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

Interviewer: Okay, thank you for accepting to have this interview with me. Now umm, just to remind you, be frank with your opinions and share your opinions. We are going to keep your information confidential. There is no right or wrong answer. Whatever you say is what we take and we want to provide better health care for RHD patients. We shall not leak your identity to your comments in any reports that we produce. So tell me a about yourself, how old are you?

Respondent: I am James.

Interviewer: You can leave out the name. How old are you?

Respondent: I am 26.

Interviewer: Tell me about your qualifications; what are your qualifications?

Respondent: I am a Pharmacy Technician

Interviewer: OK, and then, where did you train from?

Respondent: I trained at Uganda Institute of Allied Health and Management Sciences, Mulago, formally known as Mulago Paramedical School.

Interviewer: And when was that?

Respondent: I finished in 2016

Interviewer: And how long have you worked here at Entebbe?

Respondent: These are now eight months

Interviewer: So when you look at the patients that you have been seeing, if you can tell me about their demographics; their age, which is the dominant age you are seeing among your patients?

Respondent: Umm, most of them I would say are adults because, first of all we have many adult health units and the pediatric section being anemia. The others are treated in their own wards.

Interviewer: Males or females? Which one is the common?

Respondent: The largest number are females.

Interviewer: And which are the common illnesses which are being treated?

Respondent: Commonest illnesses; we have STDs, we have mostly STDs and Respiratory Tract Infections then ulcers.

Interviewer: Okay, then let's talk about your training in Rheumatic Heart Disease; have you received any specific training during school about handling Rheumatic Heart Disease?

Respondent: Rheumatic Heart Disease, we read about it but there wasn't much details I would say.

Interviewer: But you had some training in school?

Respondent: It wasn't training as such, it was more of lectures.

Interviewer: Okay, and after graduation have you received any training in handling Rheumatic Heart disease?

Respondent: No.

Interviewer: No! Okay, and in your practice; how many patients with rheumatic disease have you seen?

Respondent: They would be around four.

Interviewer: Like four! The four you have seen them here?

Respondent: Here I have not seen

Interviewer: Not even one?

Respondent: Not even one

Interviewer: Okay.

Respondent: I don't know whether the diagnosis are not ...

Interviewer: You have not seen any patients of Rheumatic Heart Disease?

Respondent: Maybe there could be another reason for that because we have what we call diabetic and hypertensive clinic, and it is up there. So it could be that most of the Rheumatic Heart Disease patients are handled from there; they do not reach this side.

Interviewer: Do they have a separate pharmacy there?

Respondent: No. They have a unit; they have some drugs but what they might not be having they come this side.

Interviewer: So this is the central one!

Respondent: Yes.

Interviewer: OK, then it's you handling most of the patients

Respondent: But now those ones, like there are some units like psychiatric, HIV, Tb and then hypertension. They usually have their basic drugs.

Interviewer: They only come here when they don’t have the drugs!

Respondent: Yeah

Interviewer: I understand. Okay, now, what is your understanding of the causes of Rheumatic Heart Disease? What do you think causes it? Okay, from the little that you had from school.

Respondent: Rheumatic Heart Disease usually is what we call Rheumatic fever. So most of them come as infections and if they are untreated, they keep on progressing affecting the valves of the heart, the joints.

Interviewer: OK, now, are you aware of any links between sore throat and RHD?

Respondent: Any link?

Interviewer: Is there a link? Are they associated; sore throat and Rheumatic Heart Disease? Are the two associated?

Respondent: I would say they could be. Okay, sore throat can be categorized, it's that they are all allergic or bacterial or fungal; it can be either of them. Most of them could be strepto, so they come as strepto and then they have a link to Rheumatic Heart Disease.

Interviewer: So what where you told can be done to prevent RHD?

Respondent: Preventing RHD ... [thinks] that's some good time back. Umm, but mostly, I think as a basic of managing that infections, it goes hand in hand with sufficient hydration especially warm fluids. That would play a big part, and also the intake, what you have taken; the infection of contaminated food. Some people are so much interested in taking clay and soil, so that could be one of the factors that could escalate the condition. So the risk factors; the intake and then the management or prevention.

