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

Interviewer: So briefly, We are conducting this to see how best we can help patients with rheumatic heart disease, yes so thank you for being part of this interview, so can you tell me about yourself.

How old are you?

Respondent: 47

Interviewer: What is you qualifications?

Respondent: My qualification...I am a medical doctor, I did bachelor of medicine and surgery

Interviewer: From which university?

Respondent: Where I work?

Interviewer: Yes

Respondent: I work in paediatric ward

Interviewer: Ok

Respondent: I have been practicing in the paediatric ward for the last on year

Interviewer: one year?

Respondent: yes

Interviewer: Ok.so where did you qualify from?

Respondent: Pardon?

Interviewer: Where did you qualify from?

Respondent: I qualified from Kampala international university

Interviewer: Ok

Respondent: Yes

Interviewer: And you have worked here for one year?

Respondent: I have worked you know I did not go to school directly, at first I had a diploma

Interviewer: ok

Respondent: In clinical medicine and community health and I had worked for some good years before I went t to school. I had worked for 8 years then I applied for and went for medicine and surgery.so I graduated in 2016

Interviewer: That is in medicine?

Respondent: Yes, so when I graduated, I went for internship for 1 year, so I returned to the hospital in 2016

Interviewer: ok

Respondent: Paediatric ward I was posted last year in November but at first I worked in another place where I came from because why I came back to this hospital, because I was an employee, my name was on the payroll when I went to school and they used to pay my salary, I went on study leave actually so I have been employed in government for like almost 20 years now.

Interviewer: Almost 20 years! Ok

Respondent: Yes, so I am not new in the field, although I am still like 2 years practicing medicine and surgery with a bachelor, but I have been practicing medicine at a diploma level

Interviewer: Ok, so which patients do you, age group do you see?

Respondent: The what?

Interviewer: Age group of the children

Respondent: Age group of the children like the paediatrics where I stay, where I work

Interviewer: Yes

Respondent: We always admit between 0 -5 years

Interviewer: 0 -5 years?

Respondent: Yes, 0 -5 years, if they are beyond 5 years, then they are always sent to medicine ward but here we admit those below, let me say 0 -5 years

Interviewer: 0 – 5 years?

Respondent: Yes

Interviewer: What is their common illnesses you meet there? The common illness you meet

Respondent: The common cases Interviewer yes

The common cases we are like meeting on the ward we are like meeting acute water diarrhoea and we also meet respiratory tract infections, both lower and upper where by you see pneumonia, bronchi pneumonia and then we commonly see malaria, malaria is common. Many of the children are having malaria and septicaemia, you know septicaemia comes maybe as a result of another blood infection, even pneumonia can make your child have septicaemia, even everything can have septicaemia, so we always see septicaemia because when we do their CBC, you white cells are increased, whatever those things are high, so we end up saying septicaemia but while there is another underlying cause for that septicaemia.so those are the common illnesses, diarrheal diseases, acute watery diarrhoea, we like seeing malaria, we see pneumonias and then once in a while we see unique cases for example we have ever, last week we had a child with measles in the ward. We had 4, they were 4 and then we like seeing also heart condition’s once in a while and then we always see them, we like sending them for cardiac echo, they always do it and then chest x-rays to make us see how the heart is and then we also see other abnormal, most un known common conditions eh...for example like paralytic ileus, the child’s intestines have stopped moving, that is partial intestinal obstruction, we also see them especially with these very new born, they like coming with paralytic ileus, most cases and then neonatal...early on set. Neonatal sepsis ,sepsis, for children who are like 0 28 days, they like giving them diagnosis like that because they have fever, they are refusing to breast feed ,crying ,so we say early onset neonatal septicaemia, sepsis, that is the most common things we see although they are unique ones. Kidney problems also can come in, heart conditions can come in, just like that ,even the liver sometimes they may have hepatitis, once in a while ,not so common

Interviewer: Ok that is great to hear. About your training, have you received any training at your school on RHD? Rheumatic heart disease?

Respondent: Specific training?

Interviewer: Yes

Respondent: I haven’t had any specific training a part from the training which I got when I was doing my medicine and during that time I used to practice medicine at diploma level. We used to meet such cases of rheumatic heart disease, hematic fever...eh, once in a while but specific training on rheumatic fever, rheumatic heart disease, I haven’t had. A part from last week, there was a CME about rheumatic heart disease and rheumatic fever but I haven’t had a special training

Interviewer: So no any training since graduation?

Respondent: pardon’

Interviewer: so it means you have never received any training after graduation?

Respondent: The training of?

Interviewer: Rheumatic heart disease

Respondent: I haven’t ok, I haven’t. I haven’t of course maybe because the program did not come here or it came and I did not know.eh...you know sometimes programs come then they might not even inform you, you are here on the ward and people are doing other things you don’t know, that may happen but so I have not had because I haven’t been called because If I am to be called, they have to come to me and say, you are selected for this training, can you , could you please come or give me a letter, they have not

Interviewer: Ok, so how many patients of RHD do you always see, let’s say in a week?

