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

Interviewer: Thank you so much, Good afternoon,

Respondent: Good afternoon.

Interviewer: Basically we are conducting this to determine how best we can provide care for RHD patients, so our major objective is to identify local barriers and enablers of RHD prevention and care with in this place. You feel free there are no right or wrong answers and you can be frank with your opinions and share with us all you have since all data here will be confidential and we won’t have any link to your identity or any comments that you provide today, so to start with, tell me about yourself,

How old are you?

Respondent: 38

Interviewer: Okay, your qualification?

Respondent: Physician.

Interviewer: where, where was your training?

Respondent: Makerere

Interviewer: Okay, how long have you been qualified?

Respondent: 9years

Interviewer: 9?

Respondent: 9years

Interviewer: Okay and how long have you worked in Lira regional referral Hospital?

Respondent: 8 years

Interviewer: 8, Okay in these 8 years, do you mind describing like the kind of patients you see, the common illnesses you come across?

Respondent: The common illnesses are usually the, the infectious diseases, common ones are HIV related problems, malaria, then respiratory tract infections like pneumonia, TB then there are others which are related to nutrition disorders which is attributed to mal absorption disorders then I see also heart diseases especially in young children and those ones age around 20 to 40 ,then there are heart diseases also in elderly patients which are usually attributed to hypertension and then there are some other cases of heart diseases we see, which are like dilated heart disorders and then those ones in sickle cell and other heart disorders but the rheumatic heart disease cuts across up to older age groups .Then we have also apart from heart diseases we have hypertension ,diabetes, and then those ones are the commonest ones and the liver diseases especially hepatitis B, liver cirrhosis, liver cancers, and then other forms of cancers are actually now common especially non estrogen lymphomas in adults and then Burkett’s in children those are the common disorders we usually see in our environment.

Interviewer: Okay, thank you so much, so tell me a bit about your training on RHD, have you received any specific training during school?

Respondent: Me in particular I have been involved in heart disease management especially those ones who were in the 4c by then that is Mulago the ward meant for cardiac diseases, so I was involved in managing of these patients and mostly doing echocardiographs for those who cannot afford doing them from other places and then those managing those ones who were admitted with heart diseases, those are medically, who needed medical treatment so we have had several what they call horizontal trainings on management of heart patients.

Interviewer: So was that during, when? Before graduation or after graduation?

Respondent: Before that is when I was still there at Mulago before leaving that place this excludes this is not with in the 8 years because with in the 8 years we have just had the training concerning the management of Rheumatic heart disease in a study which was conducted much more earlier on how to use the v scan,

Interviewer: Okay

Respondent: Earlier on

Interviewer: So do you still remember when it was done and who conducted the training?

Respondent: Which one which training?

Interviewer: The one for rheumatic heart disease, what you just mentioned about using V scans

Respondent: The rheumatic heart disease training okay there is one which was about using V scans i think about 2 years ago my memory does...but that is about two years ago and I think that was yeah two years ago early last year that is now coming to two years yeah and then there is another one where I was facilitating the training for the, the community people on detecting rheumatic heart diseases, I was one of the facilitators. That was also about the same time

Interviewer: Okay

Respondent: Yes

Interviewer: Alright, then how many patients with RHD do you see let’s say per week?

Respondent: The new ones at least I would catch like two 2, 2 new ones those ones are usually in the ward but the old ones actually I can see between 3 -5 but sometimes they pick and meaning that most times you get them when they have now presented with heart failure

Interviewer: Okay, are these in patients or both in patients and out patients?

Respondent: Ahh usually they are inpatients cause outpatients we have actually had issues of movement of the clinic so the clinic is now more not helping so much on the general medical clinic but otherwise in the outpatients we would get an equal amount especially you can get like about 2-3 new cases that is in outpatient basis but of course that was based on clinical judgment not usually based on other methods of evidence. Yeah

Interviewer: Okay then what’s your understanding of the cause of rheumatic heart disease

Respondent: The cause of rheumatic heart disease as in how what predisposes it or what causes it?

Interviewer: What brings it about?