Interviewer: What where you told can be done to treat it?

Respondent: umm, there must be some operation on this especially the ones with streptococcal.

Interviewer: Are there any other aspects in RHD management in which you think you will need more training if they were to offer you training in RHD management? Which areas would you want to be taught, or to be trained in?

Respondent: I think mostly, because now, currently due to my exposure I have not got those much cases of Rheumatic Heart Disease. And you know training keeps on, I mean Mildmay keeps on revolving, so since am not exposed, maybe I need some training about Rheumatic Heart Disease treatment.

Interviewer: Apart from treatment, any other area?

Respondent: Of course if I go for treatment, then it will encompass all aspects; the complications and all that.

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

Respondent: The long term prognosis, those would be like the complications. Umm, I think it can lead to a heart failure because if the valves can't contract, the blood will be mix up with in the heart and then it collapses. It will also lead to an infarction which eventually leads to heart failure. Basically, infarctions and heart failures. Umm, it can also lead to septicemia or that general blood infection. Because if now the heart that supplies blood to the general organs is affected then ...

Interviewer: Okay, so you said that you have encountered four in your experience!

Respondent: Yes, sometime back [laughs]

Interviewer: How long ago?

Respondent: How long?

Interviewer: How long did you last see a patient with RHD?

Respondent: I think it was around early 2017

Interviewer: 2017! Where was that?

Respondent: I was still during practice in pharmacy

Interviewer: Umm the last patient you saw, do you recall that day? Tell me about it; how was that patient present?

Respondent: umm, that one, umm ... but I think she had some, because she was a lady and she had some general body weakness. She had some profuse sweating. I don't remember others because she didn't come alone; she had some caretakers.

Interviewer: Okay, how old was she?

Respondent: She was around 54

Interviewer: How about the other three; in what age did they fall?

Respondent: Most of them they were about 60.

Interviewer: Did they look like working people, or they don't work?

Respondent: Some of them, according to how they were dressed they looked to be either working class or self-employed.

Interviewer: So the four, were some adults and children or they were adults only?

Respondent: They were adults

Interviewer: And do you think these patients know the link between sore throat, acute rheumatic fever and rheumatic disease?

Respondent: Most of them knew with time. Actually some of them had known because they have been treated with that same condition for some time, but then there are others who had no idea how it all started. Because someone would tell you that I have pressure or what but now I have this, and then basing on the diagnosis and the likes, you have to inform the patient how it comes about. You may find that some of them already have the risk factors that could lead to that; someone’s history, like what they used to take, dehydration itself. Then also the environment.

Interviewer: So when they come, what sort of symptoms do they present themselves? What do they see?

Respondent: Some of them could tell you some little chest pain, though it's not much. Then someone can come with joint pains, some temperature increase.

Interviewer: So, those patients that you saw, tell me about their follow up and adherence to the drug.

Respondent: Most of them I didn't take that much concern because we used to keep on rotating; you couldn’t be on one branch for more than a month.

Interviewer: What do you think are the barriers? What is stopping them to come for care or why do they come late?

Respondent: You mean those who already have or ...?

Interviewer: Those who already have RHD

Respondent: What I think, we have two issues now; because, some people can get that condition but since it starts as maybe a strep, most of them self-medicate. If someone comes maybe you give some treatment according to what they ... because some of them keep away some history, so you might rely on the provided history to try to manage what they have told you. So you are managing a respiratory tract and since most of them are sore throats, don't give out antibiotics. So you recommend them warm water, ginger, eucalyptus leaves and the likes. So the progress might be controlled unknowingly and by the time they know that it is now serious is when they are already down, or when maybe somebody comes to you with a chest pain and when you try to check the history, that person has nothing like carrying some heavy things, no accidents and no trauma. So that's when you recommend them to go get a chest X-ray and by the time they go for a chest X-ray, the disease has already progressed to some extent.