Respondent: I have ever seen 2, 2 sometime last yeah, we had a child in the ward and we referred to this people and rheumatic fever was confirmed because the child had joint ache, Somme un usual rash, skin rash and fevers for sometimes and we referred here and the child was checked and I think was confirmed of rheumatic, then there was also another one, that one was a girl, I have ever seen a girl child. The girl was around 8-8-9 years, a big girl 8-9 years, then I have also seen a child of a round 5 – 6 years, that was a boy, that one also came with the same presentation, swelling of the joints, on and off and some fevers that were un usual, so when we re-referred her, they checked and they confirmed and I think they are still under care with these people

Interviewer: Ok

Respondent: They are still under care still because they used to come for reviews, those are the only two I have seen

Interviewer: In almost a whole year?

Respondent: Yes, I think the whole year when I was here, those are the only ones I saw. That this one has rheumatic fever, could be that they are there but maybe they haven’t complained, I don’t know thematic fever may come as result of a complication of something, for example if somebody had maybe a sore throat can end up in thematic fever, just like that, maybe ...maybe there is always, they come like sore throat, then it goes away yet it may be thematic fever, that’s why we maybe don’t detect and the problem here is maybe the investigation system of it. The hospital does not have good investigation system, yeah, that is our major problem

Interviewer: So the ones you saw with RHD, were they inpatients or out patients?

Respondent: This one, this one was inpatients at first, but when we transferred to these people, then we discharged from the ward, they became outpatients. They have been coming from home to these people for review, they would come and they were on treatment

Interviewer: Ok, what is your understanding 0f what causes RHD?

Respondent: what causes it?

Interviewer: Yes

Respondent: Rheumatic heart disease...I think it may come as a result of the rheumatic fever that wasn’t properly handled, I could say maybe a complication that develop rheumatic heart disease. Also I may think its bacterial infection for example if somebody had a sore throat and mostly the common bacteria causing sore throat maybe streptococcus infection not well treated with antibiotics, it may end up to the heart then it cause rheumatic heart disease

Interviewer: Ok

Respondent: Yes

Interviewer: Ok, are you aware of the link between sore throat and rheumatic heart disease, you have just told me about it

Respondent: About?

Interviewer: The link between sore throat and RHD

Respondent: And rheumatic fever

Interviewer: Yes

Respondent: Yes, I have already told you, it may be like somebody has rheumatic fever not well managed. Complications rheumatic heart disease, it ends up, it end s up in the heart, that’s why we must manage these rheumatic fevers properly and even sore throat, and you give strong antibiotics that may kill those bacteria so that it doesn’t end up in the heart

Interviewer: Ok, so what were you told that can be done to prevent rheumatic heart disease?

Respondent: I think I was told anything but hat I think is maybe the public or community could be sensitised about the problem of RHD, sensitisation. And in the sensitisation, you could put there ...the first of all the disease itself, you should explain it to the people how it comes and of course the signs and symptoms that may lead to rheumatic heart fever, if somebody has seen the child is having selling in the joints and the joint pains, then fever, abnormal skin rash, may come for screening, that is what we should do. I think I just think, although I have not been told but I think that is what must be done. We should educate the public or the community about the disease, we sensitise them and then they see the child like that ,they bring for us for screening and get treatment so that we may supress those viva, those bacteria not to go into RHD ,I think so that is what we can do

Interviewer: Ok, what about the treatment option, what were you told were the treatment option for RHD?

Respondent: Treatment options?

Interviewer: Yes

Respondent: I would think of the penicillin’s

Interviewer: Ok

Respondent: penicillin’s like, IV ampicillin or IV benzyl penicillin, penicillin because streptococcus I think responds well to penicillin

Interviewer: Which treatment option do you know about?

Respondent: Treatment options, maybe, maybe if there is no penicillin’s, you may give ceftriaxone

Interviewer: What is your understanding of the long term prognosis of RHD?

Respondent: About the prognosis, yes the prognosis would be good if i6s early detected, if its detected early for example if a child has rheumatic fever only and you detect it and give good care for it or if a child has a sore throat and you give that child good anti biotics for the sore throat ,I think the prognosis maybe good but of course if it has gone to RHD and whatever maybe the prognosis can also be poor but if you manage it in its early stage for example like a sore throat has stated then you give good antibiotics, it will supress it and there it will not go into RHD

Interviewer: Ok

Respondent: Yes

Interviewer: I understand, so you talked about meeting 2 patients, could you talk about the last patient like the last patient with RHD, just briefly summarise what you saw in this patient

Respondent: ok, the last one?

