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

Interviewer: Today is the 19th November 2019, and we are at Mbarara Regional Referral Hospital to meet a Physician .Participant record ID HW011, you are welcome Doctor.

Respondent: (Coughs)... Thank you so much

Interviewer: (Clears throat)... Thank you for giving us the time to talk to you, so we are going to start right away aah. This study is to determine how to provide better care for Rheumatic Heart disease patients, (clears throat) and there are no right or wrong answers, so please be frank and share your opinions, the data we gather is very confidential and we shall not leak it to your identity when we are producing our reports, so kindly tell me about yourself, how old are you?

Respondent: ooh, thank you so much. I am a female, I am thirty three (33) years old, and I am a physician and am practicing as a cardiologist although I don’t have a formal training yet, but I am the head of cardiology unit at... regional referral hospital and I am also the head of Rheumatic heart disease registry from 2017 after my predecessor had gone back to Kampala, so I have been taking care of Rheumatic heart disease patients from 2017 till date.

Interviewer: Okay, thank you so much, so you said you are a Physician, how long ago did you train?, where did you train from, before becoming a Physician?, how long did you practice?, how long have you been a physician?

Respondent: Really not very long time ago, aah I did my M MED (Masters in Internal Medicine ) from here, from Mbarara University of science and technology from 2013 to 2016, so when I finished my formal training but from around August 2016 to December 2016, I was in MacMaster University in Canada and during my training in those four months since its mainly in focused cardiology, where by mainly reading Echos and doing ECG’s and Stress testing and boosting more of my knowledge in medical treatment of heart failure, then January 2017 was my graduation as a Physician. So in short I have been working as a physician from January 2017 till date.

Interviewer: Okay, that is a very wonderful CV, and how long have you been working here in the regional referral hospital, where we are now?

Respondent: At Mbarara Regional Referral I started working as a resident during my training from 2013, then till I finished my training, and afterwards I took over the Rheumatic Heart disease registry from 2017, then 2018 I got employed as a lecturer ... in the department of internal medicine and that’s the time I became the head of Cardiology unit as well. Anything I left out?

Interviewer: No, that’s actually great, so let’s talk about the patients you see, what are the demographics of the patients you see in your practice and what are the common illnesses in general.

Respondent: That’s quite interesting, In general we see patients from 13 years of age in our medical ward and basically because in Paediatric ward patients aged 13 cannot fit their bed as such since I came here six years ago, the practice is when you are 13 years and above you will be seen as in the adult medical side, so my patients ranges from 13 years old to 90 years old, that’s a big range and among these patients, the 13 years old are really few, we do see patients in their middle age any younger adults and we see geriatric age like those who are more than 70, 80’s and 90 years old, so since these are three different groups, demographically the diseases or the main conditions that bring them to hospital is also different. (Phone rings) Those who are above 50 or 50 and above, we do see people with stroke in their early 40’s and we see people who are HIV and coming with opportunistic infection and mainly meningitis, that is tuberculosis meningitis and viral meningitis like cryptococcal meningitis those are the most common in that age categories of 40 and above but also we do see elderly patients coming with hypertensive crisis for admission and those come with hypertensive heart disease or heart failure, so the younger population from 13 maybe up to 25, let me say below 25, we do see mainly infectious causes, others are coming really for a very short stay, maybe diarrhoea, others are having poisoning, you know due to social issues, then these are the age group when we see them with heart failure they are more likely of rheumatic heart disease. Yah, basically that is the range of patients we see, of course we see also patients with cancer, some different sorts of cancers, Leukaemia, lymphomas, five years ago we used to see a lot of Kaposi sarcoma patients coming with complications but nowadays maybe because the guidelines have changed to test and treat. Then we see less of that, yah.

Interviewer: So talking about RHD now, tell me a bit about your training in RHD, have you received any specific training while in school about Rheumatic heart disease, Undergraduate (Laughs)

Respondent: Alright, I did my undergraduate from Sudan, from Khartoum and sincerely speaking in Khartoum, we had a lecture of course about Rheumatic fever, Rheumatic heart disease, I remember in Paediatric even we saw a patient of acute rheumatic fever with Sydenham’s Chorea and all that classic presentation, but in the medical ward, during my training as an undergraduate, we had less of Rheumatic heart disease, I can remember some of the encounters I saw, those patients, I had even for an exam, like two or three of them but they had by then had heart valve surgery done so they got replacements , that is when I tend to know of Rheumatic heart disease and Valve replacement as an undergraduate student, but to find a full grown up of Rheumatic heart disease, the way I see them in Mbarara, is really quite different from the time I was trained as an undergraduate, I think because the places are different, and the type of patients we see are different, maybe that is why, maybe I have not seen a lot of rheumatic heart disease only those who had their surgeries done.

