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

Interviewer: Okay, this is a study to determine, how to provide better health care for Rheumatic Heart Disease and there are no right or wrong answers, and please be frank and share your opinions. The data we gather is confidential and we don't need to put your names. I will not link your identity to any of your comments in any of the reports we produce, okay? Okay, tell me about yourself; how old are you?

Respondent: 30 years old.

Interviewer: You are 30 years! And by the way which office are we seated in right now?

Respondent: OPD.

Interviewer: Yes OPD, but this specific room?

Respondent: This is a consultant room.

Interviewer: So we are in the consultant room number 5! Okay, that's good, so you're 30 years old?

Respondent: Yes.

Interviewer: Okay, tell me about your qualifications, about your training, where you trained from and whether nursing school or medical school.

Respondent: I am an enrolled nurse. I studied in Nsambya, St Raphael of St Francis Hospital.

Interviewer: Okay, when did you qualify?

Respondent: I qualified in 2007

Interviewer: So how long have you been qualified?

Respondent: It's like 10 years.

Interviewer: From 2007?

Respondent: Yes.

Interviewer: How long have you been working at Entebbe Regional Hospital, or Entebbe General Hospital?

Respondent: Since 2013.

Interviewer: That's how many years now?

Respondent: They are five years.

Interviewer: So you have been working here for five years, you qualified in 2007 and you are an enrolled nurse.

Respondent: Yes.

Interviewer: Okay, Tell me about the demographics of the patients in your practice or the common illnesses that are usually treated here.

Respondent: Cough, flu, malaria, hypertension, diabetes and TB.

Interviewer: Those are the main elements that you usually see!

Respondent: Yes.

Interviewer: Tell me about their age groups.

Respondent: For malaria?

Interviewer: For all of them. Which one do you mainly see? Are they young? They are for which age group?

Respondent: We get all ages because this is OPD.

Interviewer: Okay, for example malaria, do you always see the young ones? Do you usually see the teenagers or elder groups?

Respondent: Malaria; mainly the young ones.

Interviewer: What about their conditions!

Respondent: The conditions like cough and flu, I mean the young ones.

Interviewer: Okay.

Respondent: Even sometimes we get these incomplete abortions, but cough and flu are the most common, and typhoid by the way. I had forgotten typhoid.

Interviewer: Okay, thank you so much. So tell me about your training on Rheumatic Heart Disease; have you received any specific training during school?

Respondent: Yes.

Interviewer: So what did they tell you Rheumatic Heart Disease was?

Respondent: Huh! Rheumatic Disease; this is the disease that occurs ... I don't remember very well but it's the disease that occurs when someone has over stayed with ... Okay, someone who usually gets cough, flu and such; that's what I remember. [Laughs]

Interviewer: Okay, have you received any training since you graduated about Rheumatic Heart Disease?

Respondent: No.

Interviewer: You have not! Okay, so don't you do CMEs around here?

Respondent: We do, but they’re always on Tuesdays.

Interviewer: So among the so CMEs; do you have any about RHD?

Respondent: The cause of RHD?

Interviewer: Yes about Rheumatic Heart Disease!

Respondent: No, not yet.

Interviewer: Okay. So how many patients of Rheumatic Heart Disease do you often see like in a day, week or month?

Respondent: What can I say! We rarely get that condition being that someone is diagnosed with Rheumatic fever. Huh, to me it's a rare disease. I think it's because of poor diagnosis, I don't know, but since my training I haven't seen anyone and they have never told me anything like that person has Rheumatic Heart Disease, no.

Interviewer: So, um, these patients, so you have not seen any?

Respondent: No.

Interviewer: Not even in this out-patient department?

Respondent: I haven't seen any. For sure maybe it’s because of poor diagnosis, but I haven't seen someone that it is written that the diagnosis is Rheumatic Heart Disease.

Interviewer: Now tell me about your understanding about the causes of Rheumatic Heart Disease; how do you understand Rheumatic Heart Disease and what are its causes? How do you understand it as a healthy worker?