Interviewer: yes, the one you said you saw

Respondent: The last one, the boy was around 5-6 years, he came with history of joint aches, the joints were paining, all the large joints. This one here ,the elbow, the knee joint, the ankle joint, they were paining like for 1 week, then in the 2nd week, this boy ,this was paining and the boy was having fevers, the fever were running on and off while the joints were paining for 1 week. In the middle there running to the 2nd week, he began some rashes, rashes were in the face even on the trunk, that one was like for around 2-3 days, then they came to the hospital, when they came to the hospital, for us we managed, we first of all managed with anti-biotics but then we decided to take him for screening because his presentation were un usual, so we treated that pain of the jo9nts and whatever. Symptomatically, we were managing the child then we sent to those people and they confirmed him to be having rheumatic fever, those ones at the tent, so from there these people took over this patient, we discharged the patient from the ward and then they took the patient over, I think from there, it was an outpatient. It was up to around some times in august, this year they were still coming for review, I don’t know whether they still come, they were coming for review

Interviewer: Ok

Respondent: Yes

Interviewer: So what is the average age of your RHD patients?

Respondent: The what?

Interviewer: Average age group of RHD patients, rheumatic fevers or RHD

Respondent: RHD? I think the average age could be between 5 -10 years, some may even go above 10 years

Interviewer: Are most of them in school or out of school?

Respondent: They are in school

Interviewer: Most of them are in school

Respondent: Most of them are in school

Interviewer: Ok when you talk to them .are they aware of the link between sore throat and RHD, the patients or their care takers are they aware?

Respondent: They are not aware, they are not aware they don’t know, they don’t understand that if somebody gets a sore throat ,if not well managed, it may give another complications, they are not, they are not aware of that, they are not aware that is why I was saying that the public should be made aware of how that thing comes, the causes and even the presentation and signs and symptoms so that they may understand when they see somebody like that or a child ,they can be able to bring to the hospital immediately

Interviewer: Ok, so what sorts of symptoms do they usually describe to you when they come?

Respondent: what?

Interviewer: The symptoms, what symptoms do they describe

Respondent: The symptoms

Interviewer: Yes

Respondent: For them they describe that the child was having fevers that were running on and off, then the joints were paining, that the child could cry in the night, that there is joint pains and then some of them may have inability to use that limb properly. And when the child has started inability of moving and using the affected part that is when they can realise and they start bringing to the hospital because now the child is not moving

Interviewer: How is their follow up, do you think it is good? Do they adhere to their medication?

Respondent: Adherence to medication, of course if the disease is acute they can adhere to medication but of course when it comes to the time for coming back for reviewing them, some of them don’t come

Interviewer: Why do you think some of them don’t come n?

Respondent: I don’t know whether they have not understood the explanation of the review or what, but some of the defaults, they default so emphasis could also be made on that point of coming for review after the treatment when it is still acute. They like coming because they want the symptoms to go, the moment the symptoms have disappeared and the child is now running, playing around, they may forget

Interviewer: What sorts of barriers do they commonly state to getting the care they need?

Respondent: The what?

Interviewer: Barriers or challenges that they face in getting the care that they need

Respondent: Barriers?

Interviewer: Yes

Respondent: Barriers to what?

Interviewer: Getting the care that they need

Respondent: Maybe the barriers they may get for the care they need

Interviewer: yes

Respondent: Hospital barriers or barrier at home

Interviewer: No, either way

Respondent: Either way. ok let me start from back home where they are coming from, maybe these patients are living far away from the hospital, then they may complain of the transport because if somebody is living in the village for example some villages are very far from here, like maybe 40kms or 50 kms, yeah, some even 90 kms from the centre of this town from this regional hospital, then transport will be a problem. Second barrier could be poverty, the family may be poor so that they cannot afford to also pay for the transport, and those are the barriers at home. And the also a cultural beliefs, cultural beliefs because in Lango ,when there is a sore throat people like going to the traditional healers to check on the throat and see if there is a pus there, let us take to the traditional healer to remove ,in fact they even cut off the tonsils sometimes

Interviewer: That is very sad

Respondent: Haven’t you ever heard of that?

Interviewer: Yes of course

Respondent: They are very common. Local tonsillectomy. and that is what we always see on the wards, local tonsillectomy with septicaemia because already sepsis could have set in because of the local thing done and the septic techniques used and whatever, so cultural beliefs also, cultural beliefs, people believe more in those traditional healer than medical treatment especially in the villages, you know most our patients here, they’re not these ones who liv around, they are people who come from far ,these people who live around the town I think because of the care, even the families are not so poor and whatever so they don’t like getting sick like those ones far away, so it is those ones there and they have cultural beliefs there, then in the hospital here the barriers we have first of all could maybe lack of personnel also personnel for example that speciality of rheumatic fever and RHD is a special thing.so personnel thing for care may not be available although there are medical personnel you see even me you see, I am telling you I haven’t had a training , you may be there but you may be having what ,little knowledge. For me I have the knowledge from school about RHD but a special training makes it very difficult for even other personnel like nurses, clinical officers even medical doctors, so personnel could be a barrier. Secondly, in the hospital here also the investigation methods we used, our laboratory is almost dead, I am telling you that one maybe if I am talking something sensitive...

