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

Interviewer: Thank you very much for coming,

Respondent: you are welcome

Interviewer: Today is the 7th January 2019 and the interview is being conducted at the female medicine ward, lira hospital. Mainly this study is to determine how best we can provide care to the RHD patients. We have no wrong or right answers, so feel free and share your opinion and the data we gather here is confidential.yes.so feel free, we will not link your comments to any reports that we will produce. Let us start

How old are you?

Respondent: Am 50 plus almost making 51 in April

Interviewer: What is your qualifications?

Respondent: Am a nursing officer who has done sonography diploma in ultra sound scanning

Interviewer: Ok

Respondent: Yes

Interviewer: So where did you do your training from?

Respondent: My enrolment, I studied in lira regional referral hospital

Interviewer: Ok

Respondent: And then I worked for about 10 years, I went for my registration in jinja, my enrolment was from 1992 to 1994, then I went for my registration in 2004, I completed in 2005 in Jinja School of nursing and midwifery and in 2007 I went for ultra sound research institute in mengo, a school of ultra sound research institute, we were there for one year though we used to study in modules and I completed in 2008 April

Interviewer: So for how long have you been working in lira regional hospital?

Respondent: Since 1996

Interviewer: wow!

Respondent: I have been here

Interviewer: laughs, such a long time

Respondent: Yes

Interviewer: So briefly which kind of patients do you usually see or common illnesses you meet in your day to day work

Respondent: In my day to day work, it’s like it cuts across all conditions

Interviewer: Yes

Respondent: but mostly we get ladies with PID that is the most common disease which are clocking in mostly

Interviewer: Ok

Respondent: Yes

Do you do echoes?

Yes

Interviewer: what are common conditions you meet in that group?

Respondent: In echoes we get patients with hypertensive heart disease, we get with DCM, we get patients with valve heart diseases

Interviewer: Ok, so like have you ever got any training on RHD like training in school

Respondent: Yes we were trained on like rheumatic fever and heart disease mostly in my training in the nursing side

Interviewer: Ok

Respondent: We have ever had that I think it was in 2007 when we had also the other group which is generalised on the heart problem

Interviewer: Ok

Respondent: Yes

Interviewer: So it was a training after graduation

Respondent: yes

Interviewer: Ok, when was it, you said 2017

Respondent: Yes, the other group which your research followed, the other one

Interviewer: Where did they have the training?

Respondent: It was here, they trained us for one day here

Interviewer: Ok, like do you remember the group, the names of the people who trained you

Respondent: We had ..., the few I can remember.

Interviewer: Ok, about the patients you see like how many patients of RHD do you meet, let’s say in a week

Respondent: In a week?

Interviewer: Yes

Respondent: It depends because at times you get other days when you don’t have them but you also be blessed in other week’s maybe 2-3 within a week

Interviewer: In a week?

Respondent: Yes

Interviewer: ok

Respondent: They are not consistent but when they come, you get them because others you get them like incidental findings also maybe somebody has requested something else for ultra sound maybe abdominal ultra sound, when you peep on the heart or you see the other general body condition till now on your heart incidental findings, you will get the patient who has this one or he has RHD or any other cardiac diseases

Interviewer: Ok are these patients mainly inpatients or outpatients

Respondent: Ok they are both inpatients and out patients because at times they also move un diagnosed

Interviewer: Meaning you always get someone that is actually being left out

Respondent: Yes

Interviewer: Ok

Respondent: They may send us with some other conditions, maybe a patient is having lower abdominal pain, chest pain but when you access the patient, you find when the patient has cardiac disease, for me, I will be prompted a part from doing ultra sound. I have to go ahead and do echo and after my findings, I get the cardiac disease

Interviewer: Then where do you refer those patients?

Respondent: These patients when they are within the age group that fits rheumatic from 5 years to 18 years, is it 5 or 3-18 around there, I send them to rheumatic clinic but those ones above that age, I always refer them to Dr ... or I may call or I always tell her to see them and I direct them to her

Interviewer: Ok, let’s say on average, how many people would you actually incidentally get

Respondent: By doing ultra sound or maybe just by peeping into the heart

Interviewer: Peeping into the heart?