Respondent: Huh! I think, it's an inflammation, it's a complication that comes in when someone has over stayed with cough, flu and sore throat. What I can say is that it moves; when the cough, flu and sore throat over ...

Interviewer: When they over?

Respondent: Okay let's simplify it; if someone gets cough and flu for so long and keeps on getting those diseases, has signs and symptoms of those diseases it ... [stammers]

Interviewer: Explain it in a simpler way even in Luganda.

Respondent: Okay, the outcome, not even the outcome but it generates to the heart, I mean the inflammation, and then you find when someone has ended up getting Rheumatic Heart Disease.

Interviewer: Okay, so what do you think is the cause? What do you think causes?

Respondent: The cause of Rheumatic Heart Disease?

Interviewer: Yes.

Respondent: Bacterial infections.

Interviewer: What kind of bacterial infections?

Respondent: Am not sure of it.

Interviewer: Okay thank you. So are you aware of a link between a sore throat and Rheumatic Heart Disease?

Respondent: Yes, sore throat and Rheumatic Heart Disease.

Interviewer: How?

Respondent: Explaining it is not easy.

Interviewer: No, you speak in a lay man's language. You said you are aware of the link, isn't it?

Respondent: Yes.

Interviewer: So how do you understand that link between sore throat and Rheumatic heart disease?

Respondent: The pharynges ... [stammers] I just have an idea but am trying to connect. I have failed to connect very well but what I know is there is a link.

Interviewer: Okay, you are aware there is a link!

Respondent: Yes.

Interviewer: Okay, what were you told can be done to prevent Rheumatic Heart Disease?

Respondent: The quick diagnosis of it; treatment for these Common diseases like flu and cough. When they are easily treated, okay, when they are treated early I think that Rheumatic Heart Disease can be prevented.

Interviewer: Earlier on we were talking about prevention, what were you taught can be done to treat Rheumatic Heart Disease?

Respondent: I remember they told us that Penicillins are the best treatment.

Interviewer: Okay, thank you so much. Are there any aspects of Rheumatic Heart Disease management in which you think you need more training?

Respondent: Actually we need training on it because, for sure, for me since I trained ... that's why I have forgotten everything. We need everything to be trained; the causes, the treatment and how to diagnose it very fast,

Interviewer: Okay, so which means that you need training!

Respondent: Yes, we need to know more about it for at least easy diagnosis

Interviewer: So which means that you need to know more about this, anything else?

Respondent: The causes, prevention and treatment if it has occurred

Interviewer: Anything else?

Respondent: um, even the whole management and nursing care.

Interviewer: So what is your understanding about the long term prognosis of Rheumatic Heart Disease?

Respondent: The what?

Interviewer: What is your understanding about the long term prognosis of a patient with Rheumatic Heart Disease?

Respondent: It can lead to the heart failure.

Interviewer: Anything else?

Respondent: It also leads to difficulty in breathing because of the pain of the heart.

Interviewer: Okay. So according to you, is the long term prognosis of Rheumatic Heart Disease a good or bad one? How do you understand it?

Respondent: Long term what?

Interviewer: Yes, long term prognosis.

Respondent: It is bad.

Interviewer: Why is it bad?

Respondent: Long term prognosis, it can be misdiagnosed on someone, leading to poor treatment or adherence to the patient.

Interviewer: So you are saying that according to you the long term prognosis of RHD is bad!

Respondent: Yes

Interviewer: Because you're saying that some patients don't adhere to treatment!

Respondent: Yes.

Interviewer: And you also talked about diagnosis, is there anything else that you talked about?

Respondent: No.

Interviewer: Okay, so tell me about your encounters with patients with Rheumatic heart disease. Do you recall the last patient you saw with Rheumatic Heart Disease and can you briefly summarize that visit?

Respondent: Apart from studying it, I haven't seen any patient with it.

Interviewer: Apart from studying Rheumatic Heart Disease you have not seen a patient with it!

Respondent: Yes.