Interviewer: Okay, so after your graduation, did you have any training about Rheumatic heart disease specifically, that is after graduation, probably during your...

Respondent: So, during my internship, I remember I presented a case of acute rheumatic fever because by then they make us present cases every week, interested cases, and I had a patient of acute rheumatic fever who was seen I think from a peripheral treated as arthritis, you know, because of these migratory Joint pain here and there, and that’s when my eyes open again of acute rheumatic fever, and that was in south Sudan by then, when I came from Khartoum, when I was doing my Internship, but a specific teaching, except during CMEs in which we can discuss about Rheumatic heart disease and other types of heart diseases. But if you say specific training just for Rheumatic heart disease, I don’t think so. Only just a case based teaching or bed side teaching just like any other ward round you do and, you find a case and discuss about it.

Interviewer: Ok...so how many patients of rheumatic heart disease do you see like per day or per week or even per month, and are these in patients or out patients or both?

Respondent: So we see both inpatients and outpatients with rheumatic heart disease and most of the inpatients ones are those who come in heart failure, or in acute heart failure or decompensated heart failure, and per a month, we can have a number ranging from 5 to 10, this statistics is basically because of a study I have done here before looking at a presentation of acute heart failure in our medical ward so our enrolment was really between 5 to 15 per a month. And out of this majority are Rheumatic heart disease and these are very young people. And now in the clinic we have a clinic day, every last Friday of the month and we see between 20 to 30, and between these 20 to 30 who have been in care, we always have maybe up to 5 or 10 new patients into the registry. The patients basically they come from the surrounding clinics around or hospitals around because now they tend to know that there is a specific clinic for rheumatic heart disease so those patients are referred either from those hospitals or nearby clinic to come to Rheumatic heart disease clinic based on their Echo report from town or anywhere else or just based on suspicions of rheumatic heart disease because they are young and they have listened to a heart murmur, “please go to rheumatic heart disease clinic” and that is how we get our patients.

Interviewer: Alright, now I am interested in knowing what actually you were taught probably from the CMEs you have said you had, probably about rheumatic heart disease, what’s your understanding of the causes of rheumatic heart disease?

Respondent: mmh, of course right from the beginning, aah it’s important. so when we are undergraduate we focus on the history, right? So in history taking you don’t have to miss any history of sore throat, recurrent sore throat that’s associated with joint pain, fevers and things like that and knowing the cause is being group B streptococcal as the most cause for rheumatic heart disease or acute rheumatic fever and I think it has not changed since and the risk factors have still remained the same overcrowding and sometimes if your immune status is not fine you will get recurrent pharyngitis and in children tonsillitis, being the main cause for acute rheumatic fever due to the immunological action due to the antigens of group B strep., so the antigens pathophysiologically we know that it does not only attack the joints and the heart valves sometimes the kidney as well, so that's why it is always important to know how the kidney is doing, what's the colour of the urine and things like that.

Interviewer: You talked about the sore throat, which brings me to my next question actually I was going to ask you if you are aware of the link between the saw throat and rheumatic heart disease

Respondent: I think I have just answered it.

Interviewer: You have just answered that one, so what were you taught can be done to prevent RHD

Respondent: aaah the most important is proper treatment, when I say proper treatment; we know that it’s still sensitive to penicillins and penicillins are the most available drugs being in a good health care centre like a referral hospital to health centre 2, 3 which are really led by nurses, penicillin is still there. So the most important is a proper treatment and the second thing is, if a child or whatever person with recurrent pharyngitis and has joint involvement so it will be better that they are referred to appropriate service provider so that they are screened and have their echo done, yah.

Interviewer: Okay and aaah what are the treatment options for rheumatic heart disease, what were you taught are the treatment options we have?

Respondent: So I think drugs which are available for rheumatic heart disease or acute rheumatic fever?

Interviewer: Yes, for rheumatic heart disease.