Respondent: Yes, in a month we can get like 5-10

Interviewer: 5-10?

Respondent: Yes

Interviewer: Wow, it’s quite a big number

Respondent: It’s a big number, many actually missed out when they have not captured them

Interviewer: Ok

Respondent: Yes

Interviewer: Something, ok, about what you have been taught, ok, what is your understanding of what causes RHD.

Respondent: RHD is just a condition with a sore throat and it’s caused by a group of staphylococcus group A, group B not A, I think its group B and if not managed well, a sore throat, they can migrate because they like the tissues around the valves, they migrate to the valves fast leading into ...because it first starts with fever, a sore throat, a sore throat at that state is still acute rheumatic fever and If it’s not managed well or because at times they also under look it they may manage it as malaria and in our setting, there is no those swab whatever...throat swabbing and those investigations, so they can manage it as maybe, malaria or other infections. so if not managed well, it can migrate into the valves leading to RHD

Interviewer: Ok

Respondent: Yes

Interviewer: You have already answered my second question...both laughs. I was going to ask you about the link between sore throat and RHD

Respondent: Ok...laughs

Interviewer: Ok, what were you taught that can be done to prevent RHD?

Respondent: One, when somebody has sore throat, it should be managed well with a good anti biotics and it can be cured, if its managed well, they put the patient on anti biotics, the patients get cured, so that’s the stage of fever...both laughs and if the patient is managed so well, the patient will not get RHD

Interviewer: Ok, any other thing?

Respondent: Then the community should be sensitised on how this disease is got and how they should go about it.if they have realise or if the child has a sore throat, they take to the hospital as early as possible for proper management then on the other hand also.

Interviewer: I see like what we should do?

Respondent: The staff

Interviewer: Yes

Respondent: The staff is not yet well sensitised on RHD or sore throat so if the medical workers are sensitised well and they have a positive attitude towards managing sore throat, we would reduce on at least the number of patients who get RHD

Interviewer: And then do you know of the treatment option for RHD

Respondent: The treatment option is there but you see at times for me I don’t concentrate but I just try

Interviewer: But you like remember what you were taught...both laughs, they can give

Respondent: When someone has a sore throat, they can treat with Amoxicillin but I think 10- 14 days but am not very sure and then if someone really has the RHD, they also give benzathine, they treat with benzathine IM, at least there are those ones they put for a little time, there are those ones they put for sometimes depending on I think the stability of the condition. I think that is the only thing I know about it laughs

Interviewer: Ok what of those with severe diseases

Respondent: They can because there are those ones with stenosis, they can refer them for surgery like Baillie, and then there are those one with valve replacement

Interviewer: Ok

Respondent: Yes

Interviewer: Ok, any other thing for the treatment options?

Respondent: Treatment opinions, those are the few I can remember

Interviewer: Alright, thank you and then what is your understanding of the long term prognosis of RHD?

Respondent: The long term prognosis of RHD, if it’s not managed properly and in management it involves now a group of people from the patient, attendants, the care givers and even their doctor. If we stand together as a group managing and we are carrying out the correct thing and giving out the correct thing to these people, the chances for them to at least to push for some days but if we are not coordinated in our management, we end up losing this patient

Interviewer: Ok

Respondent: Yes

Interviewer: This is about you encounter with the RHD patient, ok like when was the last patient the last time you saw an RHD patient?

Respondent: The last time I think that was in November

Interviewer: November?

Respondent: Yes

Interviewer: Ok, would you briefly summarise your encounter with this patient

Respondent: This lady came from OPD, she was an outpatient, I think she was around, around early twenties, she was sent for pelvic inflammatory disease but when I encountered the patient, I had already prepared them for a pelvic scan but the patient was now on the table, I was examining her for pelvic scan doing ultra sound, I realised here breathing was not proper, she was having some difficulties in breathing and she would, she told me she was feeling tired on lying flat, then I told her can you sit up, so when she was sitting up, she felt abit relieved and I told her to go and lie again, then again she stated coughing and she was now restless, I said can you sit, then I concluded her pelvic scan and I said, can I go ahead and do for you echo because I can see you have features of heart problem, so when I saw the lady, she had a ripe thickened micro valves, there was also some reduced function and also the heart looking enlarged, so for me I also took it to be like this lady has both rheumatic and DCM so that is why now I made now two reports, for the findings and then for the echo, then I sent her to ...that day I called Dr betty but she was not around, so I instructed her to take that one of the pelvic that side but for echo she had to look for Dr ... or go to the medical OPD on a Tuesday because she was already past the age for...both laughs for research

Interviewer: Ok so what is the average age of these patients you see with RHD, those that have come to you

Respondent: The average age?

