long ago did you qualify?

Respondent: I qualified in 2008.

Interviewer: 2008! And how long have you been working here at Uganda Heart Institute?

Respondent: Six years now.

Interviewer: Six years now. Okay, and then when you look at the RHD patients you’ve seen in the 6 years, can you just tell me about their demographics; who are the typical RHD patients you see? Are they boys, girls, women, men, are they married or not married? In a few words, how can you describe them?

Respondent: RHD, what I can say is that it’s a condition that affects both age groups and both sex. It doesn’t mean that it comes to one age group or sex; both of them can have it.

Interviewer: In particular, what’s the dominant group that you are seeing? Are they children or not children?

Respondent: It’s in both.

Interviewer: It’s in both!

Respondent: Yes, but I can say it’s more in female then male.

Interviewer: And when you look at the marital status, where do you say the main ... is it the married or the ...

Respondent: No, it’s both.

Interviewer: Are they in school or not for the children?

Respondent: For the children, yeah; most of them come from school.

Interviewer: They come from school!

Respondent: Yes.

Interviewer: Thank you so much. And then, here in the ... apart from RHD, which other conditions do you handle here?

Respondent: We handle all the heart patients.

Interviewer: All the heart patients?

Respondent: Yes.

Interviewer: Which common illnesses? What kind of heart illnesses ...

Respondent: Hypertension, those who have come with heart failure, um, those who have come in with stroke, plus any other heart conditions.

Interviewer: Okay, and then if you look at the different categories like the stroke, which age groups do they lie in typically?

Respondent: So far like for the stroke, um right now, what I can say is that stroke does not vary it; it depends on what caused the stroke. It can be like in 20, 18 or 30, like that.

Interviewer: But most of them are?

Respondent: Beyond 25 years or age.

Interviewer: Okay, and heart failure?

Respondent: Heart failure, I can’t say because all age groups are affected.

Interviewer: Okay. Thank you very much. Now tell me a little bit about your training in RHD; did you receive any specific training in school?

Respondent: Actually I can tell you no, no. Why? Um, maybe I have not gotten that chance of like our sponsors or PIs or those coordinators to take us for those further trainings. No! I personally, just go on by ‘googling’ to do my own research about the RHD and I find out more about it, but undergoing training, no!

Interviewer: How about in training; when you were in the nursing school did they give you any ... did you handle the topic at any one ...?

Respondent: Yeah, we handled that topic about rheumatic fever which ended up saying that it can go on with a complication of rheumatic heart disease, and they gave us like the cause, signs and symptoms and treatment for it.

Interviewer: Can you tell me a little but about the causes you remember?

Respondent: They told me that it is being caused by the streptococcus.

Interviewer: Okay. And then what are the symptoms you remember being told about RHD?

Respondent: The symptoms; these are the patients who can come in with joint pains, fevers and sometimes they came with edema of the lower limbs, chest pain, um heart palpitations and some can come in with sore throat.

Interviewer: Okay. Thank you very much. Now apart from that little training during school, after graduation, have you had any training whatsoever in RHD?

Respondent: Actually no. When I came here, when I was appointed to be a researcher nurse we had a one day session about rheumatic disease. They trained us about Benzathine injection, the criteria; how to know that this is a rheumatic heart patient.

Interviewer: So in your training they taught you about the treatment and how to identify an RHD patient?

Respondent: Yes.

Interviewer: And that was all in one training?

Respondent: What I remember is that it was one day.

Interviewer: Ever since then you haven’t had any other training?

Respondent: No.

Interviewer: What do you have to say about that? Are there any training gaps that you can ...?

Respondent: Yes; really this is a challenging condition where by um, you know when you be in it you find many challenges. So we need like a training about it, not the other one we had in school. You know they can teach you but not the detailed part, but when you come on ground you find so many things. Like, when I came here, back in my training, my nursing training, they told us about Benzathine; they told us we give 2.4, but now when I came here and we did that training, the one day session, they told us to give 1.2, the reason being that this treatment, but the other we were giving it like a shot, like start and that’s all. So if at all you don’t have that idea, you are going to miss everything. What I have also seen is that some of our doctors really get that challenge whereby they don’t even know how to give the dosage, I can say that. When you to him or her and say, “please, change the dose to 1.2!” others are going on with the other training of 2.4. Yeah.

Interviewer: Any other challenge that you had, where you need more training?