Interviewer: Even here in the outpatient department?

Respondent: I haven't seen.

Interviewer: Wow! So what is the average age? You said you have not seen any patients the five years you have been here?

Respondent: I haven't seen, and that's why I was saying whether it could be due to poor diagnosis. Someone can be having it and they diagnosed another thing yet it’s Rheumatic Heart Disease.

Interviewer: So what do you think is the average age of Rheumatic Heart Disease patients?

Respondent: The average?

Interviewer: Yes.

Respondent: 45.

Interviewer: 45years. Okay, are they usually working or not?

Respondent: Working?

Interviewer: Those patients; are they usually working or not?

Respondent: Working

Interviewer: Do you think those patients are generally aware of the link between sore throat, Acute Rheumatic Fever and Rheumatic Heart Disease?

Respondent: They are not aware. The patients themselves?

Interviewer: Yes.

Respondent: For one to know that I am suffering from this, or that it’s a complication of cough and what?

Interviewer: Yes.

Respondent: They are not aware.

Interviewer: So what sort of symptoms do they describe? Those patients of Rheumatic Heart Disease.

Respondent: Apart from ... well according to what I studied, they present with fever, cough, flu, sore throat and a bit of difficulty in breathing and chest pain,

Interviewer: So you said you studied but you haven't seen any!

Respondent: I haven't seen, that's the little I remember.

Interviewer: About the follow-up and the adherence to treatment, you don't know because you have not seen any of them?

Respondent: Yes. From the school I haven't got that chance at least.

Interviewer: Because my next question was; what sort of barriers they usually state in getting the care they need? But you have told me you have not seen any!

Respondent: I haven't seen.

Interviewer: So now you as healthy worker, what sort of barriers do you perceive these patients face in getting care they need?

Respondent: Barriers; poverty because you can find that the treatment may be ... I am just talking because I haven't seen one, but you find someone has told you they will be getting such a treatment for such a time and that patient has to pay that money, so you end up staying, or she can get for like three days and then he drops out.

Interviewer: Okay, anything else.

Respondent: Barriers?

Interviewer: What sort of barriers do you perceive these patients get in getting the care they need?

Respondent: These patients, they know that I have Rheumatic Heart Disease but the barriers they face.

Interviewer: What barriers do they face?

Respondent: um, I think some patients, the ones I have seen that get medicine, some of them they don't want to take medicine, like men. For the men, they take just one day and you find that there are poorly adhering to their treatment. So it's according to them that treatment is not an issue; when someone gets some small improvement he just drops out from the treatment without a big reason. And some Penicillins are QID; you can find someone, the timing, you find someone has got treatment and needs to get treatment at night but if that person is not in the hospital, he can fail to get themselves to the hospital to get that night treatment.

Interviewer: So that becomes a barrier in a way that patients take the treatment, you said QID!

Respondent: That's 4 times a day

Interviewer: Which means that you mean that ...

Respondent: It can mean many times, because most of the Penicillins are eight hourly, I mean six hourly. So that patient can fail to fulfil the time even if the treatment is there because of the long time. If it was already once a day, that one would be okay.

Interviewer: Okay, thank you very much. So we are going to talk about the local health system barriers; tell me about administration and leadership in Wakiso district. What barriers do you usually face as a health worker in regard to administration and leadership, or in providing care to the patients?

Respondent: [laughs] overwork; okay, overloaded

Interviewer: Overloaded with what?

Respondent: Now here in the OPD, we are very few. You have seen the number of patients we are having, but we are few! We are like, let me count; we are like five! Yes, managing day and evening.

Interviewer: So that means that ...