Respondent: Ahh! rheumatic heart disease is just from an infection with streptococcus which is beta hemolytic basically due to throat infection variant 13, so you usually get a throat infection as a risk factor and locally here usually they do local cutting of people’s throats and they get local cutting of the tooth and some people also say they are kind of scooping pus from people’s children’s throats those are actually the things that predispose these peoples to infection, throat infection and eventually now present with heart diseases that’s rheumatic heart diseases sometimes later. But others sometimes get throat infections from home and they are not treated because they have problems of transport, access to the hospital, the place is far and also the practices we have poor health seeking behavior in this this region people don’t really take their children or those ones who are sick to the hospital immediately just because of poverty or because of their attributes of their practices which they think throat infection is a minor thing doesn’t need to be seen by the medical person first so we tend to use more of over the counter medicines, drug shops we buy drugs and so on those are the things that usually predispose most our patients to these throat infections which is poorly treated and you end up with acute rheumatic fever and eventually rheumatic heart disease. And we usually see them late, those ones who behave like that, we usually see them late. But also routine check for patients for acute rheumatic fever has not been there before and so some patients are actually misdiagnosed ,there is malaria or other joint or throat infections or other chest infections and they proceed to rheumatic heart disease eventually which we then see them with heart failure but with the event of the new whatever presented , I mean the program which has presented its self here now for about a year or so, it’s easier now at least to help in case detection but down grass route it’s difficult so we usually miss, so the actual cause is actually from the beta hemolytic strep pneumoniae but predisposing factors are pretty many with in this community and we see many of them really.

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

Respondent: What I know it is early detection is numbers one and number two, it is about prevention and this prevention is usually when you have a throat infection, you just be treated at quite an early stage ,of course there are issues of vaccination but not so many people have been involved in such. And then the other thing is that rheumatic heart disease is best prevented than actually to catch, to catch it.community aspects we haven’t yet really gone down to find out what happens there apart from the program that has been running which has been trying to reach those communities but in the hospital we just focus about treatment and most times we have been focusing about treatment of complications and because they present late with complications, that’s where we see them and being a referral facility, we see the really sick people who are referred to us that’s what we usually see.

Interviewer: Okay, and then the treatment options?

Respondent: The treatment options we have antibiotics but they are usually out of stock in a year, you find particular options you need to have, they are out of stock like more than 50% of the time, so before we really had issues to do with the medications to give them but of recent we have had some improvement in the medications to give them, the penicillins have been available but of course the stock out has been actually quite frequent like just in the last 3-4, 5 months ago we didn’t even have those medication of course except for the project which has its own medications. But from way before that is over 7-8 years ago it has been a problem to access these drugs because most of the people have to buy these drugs, yeah

Interviewer: What’s your understanding of the long term prognosis of rheumatic heart disease?

Respondent: The long term prognosis treated early good outcome good prognosis treated late creates a lot of problem in terms of medical pill burden, financial losses, complications from heart diseases heart failures with eventually the patients may succumb to heart failure if they don’t really attend the clinics cardiac clinics but when caught early the prognosis is good really when caught early but caught late we have had problems of issues to do with transplants ,valve replacement which is very costly and this place is one of the highest poverty levels with highest poverty levels in the country I think we are if not number 2 or 3 just in terms of poverty levels all of the country so people don’t afford to have those expensive cardiac surgeries and eventually they end up dying but when caught early ,it has a good prognosis but when caught late the prognosis usually tends to be poor since even the management becomes a little bit expensive and complicated for the local community to sustain it.

Interviewer: Do you recall the last patient you saw with RHD

Respondent: This morning

Interviewer: Okay you could just give me their brief summary of their visit like

Respondent: This morning,

Interviewer: Yes

Respondent: Ah,this is a the child who is about I think is fourteen, I think fourteen years has been on and off in the hospital has clinically presented with features of congestive cardiac failure the heart all the valves are affected, regurgitation of all the valve and dilatations of the heart chambers with ejection fraction very reduced less than 40, can’t walk, and aaah can’t sleep at night without coughing excessively, and has been really weak but that has been because the child first all of did not, did not come back, and the reason they gave for not coming back for drugs was that they did not have transport, and secondly the care taker says that they didn’t have any other person to help them do so from home so they couldn’t carry the young girl to the hospital. But general over look she is picking up and I think she may eventually need valve replacement but of course being poor even at this level, it may be quiet difficult for her to access those valve replacement because the stage where she is the heart failure is one where, you now need those cardiac assisted valves , those mechanical ones and maybe valve replacement, yeah the ICDs may benefit the child may benefit from those ICDS but coming from a poor family that you can’t even come back for just a medical review for a cardiac disease is bad enough so those are the kind of patients we eventually end up seeing, yeah

Interviewer: Okay quite sad for that one, then on average like what is the average age for your patients?