Interviewer: Yes

Respondent: I get them from around, you can’t get those one of 5 years ranging up to around...mostly there within 5 up to like 20 but there are few cases which goes past because maybe they have gone undiagnosed, so it’s mainly the lower age, its mainly the lower level though we have also some cases past 20 years

Interviewer: Ok, so these people who come, are they working or they are already or they are not working

Respondent: These ones who comes with...

Interviewer: Who come to you with RHD?

Respondent: Others are just housewives, other are students, and ok they are still in school

Interviewer: Are the majority of them at school or they are out of school

Respondent: I see the majority of them have dropped out of school, one because they feel sickly, they can’t now be retained at school because they are always sick

Interviewer: Ok

Respondent: Yes

Interviewer: Ok, when you try to interact with them are they aware of the link between the sore throat, acute rheumatic fevers and RHD

Respondent: Most of them do not know, that’s why I talked of sensitization has to go on, most of them do not know they just begin telling you when you inquire maybe did you have a sore throat sometimes back, they say yes, they have been doing the local tonsillectomy, you know. Whenever I feel a sore throat, they take me to a local tonsillectomy

Interviewer: Ok

Respondent: Yes

Interviewer: It seems like local tonsillectomy is a big thing

Respondent: Yes it’s a big deal here ,whenever you get a sore throat, they take you for that and they don’t give you anti biotics, so it’s like it just ready for more infections

Interviewer: What sorts of symptoms do they usually describe to you?

Respondent: They said when this thing start, they will feel abit of fever, then they would get pain on the throat and mostly on swallowing, they feel pain then after maybe the fever can also go away without even any treatment. Others even say they make this local bicarbonate, they make to take it like the oral drug

Interviewer: laughs, and they said it cures it?

Respondent: They said its ok

Interviewer: OK

Respondent: Yes

Interviewer: Any other thing they tell you or any other symptoms they described apart from...those ones?

Respondent: The sore throat

Interviewer: Yes

Respondent: Maybe after sometimes again is when they maybe at least feeling tired, difficulties with breathing at night and they could hardly run, when they try to run, they feel easily tired and coughing when they lie down flat on bed, they tend to cough a lot

Interviewer: Ok

Respondent: Yes

Interviewer: How good is the follow up system here?

Respondent: The follow up system here I could say its good but the problem is what I said before, most of the medical workers are not also...though they are sensitised but their attitudes towards management because if somebody already has different attitudes, though he sees a rheumatic patient, RHD, how he will manage it, other things leaving this patient to move undiagnosed and at times they also don’t know the criteria of management. First our patients do not get proper follow up, then at times when maybe you send them to come back ,they may come back for reviews and when there is no drugs because you know the hospital settings, there are some months when drugs are not there and they cannot afford to buy making them also to default

Interviewer: so that also affects their adherence

Respondent: Yes, it affects their adherence

Interviewer: Ok, meaning ok like at what percentage would you place their adherence

Respondent: The adherence of the patient I can give like for patients, I can give like maybe 75% because they want to get cured, they feel like they have got their disease and the drugs they are going to get it, they are willing to take it but one, when the drug is not there, they are un able to get the money and buy the drugs such thing will lower also their adherence because they are willing but the drugs are not there and maybe if they come to the hospital, there are no people willing to help them like the medics around, those ones also demoralises them, maybe they also come from far, transport to and from, maybe next time if all the medics, medical workers are sensitised on RHD, they can have on their setting within the health centre, just a unit for handling, so that they will be moving in a shorter distance that they can be managed well, that is a future plan

Interviewer: Ok

Respondent: Yes

Interviewer: And then what sorts of barriers do they commonly state to getting the care that they need

Respondent: The barriers?