Respondent: now for rheumatic heart disease, it really depends on how many valves involved and what type of valves involved in that is there, so the treatment varies based on the function of the heart, you know some patients can have rheumatic heart disease with myocarditis or pan- myocarditis so these patients tend to have really very low ejection fraction and these ones you treat them properly as all the patients of heart failure with all the medication and evidence for heart failure and aaah, patients with maybe one valve involvement let’s say mitral regurgitation if it is mild, severe or moderate, if it is severe and you have your LV cavities dilated then they might meet a criteria to get a valve replacement, which is a better option, if they are moderate and they can afford, maybe they can also have that done, if it is mild, you prevent every reoccurrence of pharyngitis and of acute rheumatic fever because even if they have already rheumatic heart disease they still have a chance of getting recurrence and that will lead to worsening of the existing valve issue which is there and it can make it really worse and that really brings us to where or why we give them penicillin prophylaxis, and from these rheumatic heart disease registry, early studies which are published we know that those who are taking their penicillin prophylaxis regularly take it better and those who did not they have poor prognosis including hospitalization and mortalities so it tends to be really a kind of protecting them from worsening of the disease, so one is the penicillin prophylaxis and two if they have pharyngitis you use available amoxicillin still works, Pen V still works, Amoxiclave of course if they can afford and Ampiclox is still there, these are all cheaper drugs that the patients can be able to get them from the main hospital

Interviewer: Ok...so what's your understanding of the long term prognosis of RHD?

Respondent: So the long term prognosis, I can say it is good, if the patient has the valve replaced if it is stenosis or moderate severe regurgitation if it is replaced, the patient’s life expectancy I Know the evidence in Aortic valve but I believe it becomes similar to the people of the peer age like the same age in the general population, but if that is not done, then they will be worsening of the disease and recurring hospitalizations, then complications then most likely they get cardio-renal syndrome and they might die.

Interviewer: Okay, so let’s recall, (clears throat) let’s talk about your encounter with these RHD patients, do you remember the last RHD patient you saw? Just of recent?

Respondent: Anywhere?, (Laughs), I just saw this two hours ago, I have a lady who is now waiting for me at the echo her she came with features of acute rheumatic fever and on auscultation she already has mitral regurgitation murmur.so

Interviewer: so... how old is that one

Respondent: she is 14years.

Interviewer: 14 years, is she a female, is she in school?

Respondent: she is not at school because for the past three years she gets this recurrence of joint pains, migratory, she cannot get out of bed, then the next time she is fine, then she again gets it with sore throat so for the past three years she is not at school because of that, I just met her today.

Interviewer: Okay, You just met her today...So you said she is presenting with signs of rheumatic fever, she has a murmur on auscultation, how else is she presenting?

Respondent: mmh, She didn’t have fever, objectively, subjectively yah she said she had fever but her temperature was normal she came with issues of joint pain which is migratory and she tried to demonstrate for me when the pain comes what happens, how severe the pain is with sometimes joints swelling and now she feels tired when she climbs a hill and she feels her heart is beating abnormally very high, she is aware of her heart beat, so that is kind of what really drove me to that, am still waiting for her blood test, then I am going to do her echo then I can be able to know exactly to what extent what she is having, so in daily practice I think it can’t miss in a week for you to get two or three new cases of rheumatic heart disease, that's how common it is, yah.

Interviewer: okay... and are these patients aware of the link between sore throat acute rheumatic fever and rheumatic heart disease?

Respondent: They are not, they are not at all, most of the patients I meet, they don’t have a clue of how this happens

Interviewer: Okay, why do you think so?

Respondent: its mainly awareness problems, these are people who have been into local clinics for treatment of a joint pain or a sore throat or they self medicate themselves with ‘double colour’, that's what they say, that must be Ampicilin or Ampiclox or something like that, so there is lack of awareness still despite much work being done about rheumatic heart disease, it’s still there is lack of awareness, it’s not enough, so most of the people still they don’t know, at all, yah.

Interviewer: So apart from this child you have said, you have seen actually a few hours ago, what are other sorts of symptoms other patients describe to you?

Respondent: It’s so rare that patients present like this little girl or this young lady I have just seen, an adolescent, most of them really present with heart failure then during the work up is when you will find that the causes of the heart failure and the underlying etiology is actually rheumatic heart disease, or when other patients start to have syncope especially when they have moderate to severe aortic stenosis then that is when you tend to know or they have severe mitral stenosis they’ve started coughing at night, they cannot sleep, they get tired easily, that's the time they come and seek for help, but as we know that rheumatic heart disease, it takes time for you to develop the full blown out features in the heart, so some people are asymptomatic and they are there in the community and they don’t know, so awareness is our biggest problem.