Interviewer: So it's self-medication and ignorance!

Respondent: Yes, it is self-medication and ignorance about the causes.

Interviewer: How about those ones you give appointments to come back maybe after two weeks, to come back every month, what do you think stops them from coming?

Respondent: I think most of them I would say, most of them would be occupied because now, take an instance; you can give someone maybe a 10 day dose and you tell him to come back after two weeks or after 10 days. When those days elapse, someone doesn't come in. The only time they come back is when they have another condition or maybe when the condition has relapsed, and when you ask him why didn’t you come back, he tells you ‘my work’ or ‘what I am doing I am the only person there so I couldn't leave someone when I am okay.’ So some times the relief somehow prevents them from making reviews. Others, others are taken up by other people's information; sometimes you handle a person and you tell them what they are meant to do, but because they had a person who had some similar condition, or maybe for them they perceive it as a similar condition but clinically it is different. So because of the peer influence they don't turn up.

Interviewer: Any other reason why you think some people don't come?

Respondent: Another reason, personally I think is the improvement they get because if someone came with chest tightness or maybe difficulty in breathing but he is relieved, some of them don't come back. And then there are others who also have poor health seeking habits; they only come back when they are badly off.

Interviewer: Okay, thank you so much. How about you people who are providing care! Now you said you have not seen even one patient.

Respondent: Here I have not.

Interviewer: Why do you think it is like that? There is no RHD in Entebbe?

Respondent: Okay, mostly we have more of interns during day time and so somehow I think it affects the prevalence. I would say prevalence because if something is not noted then you wouldn't know. But the actual thing is that the conditions would be prevalent but I would think it would affect the documentation or maybe for the conditions because, for them they might go with what they commonly see with their seniors; ‘if it is something like this ... if it is something like this ...’ and if something is not prevalent at the facility, then there is no concern put against it. Personally I think that would be the cause because mostly the people we see here would be heart failure, kidney failure and what, but Rheumatic Heart Disease ...

Interviewer: So if someone came with heart failure, does the hospital manage them here?

Respondent: We have been getting those people. I think they have been well managed.

Interviewer: But RHD you do not?

Respondent: With RHD I think what affects is what I have told you; some people don’t have much experience and when you are at the window and you see the flow, fine you can see the symptoms and then you can try to relate.

Interviewer: Let's look at the local health system barriers and you are going to tell me which systems are working for you here and why do you think they are working for you. If you look at the administration right from the district, is it working for you? Is it helping you to do your work better here?

Respondent: The administration from the district?

Interviewer: Yes, before we come to the local administration

Respondent: Umm, I have not experienced that much influence from the district because most of the things we have been running them generally as the hospital. I have never really ... okay, it's only like once or twice and usually the support we get so much is for HIV and I think that's when we get some people from the district to come. Otherwise in other conditions, not so much. Mostly we have CME's on Tuesdays and that’s within the hospital.

Interviewer: How is the attendance?

Respondent: Attendance, I would say it is fairly good. The only concern would be ... okay for the intern doctors and most doctors, because mostly they are supervised when they are going to discuss and all of us would be equipped with a copy a week earlier. Of course each one of us has a duty to research about something such that when they talk something, you know what they are talking about; you can supplement and can correct. So we do CMEs every Tuesday.

Interviewer: Have you had any RHD topics coming back

Respondent: No.

Interviewer: It has not happened.

Respondent: Basically the circulatory system hasn't been much touched on though they say that clinicians have not been that bad especially those of OPD; they try, but this side is lacking.

Interviewer: Why? What is unique about the outpatient department?

Respondent: Personally I don't know why. Maybe could it be the system favoring them, because if you don't have any one to report to, um! You know government things, hmm.

Interviewer: So how is the administration? Is it helping you do your work here?

Respondent: I think the administration is trying its best because like I told you, we have CME's on Tuesdays and we have departmental meetings on Friday, but I think somehow we are limited and I heard that it operates within the budget. So I think their efforts can be somehow sabotaged at one point, because if you take a look, we have something which maybe has just come up but some projects work on funders and donations. I think somewhere some effort is not being put in because of the limited resources but otherwise for what they can do, I think they really try.