Interviewer: The ones the patient tell you Respondent laughs, one, the parents may not be in position to keep them and maybe the parents are already tired of them so whenever they come to the hospital, they have been diagnosed and they give them schedules to come. The parents are not interested, they say this one has been sick for long, it’s like they have given up on this patient because they know this is a chronic illness and at the end of it, they are going to pass on, so they feel now they feel they are just wasting their time, so at times their response to keep bringing the patient back for review is also not there

Ok

Respondent: So one is attitude of the parents and guardians

Interviewer: Attendants

Respondent: Yes

Then maybe also these patients, they need money, one for their transportation, for buying drugs which may not be there with our settings here

Interviewer: No money?

Respondent: The issue of money

Interviewer: Yes

Respondent: So they will not come back for review, it will be a barrier for their treatment then we have, we have the perception where people misconcepts on the way people may be thinking, when someone has a drug, you have to share, now you have given drugs for a rheumatic patient, someone is getting cough and they will get this same drug and he will not be getting the exact recommended doses for him or her, that one is also a hindrance

Interviewer: Ok, what other barriers do they tell you they face on getting care?

Respondent: On getting care, at times also depending on the families, others also have even no food at home, so when the patient is not feeding well they just go down which is also a barrier

Interviewer: Ok and then as health worker, which barriers do you face in taking care of these patients?

Respondent: The barriers we always get, one its early diagnosis of these patients, most of these patients, most of them are always diagnosed late and I pray the hospital settings would have a laboratory which would be doing a throat swabbing, it would help like in x-rays, a child, like around 5 years upwards up to that age, it would be like a routine, they do a swabbing when they come with a fever that we exclude this staphylococcus infections early enough, then if the medic are well sensitised and they have the attitude to manage, we would manage these patients on early diagnosis and proper treatment and they will recover but now that there is nothing for testing them, we just treat them blindly, we don’t know what we are treating, that is making them to have RHD and usually in excess and the availability of drugs If the drugs were available and we don’t run out of stock for those drugs, it was going to help us in proper management

Interviewer: So you said you lack drugs?

Respondent: Yes

Interviewer: Because it’s not available?

Respondent: Yes, it’s not available, it’s seasonal

Interviewer: Hmm

Respondent: You get some months when these drugs are not there, the other one also not there, so it needs a frequent flow in for drugs

Interviewer: Ok

Respondent: Yes

Interviewer: And then now let’s say you are looking at the patients perspectives, what do you perceive that they face in getting care

Respondent: In getting care?

Interviewer: The challenges they face or the barriers they face according to your views

Respondent: In my views?

Interviewer: Yes

Respondent: These patients have a lot of challenges, one is the attitude of the medical workers, some body has come with a problem and needs assistance from you but you as a medical personnel already have a bad attitude towards the patients, you are not going to listen to the patient, you are not going to help the patient out of the problem, and even you are not going to diagnose the patient. If the patient is diagnosed, you are going out to begin because you already have a biased mind on the patient, you are not concentrating on the patient, so you are going to do your own thing which is not related to the patients’ complaints that is one barrier, attitude, attitude and good relationships. Patient medical worker relationship

Interviewer: Which other barriers do you perceive?

Respondent: They face they also face stigma, even from us the medical personnel’s and people outside, they may take also...you see, misconception, they, may say this is also dying and whatever a disease that will not cure, secondly others may perceive it’s the drug, I mean the disease is infectious, bringing in the stigma and they want to isolate them which is both from a medical worker or maybe from the relatives, so they need sensitisation

Interviewer: Ok

Respondent: Yes

Interviewer: Any other barriers that you perceive they face?

Respondent: I think those are the few I can say

Interviewer: Ok let’s say looking at the local health system barriers, how and do you feel that the administration and leadership at the district is doing well?