Interviewer: , no its okay, everything is confidential

Respondent: Yes, the lab here is so, so dead, these people here don’t even o mere CBC

Interviewer: Why? They don’t have the reagent or?

Respondent: Even if the reagents are there, for me I think it is just personnel attitude

Interviewer: Ok, like they don’t want to do the test

Respondent: They don’t want because I have worked with them for long, they don’t, when you send the patient there for CBC, what is the reason for not doing? We are not doing, they have not even told you. Just go to the clinic, the patient will go the clinic

Interviewer: Even if the reagents are there or not there?

Respondent: Of course sometimes it might not be there, that is true, it might not be there but there at times even when it’s there and they don’t ...I have ever noticed one time I wasn’t feeling well. I wanted to do a CBC, that time I wasn’t in paed, I was working in LIDC, so I went to see a fellow w doctor who decided to do a CBC for me, so I went to the lab, the previous day I had sent a patient there to the lab for CBC, even that morning, the patient was turned down.so when I went there myself that I was going to do, they did it for me, now I was questioning, I said, why do they ,why do they minimise CBC and yet I sent the patient and they were sending away, that was my question. That is what made me come with a conclusion that they have the reagents, sometimes but they don’t want to do for the patients

Interviewer: Ok it seems, like they want money

Respondent: That is the thing, that is the reason because there is no way you can do for the staff and the patient comes from out and you say no and yet they’re the ones who really needs that care.eh..., so the investigation here is a problem. I work in the ward there, all CBCs I send out and the patients has to pull 15.000 for doing CBC, if you’re doing liver function test, kidney test it, may be more than, the patient may pay like 75000 or even 100,000/= which is too much money. A part from the RDTs which we do on the ward, not even in the lab but on the ward

Interviewer: You gave the strips

Respondent: That we are given the strips, so that one we do on the ward but it needs the lab so they even don’t, they rarely do it, so the lab is a problem here. I think those are the barriers, then another barrier could also be lack of drugs, sometimes you may prescribe a drug for the patient and then it’s not in the hospital but if it’s there they always give, but there are at times, we always have shortages and the drugs are not there so the patients has to buy, so it may become a barrier

Interviewer: Ok, what about what you face as a health worker

Respondent: The what?

Interviewer: The ones you face, the barriers you face in taking care of them?

Respondent: I need training, I need to be trained

Interviewer: Do you feel you lack training?

Respondent: I feel I should be trained about that rheumatic fevers especially, so that I can take care of the patient that is my barrier

Interviewer: So like you feel you are not confident enough to take care of these patients?

Respondent: pardon?

Interviewer: You feel you are not confident enough to take care of these patients because you lack training

Respondent: No I can take care of them, I can be confident and take care of them but I need the knowledge yeah, I need the knowledge

Interviewer: Ok

Respondent: I need the knowledge

Interviewer: What other barriers do you perceive the patients face, what you think, what you feel they face

Respondent: The challenges, maybe I could for example when they come to the hospital and they be bouncing, sometimes they may bounce because if they come and they don’t get the personnel to take care of them, that one is bouncing, that could also be a barrier to them. and also when they come and there is no drugs given ,they may be discouraged that when we go to the hospital ,we come without drugs, what is the use of going there, let me just go to the clinic and buy, that could be a barrier.eh...,I think those are all.

Interviewer: Ok, so about the administration and the leadership in the district, what do you think they are not doing well?

Respondent: The what?

Interviewer: Leadership or the administration?

Respondent: Administration I don’t know what I can say about them, I don’t know actually, in fact that one, it seems I cannot comment, I cannot comment

Interviewer: Ok, do you think they are doing well? What about the funding for the health care?

Respondent: The what? The health care

Interviewer: Yes

Respondent: Of course the administration, I can see that maybe they also try their level best to see that maybe for example like the lab is well equipped, or the part of the administration. I think they see it that all the things are in place and then also for the drugs that may be lacking, they also try their level best to make the drugs available most of the time

Interviewer: Ok.so do you think all those drugs available like those of...

Respondent: I don’t know what they do ,what they think about training of then staff, I don’t know ether they have ever trained other staffs on RHD or not, so training they should also be able to think of training but I don’t know whether they do it

Yes

Interviewer: So what of the medications like for benzathine, anti-failure regimen, do you think they are readily available?

Respondent: Medication for heart failure?

Interviewer: Heart failure yes

Respondent: Yes, they are there, they are always available. Like today I was in the pharmacy and I saw that they have cardiac aspirins, they have there is this drug called astovast

Interviewer: Atorvastatin?