Respondent: um, the challenge is that we need to maybe go to the counselling sessions because these patients who are sick and you have to counsel them emotionally because of the condition which is untreatable, so they are supposed to be with it for the rest of their lives. So you have to counsel them plus their family members so that they can support that patient to go on with the condition; he has to be with the condition for life. It’s not an easy part or thing. It’s not so easy to counsel the patient; he has come in normal with a slight chest pain and at the end of the day the ECHO scan comes back and its like, “your valves are sick; you are going to be on life time medication.” To counsel that patient or person, you have to really have the knowledge of that counselling bit. So what we are missing out ... the good thing is that where I was working before coming here, I did the PMTCT, so it gave me that knowledge and that gap to fit in my ideas here.

Interviewer: Okay. Does that mean that here in the institute the counseling bit has not been handled? People have not been trained as counselors?

Respondent: No.

Interviewer: Okay.

Respondent: Maybe someone will just come in.

Interviewer: okay, counselling. Which other area apart from the counseling?

Respondent: that’s it.

Interviewer: Okay. So, with your work with RHD patients, any other area that you are not comfortable with or where you think you need more treatment?

Respondent: No.

Interviewer: you are comfortable you give treatment and ...?

Respondent: yeah.

Interviewer: Okay, thank you. Okay um, in a week, how many RHD patients do you see typically?

Respondent: [sighs] I can say they are more than ten.

Interviewer: In a week!

Respondent: In a week, and those are new patients

Interviewer: Each week?

Respondent: Each week, because in a day I can drop off like three to four patients in one day.

Interviewer: Okay. And then for those who are not new, the total number of the new and the old how many do you see in a week typically?

Respondent: Very many; they are very many. I can see about like 13. Let me say 15 to 20.

Interviewer: Okay, and then when you look at those RHD patients, do you have more out-patients or more in-patients?

Respondent: We have more out-patients than in-patients. They come in to be in-patients when they have got heart failures.

Interviewer: So you get more out-patients?

Respondent: Yeah.

Interviewer: Okay. And then, so are you aware of any link between a sore throat and RHD? Is there any association?

Respondent: A link?

Interviewer: Yes.

Respondent: Yes, because you cannot have RHD without having a sore throat. Why? A sore throat, that infection like I told you, that infection begins from the throat and then it goes on slowly by slowly damaging, then into the antibodies and then to your valves. But if it’s being detected earlier when it’s still a sore throat, then we call that Acute Rheumatic Fever and it’s treatable, but if you jump that part and then it goes to the valves, that’s when you have the RHD.

Interviewer: Okay. Thank you so much. And then um, so tell me about what you know about the treatment of RHD? How do you treat RHD?

Respondent: RHD, um, we treat it with an antibiotic called Benzathine Penicillin, the dosage depends on the age and the weight of that patient.

Interviewer: And then, how can someone prevent RHD? I know you hinted about it but let me get more.

Respondent: First and foremost, you have to make sure that at home your room is well ventilated, and If anyone has got a sore throat or a cough, treat it with antibiotics with a qualified person. Never to buy drugs from the drug shops because that's how our patients really die; they buy their drugs from drug shops and one day or two when the symptoms have subsided, you go off the medication and at the end of the day the infection goes on spreading and you get the infection.

Interviewer: Thank you so much. And then um, so we talked about the causes of RHD and you said it is mainly? I mean the cause of RHD.

Respondent: That streptococcus.

Interviewer: Okay. So what do you understand about the long term prognosis of RHD?

Respondent: [sighs] Long term prognosis! Um, what can I say? The prognosis is actually, I can't say poor or good. Why? We have had patients who have been with that condition for more than 25 years. Why? They have been on their medication and some of them have had the valve replacements or valve surgery, so the prognosis I can say is good and sometimes bad for those ones who are not taking their drugs properly.

Interviewer: Okay. And then, tell me about your encounters with RHD patients; do you remember the last time you handled an RHD patient; when was it? When was the last time you saw an RHD patient?

Respondent: huh, every day and even up to date.

Interviewer: Even today you seen one?

Respondent: Yes.

Interviewer: Can you briefly summarize that visit; what was the age, how was the patient, how was the visit?