Respondent: No, why I said no, there is a lot of thing happening in the health centre settings, the medics in the health centre one, they are lousy, they come late on duty around 10:00 and they leave also very early, weekends they are almost not available in the settings and secondly they can trick, they can trick what is not for them, so because...they like that one I am talking through experience, here was a kid you sent for me that was I think that was early December, they called me, the patient was being treated in another health centre in Orum and they said that kid, she was a girl around 4-5 years and they said the girl had a cardiac disease so when they called me and I told them, can you bring her to the rheumatic tent, when we did the scan, it said the kid has a normal heart but they were already managing as a cardiac disease and I had seen they had already put her on bendofin, so when I repeated, you sent her again to me. I repeated and I made a report as a normal heart scan so at times its goes back to knowledge, knowledge deficient about this RHD, so that was a wrong drug for a wrong diagnosis and it’s like we are doing nothing

Interviewer: Ok

Respondent: Yes

Interviewer: Do you feel like the supervision is not enough

Respondent: Yes

Interviewer: Back to those health workers are they not supervised?

Respondent: And most of them when they are going for supervision, it means there is something, there is some money, they go for money not for supervision because with supervision when they know they are going to get a token out of it, so they go once in a while depending on the location of being within the district, if it’s not there, they don’t go so these people are just for free, they bare just at their free leisure, so if the district could strengthen their supervision within the facilities and they are sensitised and they have a good attitude towards the management of this condition of rheumatic heart fever even we would be getting, very few patients, it’s just the same way like for ultra sound, we have even ultra sound in the lower setting but people who went and read ultra sound, they have abandoned that knowledge, they have now gone to do other things, and the machine is there but no one to use them

Interviewer: The problem is with payment or the recruitment process?

Respondent: One, once you have read something you have to practice it

Interviewer: Hmm

Respondent: Two, they have been sponsored by the ministry of health where that are supposed to continue with that there ,three, they say the promotion level, the ministry makes you to read, they don’t give the cadre. You don’t get any payments, so people abandoned them, so it’s just from the ministry down then through that hierarchy

Interviewer: So that’s why you feel that they are not well?

Respondent: Yes

Interviewer: Ok, what do you think they have at least done well?

Respondent: At least they are keeping our health centre moving though...both laughs. They are keeping the health centers well, the patients are coming there but only that they refer them more so when it’s reaching to a weekend, they refer them to a referral hospital, those ones who don’t need a referral

Interviewer: Because they don’t want to take care of them or that they will be congested?

Respondent: They want just to decongest their health centre and the weekend

Interviewer: OK

Respondent: Yes

Interviewer: What about the funding of health care in general, and let’s say RHD in particular, what do you feel it’s good about it or you also feel like you are not happy with the funding of the health care

Respondent: Yes because the health care funding should be paramount in our plan for Uganda but when you see allocations given to health centre settings, it is very low yet there are very many diseases even propping in, others would need research, even medics themselves they are few and there would be need for recruitment of more staffs that there will be...at times these health workers are still doing this because they are already banned out, maybe you get yourself a loan in maternity for one week, that one is already ban out, you get yourself a loan within the department, you work from Monday to Friday, if they could give you enough fund so that we can at least if somebody has small number of people to care for, rather than pretending to be caring for 100 patients when you have done only 5, what good is on 5 patients, that is wasting time? So if they can put more money on health, recruit more staffs in all these facilities and motivate them so that they like their work, at least there would be some improvement

Interviewer: So what do you feel, ok the funding, what good...

Respondent: For rheumatic, I don’t know how their funding are because if they were funded well, if their project is funded well then everything will be running smoothly because its funds that makes, if its funded well, the programs will run smoothly, that one I don’t have much to talk about because I don’t know about the funding

Interviewer: Ok then, what about the health workers, are you happy with the numbers, the qualifications and then the quality of care that they are giving?

Respondent: One, they are few, the medical worker are very few, not that they are not trained but they are not employed, there are many health workers who are trained outside rather than those ones who are employed by the government and there are health workers who have passed on but they are even not replaced and you hear them talking of staff sealing and we don’t understand, for me I don’t understand what they say by staff sealing because the number of patients are increasing every now and then and there would be need for them to put more health workers, sensitise them, recruit more health workers, do more orientations because others have stayed outside for so long without working, even most of them have lost what they have learnt, so they are supposed to be brought back and do some refresher courses for them, so that they pick up and begin, that is why there is a lot of fake work in Uganda, most of the health workers come out of school,yeah,they have no experience, they go and open up clinics, they open up their drug shops, they want money but now they want money but in a wrong way, so they keep running around doing every fake things they feel like or they are trying to look for means of living because the government has failed to hire them, you! That is also one of them laughs...both laughs because you can’t just study and just stay seated at home yes and more so paid fees