Respondent: Yes

Interviewer: ok

Respondent: I saw they have in stock now but there are times when you go to the pharmacy, you find when these drugs are not also in stock, I think that happens in all government hospitals

Interviewer: lack of drugs

Respondent: Yes but now they are in stock right now

Interviewer: Ok, do you think that you have enough health workers

Respondent: Here?

Interviewer: Yes

Respondent: We may not even be having enough, we may not

Interviewer: what is the average waiting time, for example you were talking.

Respondent: The what?

Interviewer: You were giving me an example

Respondent: The what?

Interviewer: You were giving me an example

Respondent: For example the ward where I work, these days I sometimes work with only one nurse during day time and yet you know during day time there are many things to be done in the ward. When the doctor is there doing the ward round, one is recording, eh..., the number recording whatever you are write and then another preparing for treating, another person preparing to give IV drip ,another person maybe to looking for the lines but these days I have only one nurse, one nurse like this during day. And then in the evening also one comes, then at night one comes, then another off duty,

Interviewer: It seems like there is as shortage of staffs

Respondent: Yes, there is shortage of staffs because at first, I used to have 2 nurses

Interviewer: On each duty?

Respondent: Yes on duty, sometimes even 3, but these days I don’t see , there’s only one

Interviewer: Have they reduced the number or they have been shifted somewhere else?

Respondent: I think they were shifted somewhere else but they never replaced them because they removed 4 nurses from my ward and they took to the other units but they were given only either 2 nurses, 2 new ones, I think some have go back to school, I don’t know what has happened or some have been transferred and they never replaced them

Interviewer: So what is the average waiting time for patients?

Respondent: waiting time for?

Interviewer: For patients

Respondent: From patients

Interviewer: Yes

Respondent: In my ward

Interviewer: Yes

Respondent: For them to be seen

Interviewer: Yes

Respondent: No they don’t take time because we are 2 medical officers, so we always see them faster, we review them very fast, even those ones coming just for admission, we review them and we write their treatment and they are given, they wait so long

Interviewer: Ok

Respondent: They don’t wait for so long, that is in my ward but in the other ward, and I don’t know what is happening

Interviewer: Ok, how would you rate the quality of care in your ward?

Respondent: In my ward?

Interviewer: Yes

Respondent: The quality of care is good, I can say it’s good because I can see when I prescribe something, those nurses even if it is only one they endeavour to make sure that each patient has got whatever I have ordered, even this picking up of samples and doing investigations, they also do, they make sure that they do it, so I can see they try, it I good.it is good in my ward but in the other wards I don’t know

Interviewer: Ok, as a health worker, what motivate you?

Respondent: ...motivation

Interviewer: Motivation?

Respondent: I don’t see but for me if I see a patient and the patient has recovered, that is my motivation

Interviewer: Ok, that makes you to work on

Respondent: More patients, that is my motivation, but other motivations I don’t see, I don’t think of them ...but if I have treated patients, I have received them well, the mother is comfortable, the child is improving, that is my motivation, that is what I think as a health worker. I get motivated as the patient is getting well because if you are a doctor on the ward and every morning you come and the patient is dead, every morning they are reporting deaths, even in your bed, there you read death,death,death,4 -5 deaths in one day ,then it means you are doing nothing. But for me when I come I n the morning, I read the report, no deaths, no what, the patients are recovering, I am happy, I am motivated

Interviewer: Ok, that is nice

Ok, let’s talk about the medical records, do you think it’s doing well

Respondent: The what?

Interviewer: The medical records?

Respondent: Medical...?

Interviewer: Records like your record departments

Respondent: Medical request

Interviewer: Records

Respondent: Records?

Interviewer: Yes

Respondent: medical records I don’t know what they do, I have never tried to be close to that department, I don’t know whether they are keeping their records well or not because I have never tried to visit, eh to investigate or to go there and find out what they do

Interviewer: Ok, but do have like registers in patients registers on your ward?

Respondent: In patients register on my ward is up to date I think, because every patient is always registered and every patient entering the ward we have a big register they always register them there. Even registration for RDTs, BT, the ones that have had hard all have their books and they are recorded

Interviewer: Ok

Respondent: If you order BT, it is recorded, if you order RDT, it is recorded plus all the results and the particulars of the patients, I think the records in my ward may be better, eh..., its better, its good

Interviewer: So do they record the diagnosis of every patient?

Respondent: What?

Interviewer: Do they record diagnosis of very patient?

Respondent: They do what?

Interviewer: Do they record diagnosis?

Respondent: Yes, they record

Interviewer: Including like ARF or RHD?

Respondent: They do but one sometimes may be the nurses, maybe they don’t record, sometimes some of them not record

Interviewer: So how best do you think we can improve the records system?