Respondent: We also get tired and we end up not giving what we are supposed to give to the patient. Then another thing, yes there are CME's but there are courses which are rare; instead of taking a nurse to study that, let me say diabetes or Rheumatic Heart Disease, we who are on ground I think we are supposed to be trained to know what we supposed to do. But you can find someone they have taken to study about Rheumatic Heart Disease works in theatre or in administration, someone who is not related at least to patients! That's the person who goes to such courses yet they leave people who are supposed to go for that. Because, to me, if I was a leader I can say, “these people working on a ward are supposed to study diabetes, this and this have to go,” instead of calling someone from a different department, because to me it's not good. That's why people say [in agitation], “Argh!” They take it easy, but even if someone comes and says that they are going to teach about, let's say malaria, I may hear someone from records going to teach malaria! You just say to yourself, “Uh, after all I studied malaria from training school, ” so you leave them.

Interviewer: So which means that's an administrative barrier for you to provide best health care!

Respondent: Yes, because you never know that person would have given you the new guidelines on such a disease, but being like, now this is someone who works in records; how can he teach me about malaria? You just leave it at that.

Interviewer: So you leave it at that!

Respondent: Yes, then another thing they increased money.

Interviewer: Money for?

Respondent: For nurses. Okay, for medical workers. They added some money but on ground people are saying, “Why is it that the registered (ones) were given good money and they left the enrolled (ones)?” They just added 100,000/= on the money we (enrolled ones) were getting, so that thing also when it comes to someone who doesn't have that heart of patients, they can just say, “Argh, those ones received money!” For us we are here overworked but now how many white people have you seen in this OPD?

Interviewer: Apart from this one!

Respondent: Yes, so with those people, if you don't have heart, they end up saying, “I am going to do the little I can” without putting much effort.

Interviewer: Okay. So tell me about the funding for health care in general and about Rheumatic Heart Disease if you are aware of any. Do you have funding in the hospital here?

Respondent: The funding?!

Interviewer: Like the funds that come from the district and government. Funding for health care in general and Rheumatic Heart Disease.

Respondent: Of course the funding for Rheumatic Heart Disease, I haven't heard anything. For other things, they fund.

Interviewer: Other things like what?

Respondent: I heard of malaria but I don't remember the organization that funded, but there are some funds that came for malaria. Then there is a fund from MildMay; they fund HIV testing and counseling.

Interviewer: What about Rheumatic Heart Disease?

Respondent: Not yet, this is my first time. I don't know, maybe it might be there in administration but to me, I haven't heard.

Interviewer: Okay, so tell me about the health care workers and their numbers; do you have enough? Tell me about their qualifications.

Respondent: Okay, the health workers, mostly like half of them have gone back to school but they haven't upgraded them. By the way it's a barrier also; they went back to school many of them but they were not upgraded.

Interviewer: So what you’re trying to say is that some of the health workers were at a different level?

Respondent: They are at different levels.

Interviewer: So you are saying that they went back for training.

Respondent: Like the Enrolled Nurses are now registered but at the District, they are Enrolled Nurses, yet they are registered. Even our in-charge here is an enrolled nurse though she is in white (dress code).

Interviewer: Here?

Respondent: Yes.

Interviewer: Wow. So tell me about the waiting times and quality of care they give to the patients; how long do the patients wait to be seen by health workers?

Respondent: Um, that one depends on the condition of the patient; some patients have to go to the laboratory, so it takes long to reach where they get medication. But the health workers are always there, but as you know that patients are many, so they take long, and some tests required take long. So someone can tell you, “since morning, I have been here,” or “me I came at 2pm but you see the time!” That one just needs an explanation like, “you know you had such a problem, you had to wait for the lab and that's why you reached this time. ” Otherwise the staffs are always around.

Interviewer: And the quality of care that the health workers give.

Respondent: They are educated, that's why we always have nursing schools that bring their students for more education and that is Nkumba and Mildmay.

Interviewer: Nkumba has a school of nursing?

Respondent: Yes.

Interviewer: Okay, thank you so much. So tell me about the medications, about Benzathine Penicillin; do you have these drugs on sight?

Respondent: We have them.

Interviewer: And anti-coagulants?

Respondent: What are they?

Interviewer: They are like the blood thinners, like Aspirin, warfarin Respondent; No.

Does the district provide them?

Respondent: Warfarin?