Interviewer: So let's talk about your departments where you deal with the drugs, how is it? Is it active?

Respondent: yeah

Interviewer: Do you have all the drugs?

Respondent: Yeah, and like I told you, we have the basics but we are limited because some conditions . . . okay the antibiotics we have, we are also limited I would say and that also brings about the poor prescription habits; someone prescribes the same thing ... the same thing because it is what is available. Buy now, because antibiotics have symptoms because someone can say, “uh, Ampicillin can work for this” so he gives Ampicillin and yet the condition or progress requires something better than that,

Interviewer: Okay. Do you have benzathine?

Respondent: We have

Interviewer: usually it is prescribed to which kind of patients?

Respondent: Syphilis. Mostly, I think that is the only condition.

Interviewer: Do you have heart failure drugs here?

Respondent: heart failure we have, though we don't have things like (min) which I think could be the first line, but the others we have.

Interviewer: Anti-coagulation drugs, do you have?

Respondent: Coagulants we have Aspirin. It is basically Aspirin.

Interviewer: Do you have Warfarin?

Respondent: Warfarin is sometimes up but there are other blood pressure ...

Interviewer: Did you say there is a dispenser there we can talk to?

Respondent: But those ones are not dispensers; they are just nurses. They are just experienced [laughs].

Interviewer: Eh, so they are the ones they use to dispense?

Respondent: Yeah

Interviewer: Then I will talk to one of them. And then do you have BPG, do you have diagnostics like echocardiography? Do you have it here?

Respondent: No

Interviewer: And then, let's look at the health workers’ numbers; is that working for you? How are the numbers of staff?

Respondent: I would say we are under staffed

Interviewer: Understaffed!

Respondent: Totally understaffed because now the physicians are few and being few, they stop working at 3pm. So now in the evening, sometimes you can have high patient load with no doctors because for us, much as there is someone, we can also the work but we cannot do prescription. So you find that a large number of patients would be served by one person. How would I do that? Someone just writes whatever comes their way and that's why I told you that that could be the cause for those patients with heart conditions; the interns, the nature of staffs

Interviewer: When you look at the waiting time, how is it for patients?

Respondent: Of course being that staffs are very few [laughs], but it can be okay sometimes. There could be some good number of people there and it also depends on the retention of those interns. If there is a good number, like around three for adults, two for pediatrics then the flow would be good

Interviewer: Like someone would spend how much time in a day?

Respondent: Sometimes we are interrupted by emergencies but otherwise on a good day, when all the people are there, at the pharmacy people take like 5 minutes because most of them we have to refer but then there are those that we don’t refer. So those ones would take us around that time.

Interviewer: Okay. So in your opinion how is the quality of care you give to your patients?

Respondent: In the pharmacy we do our best because when you try to do the prescription, you don't just prescribe; you try to see any errors, you go back to the doctor such that they correct them. So I think at our side we are doing our best because we also do CMEs we try to provide those issues but then I think what will affect us, we should probably get some staffs in some departments.

Interviewer: Which departments are really understaffed?

Respondent: It is mainly the OPD and I think that gives the general view of the hospital; if OPD is poorly staffed then ... then with the quality, I think we also need of also need some good drugs.

Interviewer: When you talk about drugs, where would you want to have more stocks?

Respondent: I think we need more cardiovascular drugs although I know, huh, I think they are affected by cost because they are generally expensive, but we need more at least things like Albuterol and those emergency drugs. Because I think for emergency drugs, at the moment we have Frusoline

Interviewer: Okay, when you look at the health information flow, how do you keep it? Is it working for you?

Respondent: We are trying to reinstall a system but by the time they brought it, it wasn't developed. They are trying to develop it on ground. So some how it affects our work; sometimes they tell you to use it but then the prescribers are not using, but otherwise if they install the system it will be fine. Then the phone networks are also not good, otherwise if they were fine you could just make a call to them.