Interviewer: So are these patients good at follow up or adherence to their medications?

Respondent: Aaaaah, to tell you the truth patients in the rheumatic heart disease clinic, they can even teach you about rheumatic heart disease because they are like ambassadors, I call them ambassadors, they are the very people who can go and talk if somebody has a similar condition, they can be able to help them, refer them or channel them to seek for help because they have stories to tell to people and how their problems have been diagnosed and how they are now living better quality of life than before and most testimonies are from patients who got surgeries, valve replacement, they are really the voice because they have been for recurrent hospitalization, they have been in and out hospitals, they have been on multiple drugs but when they had their surgery, they are now better, they are fine and they have like a testimony to tell those who doesn’t know about it, they are more like ambassadors so they are more adhering to their medication they know all the benefits of each drug they are taking, and they know importantly the benefits of not missing their penicillin prophylaxis so for me these are the real people who can educate those who are down in their communities because not everybody has a radio if it’s a radio talk show, not everybody has a TV set in the village but this normal talk, this discussion you meet and you talk is the better way to reach those who are really in remote areas to understand about rheumatic heart disease.

Interviewer: So these patients actually, you have said they are good at follow ups and adherence to their medications, so haven’t you met some who have actually not adhered to their drugs and maybe have not come to follow up and they are stating some reasons why?

Respondent: yah there are few who are lost to follow up, we have two who have completely lost to follow up, I think one has travelled to Congo or something like that, and there are few that we see then, maybe after 3, 4 months, they don’t respect their clinic days and the only time we meet them is when they are admitted in hospital for acute heart failure, and looking into that knowing the importance of taking their drugs, you find them getting more adhering to their medication and following up their appointments

Interviewer: So before that, when you meet them like after three months, what are some of the reasons they give, for actually not coming at the right time for following ups

Respondent: You know patients come from very far, not all of them are within Mbarara municipality others are coming as far as Kisoro, Kasese very long distance to come to the clinic, so money is the issue, financial support so most of them they don’t have, if they don’t have enough support from the family then they cannot follow their visits, they will say, I will try to look for money in order to come back to my visit or the money I have I better buy medicine with it, then if I get money, I will come and see the doctor and the other good thing also, the RHD nurse always is in contact with all the patients all of them if they have any symptom they call her first then she will advise them either to come to the clinic or to go to the nearby health unit or a hospital but financial constraint is the problem and aah some of the patients has issues with getting medication also prescribed for them, and aah with that sometimes they feel like not coming to the hospital because the little money you have I better get with it medication than coming to the hospital and that explains why most of the patients present late in the hospital or in failure because sometimes there is either the distance which is really very far to come and seek specialized service or sometimes it’s just the financial constraint that has not enabled them to come.

Interviewer: Okay, so most of them they actually state the financial constraint, you as a physician; do you think there are other things that probably stop them, from coming to get care apart from finances?

Respondent: There are few patients, aah not mostly, very few and rare cases maybe once or twice is a family issues if there is no like luck of family support is one of the thing you will find maybe is a young woman of 25 or 30 with severe rheumatic heart disease and has a child and the husband she has to take care of her family, now that becomes also a problem if the husband is not supportive and to seek care, yah those are some of rare instances, yah but mostly its financial.

Interviewer: Ok...so we are going to look at the local health system barriers now, am going to mention here some pieces you will tell me which ones work for you when you are trying to give care and actually which ones do not work for you, so let us look at administration and leadership at the district, administration in the hospital and leadership at the district, does it work for you when you are giving care to these patients?

Respondent: (breathes deeply) you know that the administration and the local government at the district have unit, this aaaah they call us, what do they call us? Health care delivery so for me who is really down, at the service down, let me say, I remember interviewing them for the same purpose (Laughs) yah, there is something called needs assessment if you know about it in rheumatic heart disease, we did the same interviews the DHOs and how do you call, the district amm...?

Interviewer: health educator?

Respondent: The health educators, you know somebody higher than that... aaaah, anyway the CAO, yah the CAO and everybody, there is willingness and there is lack of knowledge because this is totally a preventable disease and if I have to look at a point of your public health, this can be eradicated, yah...Alright, other countries maybe who have done it and we can do it too but we have barriers which are really multi- sectorial at different levels like now the administrative they have willingness to do that maybe what is constraining them from providing, let’s say penicillin at all...Benzathine penicillin at all levels, maybe it is the budget, maybe their budget is limited now for that I cannot intervene much but there is willingness from them to help promote services for rheumatic heart disease to go on, yah.