Interviewer: Warfarin and cardiac Aspirin.

Respondent: We have cardiac Aspirin and Benzathine. But we don't have warfarin.

Interviewer: What about the heart failure drugs; do you have them?

Respondent: Heart failure drugs like?

Interviewer: Like Digoxin and Lasix.

Respondent: Lasix, we have, but not digoxin.

Interviewer: That one you don't have. So tell me about diagnostics; what diagnostics do you have here in the hospital?

The what?

Diagnostics, for example Echocardiography.

Respondent: Yes they have. We don't have ECHO, we have ECG

Interviewer: You have ECG! So who does the ECG?

Respondent: There are some people who trained for it.

Interviewer: Okay. So when they do it, who reads the ECG?

Respondent: The doctors.

Interviewer: Anything else? Any other diagnosis which you have here in the hospital?

Respondent: Scan and X-ray.

Interviewer: What kind of scan?

Respondent: These abdominal scans, not CT scan and what.

Interviewer: A normal scan like ultra sound, abdominal scan?

Respondent: Yes, abdominal.

Interviewer: Not like a brain CT!

Respondent: No, we don't have that.

Interviewer: Anything else?

Respondent: X-ray, then laboratory.

Interviewer: So those are the ones you have. So you told me that you do ECGs but don't do Echos?

Respondent: Yes, ECGs.

Interviewer: So tell me about your health information information and medical systems; how are they integrated between the facility’s departments; the in-patient and the out patient’s? Tell me about your health information systems here?

Respondent: Health information?

Interviewer: Okay, health information like when you receive patients and you see them, do you have registers for these patients.

Respondent: Of course we have registers

Interviewer: What kind of registers do you have?

Respondent: We have a book, a logistics book. Then they introduced the computers now, they are trying so that system can come slowly. A clinician; where she sits, she types,

Interviewer: Where do they register from?

Respondent: At Number one; when the one who registers puts in the computer, those names go to the computers of the doctor, so the doctor just reads what comes on the screen.

Interviewer: So what is Number one? Not every hospital has number one.

Respondent: [Laughs] the waiting area.

Interviewer: Where patients start from!

Respondent: Where the patients start from, then go to triage where they are put in the computer and distributed to the doctors.

Interviewer: So about the medical records system; do you have specific registers for specific conditions, for example registers for Rheumatic fever and Rheumatic Heart Disease patients, or registers for diabetes and hypertension? Do you have different registers?

Respondent: We just have different departments of which they have their registers.

Interviewer: Like?

Respondent: Like surgery, diabetes and hypertension; they have.

Interviewer: But you don't have specific registers for like Acute Rheumatic fever and Rheumatic Heart Disease?

Respondent: We don't have.

Interviewer: So which means that if you’re talking about, diabetes, hypertension ...

Respondent: Those ones they have a specific one and are given specific days when they come to see their doctors for reviews.

Interviewer: Okay. So as a hospital or health worker, do you have any guidelines and protocols for Rheumatic Heart Disease care, including the referral pathways here at the hospital?

Respondent: Maybe the doctors have, but ...

Interviewer: But if you work with the doctors, at least you would have seen the guidelines and protocols.

Respondent: For Rheumatic Heart Disease! I haven't seen one.

Interviewer: You haven't seen them! Okay, so you are saying that you have not seen any guidelines or protocols for Rheumatic Heart Disease care in this outpatient department?

Respondent: I haven't seen it.

Interviewer: So what about the referral pathways! If you received those kind of patients, how would you handle them?

Respondent: I haven't seen anyone because maybe there are procedures, but I haven't seen anyone.

Interviewer: So which means you cannot know the referral pathways if you have not seen anyone!

Respondent: Yes.

Interviewer: Okay, thank you so much. What makes you leave home and come to work? What are some of the enablers in administration and the leadership that enables you to come and work? What motivates you to come and work?

Respondent: What motivates me!

Interviewer: Yes.

Respondent: They pay me on time, because last month I received money on 22nd , so am on a sure deal that they will pay me. And I think I love to work; I feel free and very comfortable with my patients.