Respondent: Yeah. Um, they come in normally. The good thing with Uganda Heart Institute, our patients were given that priority of not paying consultation. Why? Not because they are too poor but because it’s chronic condition; today they are sick and the following day they might be normal or not normal. So in a week or a month they can come in the hospital twice and you know that consultation fee is too much for them, so they come in at any time. So my patients, the ones I have seen, sometimes they come in when they are really sick.

Interviewer: Like the one you have seen today?

Respondent: The one I have seen today is sick.

Interviewer: He is sick!

Respondent: He needs that surgery.

Interviewer: how old is he?

Respondent: he is 35.

Interviewer: 35! And when you look at his compliance with the treatments, how is it?

Respondent: You know these are the patients who tell you that “I take my medication.” but physically when you see the patient, the way he has presented, he is not taking the medication well although he might be deceiving you. So you know that the patient may not be taking that medication well.

Interviewer: what did he present to you?

Respondent: he came with the chest pain, he came in with edema of the lower limb and his dosage of diuretics has been high, but the way he is saying “I have been taking my drug!” is not really convincing me.

Interviewer: Okay. And then, do you think the RHD patients know the association between a sore throat, Acute Rheumatic Fever and RHD? Do you think they see any connection?

Respondent: Yes, these patients who have been with us for some time, we have been telling them that and some of them know, but there are those ones who are new so they might not know. As I told you, the patient comes in and doesn't know anything about that condition but because of that counseling with the patient and the health education, he goes home knowing that “this is a condition and I have to ...”

Interviewer: Okay. So For the average age of RHD patients, they are mainly females and adults?

Respondent: Yes.

Interviewer: which age did you say?

Respondent: adults, what I can is that from 13 years and above. Children; 3 to 13 years. Can I say that in our Uganda setting; the adult age?

Interviewer: The official one is 18.

Respondent: 18!

Interviewer: so you are talking about 13 years and above and those are the most ... ?

Respondent: yes.

Interviewer: Okay. When they come to you, what kind of symptoms do they describe?

Respondent: Normally it is the chest pains.

Interviewer: apart from chest pain?

Respondent: It is mostly chest pain and sometimes with cough and that edema of the lower limb.

Interviewer: Okay. And then um, are they good about follow up adherence when you look at them, because you have worked with them for 6 years.

Respondent: some.

Interviewer: which percentages are adhering?

Respondent: But it's only like, very few ones who are not good with our ... who cannot come to the hospital? One; reason being they would love to come to the hospital but they don't have transport. He/she will tell you “I never came for my review because I didn't have transport” and you are not going to penalize him/her; she comes from far. Our patients really come from far, for example down there in Kisoro.

Interviewer: Eh! They come from Kisoro?

Respondent: Yeah. So you cannot penalize that patient. So what we have to do, we opened up a branch in Mbarara; we tell them “please don't come to heart institute, go to Mbarara” because at least the transport from there to Mbarara might reduce.

Interviewer: part from far those who come from Kisoro which other patients are coming from very far districts?

Respondent: Gulu, Lira, Soroti and all those places.

Interviewer: They come here!

Respondent: Yeah. But those coming from Gulu, the northern part, they can go to Gulu or Lira.

Interviewer: then Soroti?

Respondent: some of them can come here and others go to Lira.

Interviewer: You said you have those branches in Lira, Mbarara, why do you think some keep coming here despite having regional hospitals which can handle it?

Respondent: it's because sometimes they can have that complication which needs our cardiologists here and we emphasize them “if you see that you are really too sick and you need an admission, you'd rather come here” and those doctors who are there know that they refer them here immediately unless if the patient is stable.

Interviewer: so does that mean that the regional hospitals don't usually handle very sick patients?

Respondent: No, unless when the patient has just requested when he has no transport to come here.

Interviewer: Okay. So you said you have those who come and they adhere to the drugs!

Respondent: yes.

Interviewer: what do you think makes them to adhere to the treatment? What motivates them to come?

Respondent: [sighs] what can I say? Maybe because of our service, because we don't give them transport. They know that consultation is free, one, and they get their drugs. Secondly, their injection, the Benzathine injection; here it is less painful here than when they get it from the other side. So they can shoot two birds with one stone; they come for the injection plus their medications. Sometimes we have drugs here than there.

Interviewer: You have brought an interesting thing; “the injections here are not painful”

Respondent: mm-hm.

Interviewer: Tell me more about that. What makes them less painful here and more painful the other side?