Interviewer: Okay, how about the funding for health care system in general, does it work for you?

Respondent: That budget has never reached the target, and aaaah if the budget should focus more in health than other sectors that I don’t want to mention, I think it would be better, like in Mbarara maybe the budget which is allocated to Mbarara, maybe it is the budget which was used some several years ago yet the population is growing, you know the more the population grows and if your supplies are fixed then you cannot be able to give services for the rest of the people who might come, so that's another thing that if the government will allocate better budgets for the health system I think it cannot help for service delivery.

Interviewer: Okay, that was in general, how about the funding for RHD in particular in this hospital how is it?

Respondent: The hospital... funding for RHD has been through a grant, that's how it was established here. The Medtronic funding ended, 2017, then we had an extension for one more year of 2018 to follow up our patients, but from 2018 December up to now it is basically our willingness as physicians to take care of our Rheumatic heart disease paints we don’t want to lose them, we kept the clinic running and the patients peer support group they also kept on encouraging each other to be in the clinic and try to raise their own funds to come to the appointments without fail

Interviewer: Okay, so are you being paid to do that, do you have the drugs do you have whatever it takes?

Respondent: No, so I am not getting any stipend for following up rheumatic heart disease patients or clinic, the funding ended way back, so this is good will, I can say so, and the drugs of course the drugs that enter the hospital is really through what...? one channel let men say it’s a channel drug supply. Mmmh Penicillin has been around that's a good thing although it has been out of stock sometime around last year but now it’s available so when it comes for prophylaxis I know my patients will get that, those who come with volume overload diuretics are available but now going for some other drugs like those which are for atrial fibillation or things like that who might need anti coagulation they have to buy, those who have mechanical valves, those who had theirs from Salam centre they have drugs but those who got it on their own ways or through some good Samaritans that help them to get it done, then they have to buy.

Interviewer: How about anti-heart failure drugs?

Respondent: Anti-heart failure drugs, what do we have the supply is really fluctuating, sometimes it is there, sometimes it is not, yah.

Interviewer: Ok...so you have already talked about drugs that one, we shall actually jump it, the medication, how about the health care workers, the numbers and the qualification

Respondent: For rheumatic heart disease?

Interviewer: Yes, is it working for you, do you have the numbers of the health workers to take care of these patients; do you have the right qualifications?

Respondent: not really because, we have only one trained Nurse for rheumatic heart disease and she has been around for the past five, six, seven years and she understood a lot about rheumatic heart disease more than any other nurse at her level.

Interviewer: Is one person enough?

Respondent: it’s not enough, but now that comes back to funding who will allocate a nurse to rheumatic heart disease without training, one is training which we believe Heart institute will not let us down if there is a human resource and the human resource officer here in Mbarara they are not currently employing so it’s so difficult using the limited human resource that we have to stretch them over other departments that becomes a problem but if we can get more than one, that would have been better.

Interviewer: Okay, how about the waiting time for these patients, how is it?

Respondent: waiting time, we have tried to improve that, so we used to have only one cardiology clinic which sees everybody except the paediatrics with that the waiting time was very long then we created our own rheumatic heart disease clinic because we believed that these patients, these are young people they need more time to understand exactly what they have and the treatment how it works and what are the potential side effects the young people you need to talk to them about contraceptives and so many other so we thought these are patients that needed more time than the usual patients we see we created for them a clinic to reduce waiting time, to create doctors- patients time this is not about just refilling drugs, that is a lot to do with that, yah so their waiting time is really not that long, I believe, yah.

Interviewer: Okay now, okay I can see, alright so I can see we are beating time, so let’s try to actually wind up, and how about the health information system and the medical record system for the patients, is it working for you? Medical record systems for examples do you have the registers for ARF and the rheumatic heart disease patients?

Respondent: Yes, we have, we have files so our nurse does a lot since she is one, so she does good record keeping of all our registered rheumatic heart disease patients because there are people who are not registered we have more files for them which we do the follow ups and in case if they are lost we can follow them up with their address and their contacts and we keep records of those who are new and the old ones, we do that.

Interviewer: Okay, that is or out patients, how about the in patients?