Interviewer: So you said that they pay you very well!

Respondent: I am paid on time.

Interviewer: What about the funding for the healthcare; are you happy about it? Funding in general and in Rheumatic Heart Disease; are you comfortable with it as a health worker?

Respondent: What can I say! I am not all comfortable because today it's my first time to see that there are people funding Rheumatic Heart Disease. So am just eager to see what you’re going to give and do for us. I am just happy that there is a program taking on such a disease.

Interviewer: So as a health worker, how are the numbers that you have? For example at this facility, do the number of health workers enable you to provide your work properly?

Respondent: The number of patients?

Interviewer: Yes, the number of health workers. Are you enough?

Respondent: No, we are not enough.

Interviewer: We have been talking about barriers, but now we are talking about enablers to you as health workers; the numbers and qualifications.

Respondent: For qualifications, most of us are enrolled nurses. We would like to go at least for upgrading although there are some issues that cannot help us to go on. But at least people are knowledgeable; however much they have little, they are knowledgeable on what they can do.

Interviewer: Okay, so about the drugs, the medications; do the health workers have enough drugs and facilities to be able to provide care for the patients?

Respondent: It is just once in a time when they are out of stock. In the past it was bad but these days, at least the management has improved; we get medicine, just little medicine. Now those like Digoxin and Warfarin for sure, I haven't seen them, maybe because they don't get such patients or they expire that's why they don't stock them; it might be the reason. What I know is that the administration can explain that very well because there are medicines they bring and they expire.

Interviewer: Okay and then, as a health worker, do these medical report systems enable you to do your work?

Respondent: The what?

Interviewer: The medical records system, like you were telling me about the health information systems or records system. Do they enable you to do your work smoothly?

Respondent: Yeah, they help us.

Interviewer: How?

Respondent: Congestion of patients; that habit of patients standing. Now someone knows that even if I sit, they will call me. The stipulation of duties too, where you know that from here, you go there and from there, you go to such and such place. Those arrangements can smoothen the work very easily, because you know that the patient from here, they have to go to the next step.

Interviewer: Okay, so you have told me earlier that you don't have guidelines and protocols! Because, I was going to ask you how they enable you to provide health care.

Respondent: Me I don't have, we don't have.

Interviewer: And the outpatient department?

Respondent: They just have these ... they are called NBF.

Interviewer: BNF? Like, British National Formula, but not proper guidelines?

Respondent: Yes, on such a ward.

Interviewer: So question number seven, this is my last question; generally, do you think that patients get the care they need or not?

Respondent: Do I think that patients get what?

Interviewer: The care they need or not?

Respondent: I do think they get.

Interviewer: What about surgery! Do you think they get.

Respondent: They do because we have surgeons.

Interviewer: Because you have surgeons! And in regards to Rheumatic Heart Disease?

Respondent: Rheumatic Heart Disease, I haven't got any.

Interviewer: So according to you, do you think the patients get the care they need?

Respondent: They get the care they need.

Interviewer: Why or how?

Respondent: Because when they come, they find when the health workers are there. If it's about a laboratory, it’s there, except for the few they tell, “With this one, you are supposed to buy,” or “with this one, you go outside because we don’t have it inside.” But for the best of the staffs, they do their best so that the patients get the medicine that they are supposed to get free of charge, and that's why you have seen them in large numbers. It is because they know where they are going to get and what they are supposed to get.

Interviewer: Thank you so much. So about patient safety and quality of care concerns, do you think health workers ensure safety of patients, and that the quality of care is given the way it should be?