Interviewer: So how about the flow between the in-patients and out-patients; is there a coordination?

Respondent: Yeah, like I told you we have the outpatient and inpatient sections, we assign numbers to those people; if it is an OPD number, then it is an outpatient. For inpatients, we to give some medicines, basic medicines because we are not here for so long. So we give them some medicines just in case we are not around, and they also bring their files during day. Caretakers or the nurses can bring their files and then we serve them. Then we have records where we follow up inpatients and outpatients.

Interviewer: Is it easy to trace a record of someone who came a year ago?

Respondent: Yes

Interviewer: So does that mean it's working for that you are okay with the information flow and records system?

Respondent: I think we have been using the manual system, so far it has been manual but I think that if we restore the computer system it will be far better in terms of time.

Interviewer: So do you have different registers for the different conditions here, like if I wanted to look at the ... of course you said that you have not seen the RHD patients but maybe for TB patients?

Respondent: Yeah, TB patients are there most of them are at the same clinic with HIV because we make weekly reports. Those weekly reports contain number of patients received, the most prevalent condition, the medicines we are meant to get and what is not available for distribution. So I think the records are well kept at any point that you want; at the pharmacies, TNO ... I think they are there.

Interviewer: Eh, good to hear that. Do you have guidelines or protocols you use for ... now you said you don’t handle RHD here!

Respondent: Yeah

Interviewer: but could you be knowing the referral path? What would you do in case got a patient with RHD?

Respondent: RHD?

Because they know this is a hospital.

Usually patients who come for emergencies, they are taken to emergency room, so they are given some basic care just to improve the condition and given some rest and they are referred to big wards.

Interviewer: So have you seen any RHD protocols here?

Respondent: Not yet.

Interviewer: So looking at all these things you have gone through, how about the funding! When you look at the funding for health care, is it working for you?

Respondent: Funding is very, I would say poor. It needs to be doubled or tripled because most drugs and equipment, we have a two months’ gestation period waiting for the supplies but sometimes the supplies might be small and they can take you for a month and a half and of course you try to give the patients half doses and tell them to go and refill in the pharmacies, but some drugs are not there. So you realize you are speaking what is not applicable [laughs]

Interviewer: You don’t have! Because, you are near NMS ...

Respondent: Yeah, we are near NMS but we are not exceptional from any other facility. As long as you are not given the money you cannot ...

Interviewer: So from what you have said, at least the administration is working for you, and then the health information, funding no, health care no, the numbers are low, is that right?

Respondent: The numbers are high

Interviewer: I meant for healthcare workers

Respondent: For healthcare workers we need some more especially, more and qualified.

Interviewer: Actually let's talk about qualifications; when you look at qualification of the workers, what is your take on that?

Respondent: Qualification is not bad but the only problem I would say, okay since some of them are old they are so much reluctant; they know how the system works and they know the loopholes in the system. So, and also the information that is being put back is very different from what is going on. So you see, and they are the same people who are not attending CMEs. So that is how they affect us. So you find that you are at the window but you have to keep on going to each of them that has prescribed to carry out the prescribed. So I wouldn’t say that they should be taken away but I would say that we need some more who have the urge to improve. Yeah.

Interviewer: So as you do your work, what has motivated you to keep doing this despite all the challenges around?

Respondent: I think I like my profession and I like creating a difference. I don't think we are still at the same level I found.

Interviewer: And then, let's looks at your perception at the patient outcome. Generally do you think the patients get the care they need here?

Respondent: I would say they do. For patients, they can't appreciate if you don't have the drugs. But for me what I think is that if you have talked to the doctor, they have sent you to laboratory, they have sent you to the cardiograph department and they have known what you are suffering from, I think that would be enough for a person. So I think the patient care is not bad; we are really doing our best.

Interviewer: How about those who need surgery, do they get the care?

Respondent: Yeah

Interviewer: They do!

Respondent: Very well, and without sepsis [laughs]

Interviewer: Do you have any patient safety and quality concerns apart from your concerns you as you?