Interviewer: Ok, what about the quality of care

Respondent: The quality of care, there is a lot of hindrances in the quality of care

Interviewer: Yes

Respondent: One, knowledge because there is that challenge I have seen in my practice, if we were together with you in class, we come out to work, we are different just because we have not put what we have learnt into practice, you have to marry what you have learnt into practice, you have to marry what you have learnt and ransomed together, that is when you have quality of care, with that knowledge being put in practice, but why our quality of care is not good. You get somebody who has a lot of knowledge but has never bothered to put it practically and when it comes to handling of patients, they are not competent, that one also hinders the care of our patient, they don’t get a holistic approach because the medical worker is 100, I can say 99 or 98 %,most of them I would say like 50% down wards because knowledge they have but practice they don’t have, then secondly depending also on the incorporation of the ministry of education and ministry of health into the training, it makes those other ones who are trained by ministry those days, those ones also under looks them to be those ones who are not knowledgeable, so there is that gap

Interviewer: So previously you were trained by...

Respondent: Ministry of health but now the ministry of education has propped in, it’s like the ministry of health gave them some portion and the ministry of education is over ridding the ministry of health in training so that one brings a lot of things, the student’s feel they are for ministry of education, these ones were trained by the ministry of health so there is that gap

Interviewer: So what is the difference, those ones trained by ministry of education, are they more of a theory bit

Respondent: Yes

Interviewer: Others of a practical bit

Respondent: Yes, for them they know more of the knowledge other than the theory so they don’t bother coming to practice and secondly their number, the number is bulky that training them is not easy because by then, they used to restrict the number of personnels being trained and they make sure you know what you are doing, when you are coming out, third year, they can leave you in the ward alone to run but these days they dodge work, they only like to pass their exams full stop, they don’t mind so much about ransume,so that is the challenge.

Interviewer: Ok, quite interesting...both laughs. And then as a health worker, what motivates you to go on working?

Respondent: What motivates me is this work is not, you take it maybe the work you got because you are bright, you are whatever but for me as a nurse in a profession, I know it’s God’s work, I have been chosen to serve God’s people with or without money I have to help God’s people and I know God will reward me, so when I come, I know am working for God’s people and the bible says if you are working you have to work like you are working for God not or human beings. Though there is a lot of work load but I still push on with the help of God almighty

Interviewer: That is nice

Respondent: Yes

Interviewer: And then do you really see that there is enough medication in the hospital like bendofin, heart failure drugs and all that

Respondent: At the moment I can say no because I see these patients at times they buy, maybe under the program of RHD, if they put some drugs there will be consistency

Interviewer: Ok, what of the general population?

Respondent: For the general no because at times they just come for prescription, they prescribe for them, they tell them to go and buy the drugs, we don’t have and if somebody has no money, he is just going with the prescription, I went to the hospital, there is no drugs and I don’t have the money, then the patient will not get any help at all

Interviewer: what about the diagnostic?

Respondent: The diagnostic?

Interviewer: Like echo

Respondent: But am just saying one year back, I called lira hospital blessed because when we did that bone on echo and they supplied us with those small echo machines and this scan, that one has helped us so much in diagnostic and I feel grateful

Interviewer: ok

Respondent: Yes

Interviewer: So what do you think the hospital hasn’t done well In terms of medication?

Respondent: That one is not the hospital, I could just blame it in our budget, the Uganda budget. If they budget what is not enough for the ministry of health, definitely the drugs will keep lacking, so if they can improve on the budget for the ministry and a good portion is put on drugs, definitely the whatever, the drugs will be consistent and our patients will have their drugs consistently

Interviewer: So our problems stems from the ministry of health? Ok

Respondent: Yes

Interviewer: And then are you happy about you record system, records department?

Respondent: In the whole hospital or where I work

Interviewer: In the whole hospital, the inpatient, the outpatient, the registers and all that. Like let’s say I wanted to get the total number of RHD patients, is it possible that it’s being captured?