Respondent: Um, I do because with safety or privacy, each patient goes to the doctor in their separate room, and from there he (patient) has a book that he presents to the pharmacist or nurse; that is privacy. There is no packing for a patient in front of everyone; that is privacy. Then to the quality of care; being that they are handled by qualified staffs, most of the things they do are at least a standard. Another thing is that we are educating; we have students. Everyone tries her or his level best to give the right thing because he is teaching someone, like temperature. You have to explain whatever you do and even the student is behind you to learn what you are doing. So tomorrow, if there are students to treat us, you do the best of your knowledge. We always get CME's at least for some diseases. [Laughs]

Interviewer: So have you had preventable deaths here in the hospital, for example you see a patient, you lose a patient and as a health worker you think it would have been prevented? Have you had any of those?

Respondent: Yes.

Interviewer: What do you think could have caused any of that?

Respondent: Negligence.

Interviewer: Negligence of health workers? Negligence of who?

Respondent: Some of them, it's for the patients; they take long to come to the hospitals. They first go to clinics, and other things I think occur because of money. There are some things that need that, like we can tell you, “buy this such that we continue with our job” and that’s when the medical worker is there. Otherwise there are some things that are not in the facility but the patient is supposed to buy them, so you continue with your work and then that time for looking for money comes. The patient will look form money here and there but you find that you are losing someone, and yet also the medical worker also cannot provide.

Interviewer: So do you think that patients are dying in the community?

Respondent: They are there dying.

Interviewer: Without presenting to the hospital for health care?

Respondent: Yes they are there.

Interviewer: Why do you think they could die in the community when there is a hospital like this one which has everything a patient needs?

Respondent: Some of them think of witchcraft! Now let's say I am talking of Rheumatic Heart Disease ... I have talked but I don't know if I have talked the right thing or not! I don't know because you haven't corrected me whether I was on track.

Interviewer: No, we don't have wrong answers or right answers.

Respondent: But If someone treats flu and cough for so long and he goes to the hospital and gets all the medication for flu and cough, at the end of the day when he gets pain of the heart, he will just end up saying, “now this time this is a witchcraft which has witched me.” They are there because we have seen many coming saying that someone or the grandparent bewitched her. At the end of the day, this is a sickness that can be treated, then they die. Now for those that stay on islands, because for us here we get patients from islands, so they say, “we didn't have transport to reach.” So someone has died there because of poor transport. So they die like that.

Interviewer: Okay, anything else?

Respondent: Those are the ones I remember.

Interviewer: What in your opinion are the one or two most important things ministry of health could do to improve patient outcomes.

Respondent: To improve?

Interviewer: Yes.

Respondent: For those ones in the islands, it is transport or at least to put a facility there with everything for them. Then motivation of health workers; they need to be motivated apart from the salary they get. I know everyone gets a salary but we need motivation. Then the stock-out; to give enough things to the facility to prevent those stock-outs because some people die because of that money. “You go and buy this” or “we don't have this in the hospital” or “go to CT scan!” In fact there are so many who die because of CT scan.

Interviewer: Anything else?

Respondent: To help people to upgrade; there are so many nurses who want to upgrade, because for me, when I was joining the whatever, the government, they supported nurses or doctors to upgrade because it is a government policy. At least in the hospital, they should take some for upgrading but ever since I got here, I haven't heard anyone going for upgrading because of the government; people just put in their own money to upgrade.

Interviewer: So what about in regards to Rheumatic Heart Disease! What do you think they need?

Respondent: Ministry, to provide for us ECHO, the ...

Interviewer: Echo cardiography the machine or?

Respondent: The person who can do that, the management, the machine and everything because you never know; I can't say that our doctors are bad or what, they are doing the right thing, but it's because of the patients. If they tell you that you go for Echo, you find that patient goes home and sits because of the money. But if it was the government, you just tell them, “you go for that test and come back to us, ” (in that case) they would have diagnosed heart disease. I can't say that RHD is not seen here completely, it is. But because of poor diagnosis and investigations, whenever they send them that you go do for me this and this, when they reach there that money is high, so they just sit at home. So they lead doctors into giving poor diagnosis. They provide more to us.

Interviewer: Anything else?

Respondent: The ministry should also give specific training to the worker's about the heart disease and other rheumatic fevers.

Interviewer: Thank you so much for your time.

Respondent: You are welcome.