Respondent: Yes. As I told you that the other session which we had in the beginning, they told us that we should localize the pain with Lidocaine. So we try to localize that pain with putting the Lidocaine, than those people; they don't know that trick. It’s actually these patients who are introducing this trick to them when they go to their health centers. They be like, “Doctor, I have got my Lidocaine; the nurse told me to be mixing it like this and this and then inject” and sometimes they call me and I tell them what to do.

Interviewer: so what do you think should be done for those health workers in the regional hospitals about the way they give the injection?

Respondent: those health workers, what I can say, is the training about RHD. Most of them don't know about RHD although they trained them in school. But you know there are many topics and really you can skip one topic and forget unless when someone has just reminded you. So they should go with that training about the RHD, the cause, signs and symptoms and the treatment.

Interviewer: Okay, thank you very much. And then um, so for the barriers from what you have just said, it looks like transport.

Respondent: mm-hmm

Interviewer: Some people don't have transport to come!

Respondent: Yes.

Interviewer: what else.

Respondent: drugs.

Interviewer: Drugs! What is it about drugs?

Respondent: um, what can I say?

Interviewer: how are drugs a barrier to them coming for treatment?

Respondent: for what?

Interviewer: how are drugs being a barrier to them to come to treatment?

Respondent: no, no

Interviewer: Okay, you talked about, why they would rather come here is because they will get the drugs. Does that mean that um, can I assume that those facilities/regional hospitals where RHD is managed, drugs are lacking?

Respondent: Yes, they are lacking. Why? Sometimes here we might not have one drug for example I can say Spinalactone or Digoxin, so you tell them to buy from outside, and they will tell you, “Nurse, I would rather buy from Kampala than there because in our village there are not there.” So they are not there, they would rather come here because they know drugs are available.

Interviewer: and how expensive or cheap are these drugs when they come here?

Respondent: they are really cheaper than they go out.

Interviewer: if an RHD patient came in today, how much can that RHD patient spend on treatment and drugs typically?

Respondent: it depends on the drugs which are not on the government side, because we have got drugs from the government side and those ones from the pay side. So the patient can go without paying for any drug when have got them at the government side. [Receives phone call]

Interviewer: so on your part what barriers do you get when you are providing RHD services? What are the challenges you face?

Respondent: When I am?

Interviewer: When you are providing RHD services: care and management.

Respondent: Actually, the only painful thing on my side is that I am handling very sick patients who are poor. So when you admit this patient, when she is for admission, she will tell you that “doctor, I can’t be admitted because I don’t have the medical fee.” So you try to advise that patient to go there because at least it can waive. Well I am not going to disclose to my patient that we are going to waive for you, but I convince her/him to get admitted here to get the proper medication. At the end of the admission I will try telling him/her, “Please try to raise some money according to the medical bill.” Sometimes they raise and sometimes they don't and the hospital can waive for them.

Interviewer: so for those drugs which are not on the hospital, you said you have those for the hospital and those who are not on the hospital!

Respondent: yes.

Interviewer: Like for RHD drugs, how much could a patients pay on average?

Respondent: Actually, my patients, I think, one; sometimes they don't have Warfarin and ...

Interviewer: It goes for how much per tablet?

Respondent: each tablet is 500shs.

Interviewer: so for 30 days, how much?

Respondent: Now, I can't estimate.

Interviewer: which other drugs is usually needed by RHD patients that has to be bought?

Respondent: Warfarin, Digoxin.

Interviewer: and how much do they spend on that drug?

Respondent: the Digoxin?

Interviewer: yes.

Respondent: Actually I have never taken that urge to know how much.

Interviewer: Okay, so on your side you said that the patients come in when they are very sick and when and they don't have money. What other barrier do you face when you are doing your work?

Respondent: [no response]

Interviewer: None?

Respondent: mm-hmm

Interviewer: Okay. Now let's look at the administration here, how is it, is it favoring you or not. How is it working for you?

Respondent: Here, it’s favoring me.

Interviewer: why do you think? Why do you say that?

Respondent: it’s okay.

Interviewer: How does it support you in your RHD management?

Respondent: Personally or with my patients?

Interviewer: when you were handling your RHD patients, how has the administration favored you to do your work?

Respondent: it has favored me because they don't have that segregation that these are only RHDs, or no one is going to touch my patient. Every doctor, if I take my patient to him /her, he handles my patient.

Interviewer: he handles them!

Respondent: yes.