Respondent: Records system?

Interviewer: Yes

Respondent: Like in the wards, first of all if you want to improve such a thing, you need to call people, you need to call a meeting and then then you address the problem to the staff and then they will see how to make it better. I think that is what we can do ,we should call a meeting, then make an analysis of the records and see ,are they doing it properly, then we tell, them to improve on them, I think that would be better

Interviewer: Ok, and then do you like have a guidelines and protocols of RHD care

Respondent: Protocols?

Interviewer: Yes

Respondent: On the ward?

Interviewer: Yes

Respondent: No we don’t have

Interviewer: Ok, so what do you think the administration can do like to improve on, let’s say funding in the health care?

Respondent: To improve about.

Interviewer: Funding

Respondent: Funding?

Interviewer: Of health care

Respondent: Funding of?

Interviewer: particularly on RHD

Respondent: Funding, of course funding should be increased, not only funding of course funding is a big title but there are sub groups down there. Funding s good it can be done but it can be improved but when they are funding, they should consider their training and also the protocols that you are talking about. I think it must be distributed to every ward so that everybody is there to see ,eh...,to see because I have seen many ,many things for example the management of pneumonia and whatever ,I have seen the things on the wall, even diarrheal diseases, diarrhoea and rehydration, you see the charts on the On the wall, so I think that can also be done for rheumatic fever and RHD, so that could all the funding because all those things will need money..., that is why I said funding Is a big but under funding there are small ,small things that can be done

Interviewer: What about for the health workers?

Respondent: The what?

Interviewer: Health workers

Respondent: Health workers?

Interviewer: What can be done to make them better?

Respondent: Health workers, for me I was thinking of making them have a training, if possible you can even do a mass training, a mass training for every health worker, that would mean either through workshop, work shop mainly. You can organise and then people go on going like one by one. You don’t go all at the same time because if you go all, work will be at stand still, you pick some, you train for this time, you pick some ,you train, just like that and also I think the health workers also they may ,the health worker themselves ,the number may be increased somehow, eh they should increase for example like the nursing department, even medical officers for example if you are now caring for the RHD as special thing, when we need a medical officer, he sits there at the rheumatic fever tent ,yeah ,here in the tent, I don’t think there is a medical officer there. That place would be having good, if it was a good setting, it could be having a medical officer in that team because I can see people who are in that team, yeah because I can see people who are in that team the other cadres of trainers, training, they are not medical doctors, for me I think it would be good also to put there one medical officer

Interviewer: Ok

Respondent: one or two at least two o that they can be alternating, you know, you can’t be on duty all the time, this one is on, this one I off, just like that and so the health workers ,government should plan to employ ,either employ more health workers to fill that gap of rheumatic clinic because they will ,I know this hospital is going to have a clinic for RHD one time, a bigger one, so they should plan for that, eh...,they should plan for that so that they put medical officers, put there all cadres of staffs ,eh...,so that they can be able to manage the patients properly

Interviewer: Ok.so generally do you think they are getting the care that they need?

Respondent: The what?

Interviewer: The RHD patients

Respondent: RHD?

Interviewer: Yes

Respondent: I think they could be getting the care that they need

Interviewer: Especially surgery

Respondent: surgery?

Interviewer: Yes

Respondent: No surgery, not here

Interviewer: Why?

Respondent: I don’t think they do surgery here for that

Interviewer: Is it because they don’t have the equipment

Respondent: May be w don’t have a surgeon...

Interviewer: Ok

Respondent: We don’t have a surgeon here, that is why I was telling you that personnel, personnel are important in that management of rheumatic fevers, .RHD because is it a speciality, so it needs it to have its own team, ideally even there could be a surgeon working with them, specialised in that, not just a general surgeon because a general surgeon may not do it, it needs a special one

Interviewer: Do you have any patient safety and quality of care concerns?

Respondent: The what?

Interviewer: Patient’s safety and quality of care concerns

Respondent: Patient’s safety?

Interviewer: Yes

Respondent: Yes of course, like am now talking in my capacity, when we take care of these patients, we make sure they are safe, we make sure that business of cross infection, therefore we may be protecting ourselves with the gloves and we use only one for one patient. I don’t put gloves then touch this patient, then put on it again, touch the other one, no each patient you use a different gloves.

Interviewer: so you feel they are protected, there is nothing you are concerned about like

Respondent: About?

Interviewer: Their safety of care

Respondent: About?

Interviewer: Any concerns on their quality of care

Respondent: The patients?

Interviewer: Yes

Respondent: They may be having concerns of course, they don’t express it you know, eh but they may be having their concerns also but they may not express it to us also

Interviewer: Why?

Respondent: I don’t know...