Respondent: In patients record is for every patient who is admitted, of course the place of diagnosis will be rheumatic heart disease, yah.

Interviewer: So there are no separate records for the inpatients.

Respondent: No, no there is no separate record

Interviewer: And aaah, do you have the guidelines and protocol for rheumatic heart disease care?

Respondent: Yes there is the old one although now according to the new published data we have also the WHO has re-defined rheumatic heart disease so the old one yes we have and based on that is how we screen our patients, yah.

Interviewer: So you said these pieces we are going to actually go through them again, you said the administration is fair, is not working

Respondent: They are willing, the willingness is there.

Interviewer: but for now it’s...

Respondent: mmmmh mmmh

Interviewer: It’s not working. Funding for health care in general for rheumatic heart disease patients is not working

Respondent: it’s not, yeah.

Interviewer: Health care workers, that is numbers qualifications is not working?

Respondent: Specifically for rheumatic heart disease, no we only have one nurse.

Interviewer: Okay, and...Medications you talked about

Respondent: The supply is really up and down sometimes its available, sometimes it’s not

Interviewer: So it is fifty fifty

Respondent: yah, its fluctuating

Interviewer: Okay and the medical records is working for you?

Respondent: The record for the out patients of rheumatic heart disease, yes but the inpatient we don’t have a separate record

Interviewer: Do you think it’s important to have an in-patient separate record?

Respondent: I am thinking, having the outpatient is good because that is how we truck them and the good thing is every patient admitted to rheumatic heart disease is discharged through rheumatic heart disease clinic so that we capture even those who are new, those who have just come for admission, aaah I am not sure whether we have missed any the system has been really good through the SHOs they always channel rheumatic heart disease to their specific care upon discharge, has been working well, but if it for record keeping specifically inpatients, I don’t know whether it can make any difference, am not sure. Interviewer; Okay, and the guidelines are there, guidelines of protocols you said it’s working for you?

Yah it’s there.

Interviewer: Okay, good, so let’s go to the last set of questions, this is the last one, the last one; generally do you think the patients get the care they need, for rheumatic heart disease

Respondent: In the rheumatic heart disease clinic is a yes,

Interviewer: And do you have any patient safety concerns for example, do you have any preventable deaths in the hospital that are happening?

Respondent: Because of rheumatic heart disease?

Interviewer: mmh

Respondent: Preventable deaths, none that I can think of you know most of our patients who come in failure they are really end stage heart disease and in that stage sometimes what we can do is really limited so the best strategy is actually prevention of rheumatic heart disease

Interviewer: Okay, and do you think there are many patients there in the community dying without actually presenting to the hospital and why?

Respondent: Yes that’s a big yes, still awareness is the big problem it’s still long distance to access care why am saying is a big yes is one time I visited Kisizi hospital in Rukungiri and each day I could go there I could find people newly diagnosed with rheumatic heart disease and there was a young lady coming to deliver but unfortunately already had a stroke so I managed to find three or four with multiple intra cardiac trauma seated , that gives me a crew that there are many more people like that in the community it’s just because they are not aware, they are there and maybe even dying and people don’t know, yah.

Interviewer: Okay, so in your own opinion, what are one or two most important things as we are winding up, ministry of health can do to improve on the outcomes of these patients

Respondent: One is availability of the drugs for these patients, is the most important for me, and if the ministry can put rheumatic heart disease at the top of their agenda and raise the awareness at all levels in the country, that will increase peoples as diagnosing them earlier on and preventing death. if they can put it at the top of their agenda, that will really be great we will not be seeing people who are really dying at a very late stage and we can’t do much to them, then if we can have, that might be ministry level or not ministry level, wide spread, like you do screening especially to specific neglected population, let me put it that way, you have the street kids, you have those in the refugees camps you know, it’s so important because they are also at a high risk of developing rheumatic heart disease and if to simplify I know people started the nurse hand held, ultra sound, just with the simplest guidelines to check possibility, probable a rheumatic heart disease if that government can also take it up and the nurses down in health centres 2,3 are able to screen for rheumatic heart disease I think we can be able to reach out, we can be able to prevent others, and diagnose early and prevent death.

Interviewer: Anything else, do you have any other thing you want to add before we close.

Respondent: What I can add is really for these people in the lower health unit if there is a simplified diagnostic criteria or approach that would really help them to be able to diagnose and refer early, alright.

Interviewer: Okay, thank you so much for allowing to participate.

Respondent: Thank you too.