Interviewer: Okay. How about the district leadership, does it work for you? When you are handling your RHD patients do you feel they are helping you in one way or the other?

Respondent: What I can is, sometimes yes. Why? We had a challenge with one of our patient and we took that patient of Khartoum, that is Salaam Center for Surgery and unfortunately that patient died. And you know those people, since it is a Moslem country, they had to bury there and then, but we needed our body this way. We had to contact the minister and the body was transported this way.

Interviewer: Okay. So when you look at the funding for health care in general, is it working for you?

Respondent: no.

Interviewer: why?

Respondent: the money is little.

Interviewer: money for what?

Respondent: salary.

Interviewer: Okay. Any other funding issue apart from the salary?

Respondent: Yes, and also what we want is the district or the government to help us with is our INR strips because most of our patients they go on for surgery, they have to be on Warfarin, and on Warfarin, we have to take off blood for INR. You can't take Warfarin without removing off the blood; that blood is the one to give us the dosage, so our patients don't have that 20,000shs per visit. Lucky enough for the past days, we had some funds from out; they used to fund us and our patients used pay only 5,000shs for that blood test and it could work for them properly, but right now the fund, the donor ...

Interviewer: which donor was that?

Respondent: it was the Case Western

Interviewer: they pulled out?

Respondent: yes, the study stopped and now the patients had to pay for the investigations, I mean that blood test. You know these patients come in and although they are not paying for consultation, but this 20,000shs plus also some drugs ...

Interviewer: so how are they managing?

Respondent: they are trying, although ...

Interviewer: do you have some who have gone without the tests?

Respondent: yes.

Interviewer: and what did you do with the doses?

Respondent: Actually, it was nothing. Sometimes, little but not too much, I try to put it on myself and really, they have to be on my bill. At least when I see she has missed like for three times and I can believe that she has not been taking her Warfarin and am scared this patient will get stroke.

Interviewer: Okay. Sometimes you even put in your money!

Respondent: yes.

Interviewer: Okay. Let’s look at the numbers of health workers. Are the numbers working for you, the qualifications and training? Let’s look at the numbers.

Respondent: the numbers in general?

Interviewer: yes.

Respondent: the numbers in general, we are under-staffed and the work is too much.

Interviewer: what about the qualifications of the health workers here?

Respondent: the qualification of the health workers is improving; it’s good because some of them have gone for further studies.

Interviewer: Okay. And then when you look at the waiting time for the patients and the patients you see ...

Respondent: It’s not too much because our doctors are there; they don’t wait too much, unless when they are going in for further investigations, that’s when they will delay. But if they have come in for out-patients, they don’t delay.

Interviewer: for a typical out-patient, when someone is an out-patient, how much time do they spend? An RHD patient.

Respondent: I believe, you know these patients are stubborn, unless if they have come late, it is when they will leave here late. Sometimes they can come at mid-day because they know they will meet Sister so and so who is her friend, and that she will just by-pass and go in.

Interviewer: but typically, how long does a person spend here? If someone came in at 8am, what time will they leave?

Respondent: 10am.

Interviewer: Okay, that’s almost two hours. When we look at the medication for RHD, is that working for you? Do you have the drugs? How are the drugs here?

Respondent: Yeah. It’s working but the problem is that I wish they can really find the real drugs which can really kill the infection; that’s a challenge. You know these are patients who are on Benzathine from the day they have been affected till death. At least let them find, maybe a researcher comes out and they find a curable medicine.

Interviewer: When you look at the heart failure drugs, how are the stocks? Are you comfortable with the stocks?

Respondent: No, I am not comfortable because sometimes we are lacking.

Interviewer: how about the diagnostics, particularly ECHO-CARDIOGRAPHY, are you happy with it?

Respondent: yes.

Interviewer: And how about the BPG and the anti-coagulation drugs? How are they? How are the stocks?

Respondent: BPG is there; it is good

Interviewer: so which drugs are lacking in stock?

Respondent: These anti-coagulants, because sometimes they go on the pay side when it is finished at the government side.

Interviewer: Okay. When you look at the medical records here and the flow of health information here, the health information system here. Here we mean integration of facilities and the in-patient-outpatient registers, so here if you need something about your RHD patient, can you easily get the information or records? How is the flow of information here?

Respondent: Yes, it’s so nice and smooth.

Interviewer: why do you say so?