Respondent: I can’t say no or yes, am just saying it’s within because from my experience and the time I have worked, there are many patients who are not captured and more now with the setting of our hospital, we have the OPD on the other side where you are supposed to get the number. there are times when they are seen and they disappear or diagnose from here, You send them to go and get the number from the other side and they just vanish, so for me I feel the record is so improper because if we are in one setting now like maybe I think maybe it will improve when that complex building will come in. when we have the OPD with everything in it but if we are still sending them to akiibua its distant ...hiiiii up to there, the patient will just vanish on the way

Interviewer: Ok

Respondent: Yes

Interviewer: Let’s say like in your department, when I come there and I look into your registers and I want to see the number of RHD patients

Respondent: You will get them, you will get them

Interviewer: Ok

Respondent: Yes

Interviewer: and it’s easy for me to actually trace them?

Respondent: Yes, yes

Interviewer: So what else don’t you like about your record system?

Respondent: One, in the hospital, in the record system, the records system is good but my fear is capturing those patients because if the OPD, take in for example, a patient comes in emergency and has been managed in emergency and has been put in ward but before the patient goes to the ward, the patient is supposed to have a number, or the patient has recovered, the patient is supposed to get the number, so there is that possibility of the patient vanishing between emergency to the OPD, they can decide to pick their medical form pretending they are going for the number and they go home or they go somewhere else because they know already the drugs has been prescribed, why do I have to waste time to go to that distance again and more so am sick and others without attendants

Interviewer: Meaning they are losing patients in between

Respondent: Yes, that is what I see

Interviewer: ok

Respondent: Yes

Interviewer: Anything else you don’t like about the record system?

Respondent: For me I feel they have to recruit even more record workers almost in every department like emergency, they should be having a record personnel to capture these so that they don’t go and vanish on the way, at least if they were captured within there, it would be nice because I see it’s only the very sick patients that remains in the ward but those ones recovering, they go away without the number which means our say 100% but there is some problem with it

Interviewer: ok then you have talked about dislike, what do you like about the record system, the good things that they may have done

Respondent: They have a good reception, when I enter their, the records whatever, that communication centre, they have good settings, their chairs are nice, they are interesting in what they are doing, i think they love their work too and I always see them when they are looking for their quarterly reports and monthly reports, so I feel they are also doing, they are doing enough

Interviewer: Ok

Respondent: Yes

Interviewer: Do we have guidelines and protocols for RHD care?

Respondent: Protocols?

Interviewer: Yes

Respondent: Yes they are supposed to be there

Interviewer: But like have you ever seen one, like do they exist actually here

Respondent: No, they are supposed to be there but I have not seen one here

Interviewer: Ok, including referral pathways,

Respondent: We don’t have the referral pathways, maybe I have not seen but I feel it’s there because you can’t see a patient and you don’t know where to refer them, it has to be there

Interviewer: So generally about the patient outcomes, do you think that they get the care that they need or not especially surgery?

Respondent: The surgery?

Interviewer: The patient in the ...

Respondent: RHD patients?

Interviewer: Yes

Respondent: I think that they get what they need but not everybody is a beneficiary because its sponsor, it is sponsor, it depends now on those ones sponsoring, and how they are going to select these patients because you can sort them out, you send them to be accessed by those ones are going to sponsor them and it will depend on their choice, you may think this one is better, they would rather work on this but if they have decided to pick on the other ones, you have nothing to do

Interviewer: Ok

Respondent: Yes

Interviewer: So their surgeries depends on...

Respondent: Yes, one getting a sponsor

Interviewer: Ok

Respondent: Yes

Interviewer: So why is it so?

Respondent: Why is like that, like they are unable to afford the care,one, it’s very expensive and our patients are not in position to get the care, then secondly, it’s a specialised area and getting specialist for those areas is not easy, that is why I feel our patients are not in the position to get the care and I find this research because at least it has put us somewhere, we have some hope somewhere that at least they can screen the patients, they can diagnose the patients, those ones who need surgery are also sorted out and now they choose according to the donors

Interviewer: And then, do you have any patient safety and quality of care concerns?