Respondent: Like?

Interviewer: Patient safety like how you handle them, the environment, the equipment you use. Basically do you think everything is done to make sure that the patients are treated in the safe way and that the quality of care given to them is okay

Respondent: Sometimes they will be affected by equipment like gloves; gloves can be completely done and the nature of patients we receive, most of them are from the islands, most of them don't have money, most of them have issues. So it would affect because, if the patient comes and you don't have gloves, it's not me who is supposed to buy gloves; they are the patients. So most of them in their understanding would think that maybe doctors are doing it to get money from them, but I think the equipment are lacking in every department because even when you go to the laboratory, sometimes they have issues. Everywhere there are issues but I don't think ...

Interviewer: Like in the laboratory what issues do they have?

Respondent: Sometimes the system will be down and that could affect them because there are some tests that can run for two hours, those genetics sometimes. So basing on the patient’s condition, some people can wait long but I don't think ...

Interviewer: In general do you think the symptoms of the patients are really taken care of?

Respondent: They are. I feel they are taken care of because if a person comes in and we see that the condition is not good or is likely to affect others, we usually separate those people, or if you see someone geriatrics or someone is too old and they can't wait, we usually forward them first. So for accident people and what, we usually handle them before others.

Interviewer: And then, do you think there are some preventable deaths that are occurring here?

Respondent: Preventable deaths?

Interviewer: Yes, maybe there is a death that you look at and you be like, “this one shouldn’t have occurred!”

Respondent: I think sometimes I think, like I have told you some equipment are not enough, like oxygen cylinders. So they are trying to put some oxygen whatever ... what is it called? The one which they put . . .

Interviewer: In the wards!

Respondent: Yeah, but somewhere they said in June or some time before. So sometimes it can affect some people who are brought and they are in bad condition. I think there is a case that was lost some time but it was because of oxygen; cylinders are not enough and those few that are there were not repaired. Then there are those, because you don’t have the basics, like I told you especially in cardiovascular system, sometimes most of them are brought in bad conditions and there those who come and there is nothing like they are better off or nothing like drugs or IV. So you might lose those people in a hypertensive crisis.

Interviewer: Then do you think there are some patients who are dying in communities without presenting to hospitals?

Respondent: I think most of them are there due to poor health seeking behaviors. Most of them are there because now there are people who come and tell you, or someone dies at the gate or someone dies as soon as they have entered the ward.

Interviewer: But why?

Respondent: Because for most of them, as soon as they discover they have a condition it's when it's almost the last stage. So many of them die because those who die from out, they don't come here. So I still think they do.

Interviewer: So what in your opinion are the two most important things Ministry of Health should do to improve patient outcome?

Respondent: umm I would think they can do some monitoring not only at human resource level, but in all aspects. I think they shouldn't take that longer time to keep checking on what is happening because there are some things we discuss that have been identified and they are still happening. I would say of there would be more like, I don't know whether it's the MS’ work to report but I think they also need to put in some efforts to keep checking, and also because if they keep checking, then also there will be more sensitivity about some conditions, sensitization. If you ask for the papers or ‘where did you write this’ then people can be more vigilant about documentation. And also, I have rarely heard of those Ministry of Health CMEs; most of them that am hearing or that I have attended are just for some few bodies like PSU, Intra Health, Reproductive Health and the like, but not from the ministry. I think they need to do more, and also reassessing the staffs especially those who have been in service for long; are they still capable to serve?

Interviewer: So what can they do for RHD? What should Ministry of Health do for Rheumatic Heart Disease?

Respondent: I think we need like a seminar. A seminar, conference, leaflets, and those books. I think they need to do that or even ... umm, yeah basically the seminars and literature.

Interviewer: Any other thing before we finish?

Respondent: Any other?

Interviewer: Anything you want to add on before we finish.

Respondent: umm, no

Interviewer: Okay, thank you so much for your time, we appreciate and we shall use the information to help and make the RHD program, management and prevention better. [switches off recorder]