Respondent: Because each patient comes in with his/her card and getting the file is easy and nowadays, we don’t use the files; we are using the computer system. So all the information is in the computer.

Interviewer: Okay. Anything lacking in the health information system?

Respondent: no.

Interviewer: Okay. And then in case you wanted to communicate with another health center about your RHD Patient on how to treat him and you have to get the files from there to here, is it easy?

Respondent: from there?

Interviewer: yes, like maybe if it is a referral?

Respondent: For them, when they send, they write down on the referral form what they have done, but mostly they (patients) go there with all our documents. For them they go there with all our documents, for them they treat what the patient has presented that day.

Interviewer: Okay.

Respondent: Yes.

Interviewer: How about the guidelines and protocols, do you have RHD protocols in place; RHD care protocols and care?

Respondent: yes.

Interviewer: have you seen one around

Respondent: yes.

Interviewer: so you have them!

Respondent: yes

Interviewer: so you have the protocols!

Respondent: Yes.

Interviewer: Okay. And then do you have a proper referral pathway that you follow when you are handling RHD patients?

Respondent: yes.

Interviewer: And then um, so you said that what is working for you in the list we have mentioned, you said flow of information is perfect for

Respondent: Yes.

Interviewer: the administration is okay

Respondent: Yes.

Interviewer: So what else has made you work and just continue working with RHD patients?

Respondent: For me, I am not going to say money, no! It is maybe because I just love my job, I can say that. Because if I say money, it’s not; me I am a person who can take 2-3 months without getting paid, otherwise I would have even left the place, but it’s because I love my patients; I love my job!

Interviewer: So it’s the love for the patients!

Respondent: Yes.

Interviewer: And then, um, so generally, do you think the RHD patients get the care they need or not?

Respondent: they do

Interviewer: why do you say that?

Respondent: why do you say that? It is because they meet us on the ground and the doctors on the ground. Even if the patient wants to be admitted, if the patient needs ECHO or ECG, it’s done.

Interviewer: What about surgeries?

Respondent: They do. They get the surgery, but not free of charge. Unless when we have get like a couple or donor who comes in and says “I will deal with some patients”

Interviewer: When you look at the patients’ safety and quality of care concerns, what are some of the safety concerns you have about your patients here? Do you see any patient safety concerns here or maybe the quality of care concerns? Respondent. No

Have you had any preventable death occurring? Preventable means surely the person has gone but they wouldn't have gone, but because of the conditions that would have been probably managed but they were not managed.

Respondent: no.

Interviewer: No! There is no single scenario you remember where you felt like no this patient wouldn't have died?

Respondent: maybe when like, I can say, our patient come in late and needs admission and maybe on the time of admission, he kicks off. Maybe if there was a quick means of transport for this patient or maybe if he had an ambulance on the ground, they call us, a standby ambulance runs to that patient ...

Interviewer: Okay. What are the two most important things Ministry of Health should do to improve the RHD outcomes?

Respondent: Health education; they should come in and support. Why? We need more education on RHD of the health workers because that knowledge we shall deliver it to our patients. And also facilitation, like supporting us on drugs.

Interviewer: Okay. So as we are winding up, what do you think we can do to motivate our patients to adhere to drugs and even come for care?

Respondent: What I can say, drugs; if at all they are on grounds, patients will come from wherever they are coming from knowing “I am going to meet my doctors and I will get my drugs” rather than you coming and they tell you, “pay” and yet you don’t have that money. Imagine if you are coming from let me say, Mpigi down there or Sembabule, and maybe even the transport you had to first borrow and then when you get here they tell you to pay 40,000shs for the drugs! The patient won’t really buy, or she will buy for like a week ...

Interviewer: besides drugs, what else?

Respondent: Even the space; we have got limited space. We send our patients to the referral hospital and they can say they may not get good care. Sometimes they can tell you “doctor, we are going” but what I have experienced is that they don’t reach there because they know that they are not going to get the service there. She will end up dying from home, and when you end up calling to inquire, the family members will be like, “doctor we never took our patient there; she died from home.”

Interviewer: they don't want the referrals because they know they won't get the care they need?

Respondent: yes.

Interviewer: anything else before we wind up?

Respondent: no.

Interviewer: thank you so much nurse for your contribution to this study. Just to remind you, we are going to keep your information confidential and it's going to help us to come up with better programs for RHD management. Thank you very much.