Respondent: Pardon

Interviewer: Any quality of care concerns or patients safety concerns

Respondent: Patients of RHD?

Interviewer: Ok now this one is in general, any concerns, special concerns that you see or quality of care concerns like do you feel that they are getting the right quality of care needed

Respondent: Yes, people are trying, people are trying amidst a lot of things which are missing and drugs not being available, still we try as medics to do what is needful, or we can do at least to make them come out of their problem or to sensitise them about their conditions and also to see way forward, if others need referrals, other who needs other investigations still they try to have some care, good care also

Interviewer: Ok

Respondent: Yes

Interviewer: And do you think that there are prevented deaths that happened in the hospital

Respondent: Yes

Interviewer: Why, like in what circumstances

Respondent: Like let me say somebody has come in an asthmatic attack and if the patient has not been pushed in the hospital, definitely that patient will die just due to asthmatic stress, so I feel there is good care because if they come in that status, asthmatic attack, definitely they are going to be managed and the patient will come out of it

Interviewer: What of now, let’s say the patient who is already in the hospital, do you feel that there are some patients who are dying when they were actually not supposed to have died in the hospital

Respondent: Yes, one, I had talked about knowledge deficit, if somebody who handling the patient is not aware of this patient’s condition, like in a heart disease, you are supposed to withhold fluids but the patient may be decimic and somebody who is in the ward has not seen the other part of it, in fact the patient will flee which means you have shortened the lifespan which is not supposed to be like that so it’s always about knowledge deficit and you experience in managing this patient generally

Interviewer: Ok

Respondent: Yes

Interviewer: And do you think this is happening a lot in the hospital?

Respondent: Once in a while, when you get somebody who is not knowledgeable because this is a training hospital, I can’t deny it wholesomely because you get somebody who is a student or whatever, would be rushing to do something in an attempt to save life but on the other hand he is killing the patient

Interviewer: Ok

Respondent: Yes

Interviewer: Ok and then do you think patients are dying in the community without presenting in the hospital

Respondent: Yes, very many

Interviewer: so why do you think they are dying without coming to the hospital?

Respondent: One, the attitude, people have wrong attitudes about the hospital, Misconception, they believe that they are being charmed it does not need medical treatment. People are not interested, attitude, they are not willing to bring them to the hospital, even money issues, times, they bring them to the hospital but even some body to care for them is not there, they just come and abandon them in the hospital

Interviewer: OK

Respondent: Yes

Interviewer: 0k, then in your opinion, could you give me one or two most important things ministry of health should do to improve outcomes, patient outcomes

Respondent: One, the ministry is supposed to revise laws and whatever governing the hospital and health care setings.They have to pass all through those things because there are those laws which they put long time which is not complying now because when they talk of staff sealing, what do you mean by staff sealing when the number of patients are over whelming the staff, which is those ones they are supposed to at least look into it and they raise the number of staffs per the ratio of the patient, per staff. That is one thing the ministry of health should do, then secondly the ministry of health should learn to distribute specialists evenly in the whole country because when you see, there are only specialist around central and western and maybe some few in eastern but up country almost nothing hence making health care working as it’s not supposed to because it; like a referral, how can you refer a patient to a setting which is not having a physician? No surgeon, no paediatrician, no gynaecologist, it’s just like we are in un health centre setting, so the ministry of health should learn to distribute these specialists evenly in the whole country and motivate them also to stay in hard to reach areas because they don’t like hard to reach like north

Interviewer: laughs

Respondent: Yes

Interviewer: Alright, anything else you want to add on?

Respondent: I feel they should like the ministry of health should also have a program like to extend the care for like heart diseases. If they could get a specialist also on heart disease and they put them, if they could train more and they put like one, one on every hospital, it would also be so good to help in the referral system rather than us screening from here, sending to them, that person would just screen everything for them, the post for surgeries or the other things

Interviewer: Ok

Respondent: Yes

Interviewer: Anything else

Respondent: I think that is all I can say

Interviewer: Alright, thank you so much for giving us your time and participating and I hope the ideas you have given us will really help us in improving the care for the RHD patients in future, thank you

Respondent: You are welcome