Interviewer: Is it because the fear interacting with you

Respondent: I don’t know why they don’t ,it could be sometimes also its just out of fear, they feel these are medical personnel we cannot attack then, what ,what ,eh they don’t speak up but they also have their issues, I am sure if you are to ask one of them, will talk for you, will talk for you the issues they have, they have issues but they have failed to express to us, they don’t express because of fear, I know fear because most of them they don’t speak while they are on ward but when they go outside there and you sit like you are not a medical personnel, you will hear what they are talking..., you will hear what they are talking but when they with you here they will not talk anything, they will pretend that they are comfortable

Interviewer: Ok

Respondent: Yes

Interviewer: So during your time, are there any preventable deaths that happen in the hospital?

Respondent: Preventable deaths?

Interviewer: Yes

Respondent: preventable deaths like in my department, in my department, in my department ,it has not so happened because you know paed how it is, you know paed is always a very specific thing because you know paed patient will either come when he is very pale anaemic and that one you will do x-matching properly, group and bring blood and put already, so the patient will be safe from death because if you don’t do that, the patient will just die, in fact one day a patient was referred from ... HCIII, this patient on examination from there was paper white, so this people I don’t know, either they delayed nor what transport the patient, on reaching the ward, the mother, midwife from there was the one carrying the child, I was thinking that maybe she was an attendant, then I asked her where is the mother, then she said, this is the mother, then I asked her, you give the kid to the mother because here I want to talk to the mother, I don’t want to talk to you if you are an attendant, so she gave the kid to the mother, the mother sat, on examination, the baby is dead

Interviewer: What!

Respondent: ... The kid died, even I think as she was coming, and she brought a dead body, the kid died and of paper white, a baby of 6 months

Interviewer: What!

Respondent: Paper white, paper white, but that one died even before ,I think as they were entering the ward, the kid was already dead, even she told me that bushel felt it but she wanted me to confirm

Interviewer: so that was due to delay

Respondent: Yes delay, that was delay but if they had reached the ward early, that kid would have survived because for us in the ward there we have stand by staff that always receives those patients with less blood, they do, they do grouping and x-matching straight away, they put the blood. Preventable deaths could also be occurring in other departments

Interviewer: What would be the reason?

Respondent: Other departments for example Obs and Gyn, I think preventable deaths may occur there ,I just think because thee mothers they may come for example a mother with a raptured uterus, so that mother arrives, it needs you to be so fast and here in the hospital, what delays people sometimes, sometimes the mother has arrived you are still calling laboratory, you know what I told you about the lab, they are even not there, whatever you delay in the grouping and x-matching because you can’t put a patient on ward with what without having blood and without you doing blood grouping, eh, so you see, that is an emergency which needs everybody to b standby which is not possible in this hospital, here in other wards am sure, that is the preventable deaths I know because the mother was, if the people were standby straight away, grouping and X-matching, takes like only 5 minutes, you are in the theatre, you open the mother, see the uterus or whatever, you rescue the mother or the baby and then you close the uterus but I don’t think it happens here, here it takes a process, it might take you one hour to take the patient to the theatre just because you are calling the lab person, he is nit around or he is still somewhere and is not even willing to come ,such things

Interviewer: So there are a lot of delays?

Respondent: There are a lot of delays, delays, delays in the hospital and I don’t think only here, all the government hospitals, even Mulago

Interviewer: So why do you think it happens for government hospitals

Respondent: Pardon?

Interviewer: Why do you think it happens from government hospitals?

Respondent: It’s because they are not so motivated, government you know the problem, it has ever been like that people are as if they are not motivated, the workers are not motivated, the worse thing with government is corruption, corruption so it makes them not to motivate the workers

Interviewer: So people are not motivated?

Respondent: You remember the other time when we had a strike, how things were, discussing about payment of the health workers almost took so long for them to come to a conclusion and they just did it by force, I think to increase the salary but they could have not even increased, so the problem is like that. It’s in I think all government hospitals and you know people, you know a person can get used to a habit, people are used to that habit that you know government ha ,ha everybody ha-ha it’s just a habit it’s a habit, You see I trained from KIU and also did internship from KIU teaching hospital. There is no delaying, things are done on time, duties are done or covered on time, everybody is on duty, if you are on duty, you are duty.no saying eh...that was people were strict and everybody does what is needed, if not, you don’t get the money, they even cut your salary for that but here you people are just, people are just, you know it’s the nature of the government and it may take people time to correct that

Interviewer: I hope they correct it really

Respondent: They may correct but not even if they correct, they slip away just like that, they will correct it slowly, slowly ,slowly and you know now days things have been commercialised ,commercialisation of health. Let me say commercialisation of everything, so a person may just think of money, it’s very hard and once they have even commercialised a hospital, a person can open his own hospital

Interviewer: Don’t you think it can happen in Uganda?

Respondent: Of course, like schools ... A person can open his own schools, a person can open his own hospital, you see, so it has affected, it affects us.it can affect the health system also if the commercialisation process was not done, then people would be better, strict even but you can’t be strict all that when people are doing other things outside. Clinics are all-over, for me personally I don’t have one... but people have clinics all-over, small ones, big ones, they have, so those ones can affect their work, you see when you are working and you also have your clinic somewhere, you will be thinking of money, oh...let me do and go to my clinic and get money, you don’t concentrate, that is the problem and it has happened and it’s very hard to reverse it, hmm..., commercialisation, they have commercialised even the training of health workers, all of it, money, for me by the way when I first trained, it was not commercialised. I qualified in 1996 from Gulu clinical officer’s school but our training was not commercialised,

Interviewer: No paying of money?

Respondent: No, it was strictly government, you enter as government and you come out as trained staunch person but these days, you find someone who hasn’t passed well, because of the money, has paid some money and gone to train and has become a clinical officer, what do you expect out of such a clinical officer, nothing good of course because they have paid money, the back ground alone but for us it was government. We did interview those days, the interview was in this training school, and they took us from here, we were given admission, we went for the training, no payment of money, you just pay your personal things and go to school and train freely

Interviewer: I guess some of us missed that

Respondent: They could even give us money we missed that time, you missed it, for you, you paid money?

Interviewer: Definitely...

Respondent: You paid money for?

Interviewer: Of course now days we pay tuition

Respondent: What did you do?

Interviewer: Nursing

Respondent: You paid it?

Interviewer: Yes

Respondent: You paid the money and that is what is happening, for us, I think we were the last lot, after us they started now this commercialisation, for us they used to even give us money, eh...they would give us money but paying money for education it is hard, that is why when a person comes out, if it is not a very good person, he may not even be willing to help the patient because first of all, you have wasted a lot of money, you want to regain...

Interviewer: Ok, back to our interview, do you think the patients are dying in the community without presenting to the hospital?

Respondent: The what?

Interviewer: Patients, do you think they are dying out there without coming to the hospital

Respondent: Yes they do

Interviewer: Why do you think that is happening?

Respondent: First of all, some of them are poor, poverty, number one is poverty, and maybe they cannot even afford to climb on the vehicle and come and meet the expenses here, so he fears. And also even cultural beliefs can affect them, some of them are still going to witch doctors up to now.

Interviewer: And they believe that they work?

Respondent: They believe and they are even having wrangles in the village there, loggerheads with the neighbours that the neighbour has bewitched them because he has gone to the witch doctor and the witch doctor has said it’s your neighbour, have you seen?, so that makes them to die from home

Interviewer: That is really sad

Respondent: They are, these dying from home, dying from home and some of them just have bad attitude, some of them say now if I go to the hospital, who will help me, I don’t know any person there, if I go, I may not get help, that one is their attitude

Interviewer: Ok, then in your opinion, what are the two most important things ministry of health should do to improve outcomes

Respondent: The what?

Interviewer: What can ministry of health do?

Respondent: To?

Interviewer: Improve outcomes

Respondent: Outcomes of care for RHD?

Interviewer: Just in general

Respondent: Health, health is general

Interviewer: Or particularly in RHD

Respondent: Ministry of health maybe...,maybe on the side of life drugs, they can do something but of course I can’t say they can do something on the part of maybe the motivation of health workers like what their salaries and whatever you know they also just wait on the decision but on the side of the drugs and personnel, they may do something because fir them they do sit down and budget and if they would increase on their budget for the drugs because I can see here they give us the drugs 3 quarterly,3 monthly but these 3 months, you just use the drugs for one and half months and the drugs are finished, the number of people, they should consider the population and then they budget, you know people are than our population of these days, it seems they are still using the budget of the 1990’s but they are not budgeting for this population of almost 40 million-Uganda now harbours about 40 million people, they are still giving a population of 10 million because the drugs they give here it spends around one and half months, sometimes one month out of stock and the rest of the two months ,we are there buying drugs

Interviewer: Buying what?

Respondent: Buying all the things like the last two weeks, I was in the ward and people were buying cannulas, these yellow ones, cannulas, it was not in stock, it was out of stock, even sometimes gloves for examination, things here like alcohol sometimes they run out of stock, JIK, whatever, so for them, they plan for a smaller population. They should be planning and give the drugs for three months for a greater population and then that one also will lead them to increase the budget...the funding and then the peroneal, they should either have a recruitment for health personnel so that at least you may have enough and then those ones on the ground, should be having on-going training so that they can be trained and they take care of the patients properly

Interviewer: ok, alright, thank you for giving us your time and accepting to participate, I know whatever your views has been will help us and the government in trying to figure out a better way to improve care for RHD patients

Respondent: It was also good, my answers may not be so good

Interviewer: No, all answers are right, we don’t have wrong answers, those were your views and we welcome them

Respondent: It’s okay

Interviewer: Yes, thank you