Respondent: The ages are usually, the ones I have been seeing are between, between 5 I see them between 5 up to about 20 for children then there is that group I usually find late about 40s they, usually present when they are now having other issues then the Rheumatic heart disease just got worst that’s why they present back to the hospital, but the Majority are age between 5 to 20 the ones I see

Interviewer: Okay, are most of them in school or and working or most of them just left work and are out of school because of the illness?

Respondent: These are children, they don’t work most of the children are actually because of illnesses, they are actually the school drop outs ,majority of them very few are struggling with school because they have problems of first of all the distances, they move to schools on foot, then also the care takers, then leave alone that those ones who go to school they have problems that they lack those ones who can take them to school, and sometimes they even default on coming back for medicine and then they eventually develop heart failure from home then they just drop off school and because of a lot of financial constraints they end up just staying at home and parents prefer treating I mean they give preferential treatment to children without heart diseases but sometime it’s unfortunate you may find like 2 or 3 children from the same family have the same thing so sometimes it becomes also a little bit stressful for the families but the older people usually they are not doing anything because they have been ill, they can’t move , exhaustion intolerance they are usually they are in the vicious cycle of poverty, they are sick, they can’t do anything then also poverty sets in because they are doing nothing and yet you need to spend on drugs spend money on drugs and so on so they are really not productive in their own communities because of illnesses.

Interviewer: Okay

Respondent: Yes

Interviewer: And these the ones you interact with are they aware of the link between sore throat, acute rheumatic fever and rheumatic heart disease?

Respondent: They are beginning to pick because of this research and ahh the cardiac program which has started with in the hospital they are beginning to pick but before it was absolutely not connected absolutely it is me as a medical person who knew but the community had their own way of attributing heart diseases just like I give you an example of three children all with rheumatic heart disease in the same family they said it was because of these traditional witch crafts at home that is why all the three children had rheumatic heart disease basically it shows that most people didn’t know much about rheumatic heart disease they know there is a heart disease but they didn’t know the one that they could do something about and the commonest one near them because thee commonest here is rheumatic heart disease in more than actually even 50 60% is just the majority basically.

Interviewer: And then these ones who present, what symptoms do they always describe to you

Respondent: Most of them just present with symptoms of heart failure they can’t walk, lower limb swelling, they get tired, they feel dizzy some people come when they have collapsed , others come when they can’t sit, can’t breathe, can’t sleep, with excessive cough others even come coughing blood so they come very sick.

Interviewer: And then how is the follow up and adherence?

Respondent: Before this project, Makerere guys from Uganda Heart Institute., we had tried to have a program where we were giving them injection of benzathine penicillin every four weeks but of course the guideline was saying three weeks but because of transport problems and they come from far and so on we just had to increase one more week so at least we do one month. And they would basically come for the treatment sometimes they would buy some times the hospital has but stock out are actually quite a number. And before also this this rheumatic heart disease program which is from Makerere the one from Heart Institute before that one, the mortality was a little bit high so most of them would also die actually, but now at least they are they are living a more reasonable life the quality of life is I think more reasonable now.

Interviewer: That’s nice to hear and then what sorts of barriers do they commonly state to getting care that they need?

Respondent: Transport, distance from home, money, stock out of drugs from the hospital, lack of caretakers from home, some of them they get constraints because they get pregnant and they do other things some of them are orphans and some of them actually don’t even have relatives who actually care about them they bring them when they are already sick, then most of them didn’t know even what to do with rheumatic heart disease if you have they put for you a lot of restrictions this is usually the medical workers who don’t know what to do initially so the restrictions were pretty many and the patients would not adhere to because some of them were not evidence based you give unnecessary restrictions and patients would default because they had been given many restrictions, the injections we were giving benzathine we were giving without even local anesthesia painful they don’t come back because they are fearing pain, the other one is that the drugs for heart diseases sometimes we order for them from National Medical Stores then you get supplies late or even they don’t supply or if they do they bring very few that gets finished quickly then also the other thing is that the doctors are kind of now becoming apathetic because the patients are sick you want to do something and a doctor as you don’t have what to do for them because what you want do, you can’t do like by then you can’t do Echocardiography, you can’t do ECG ,you can’t do laboratory test for these people so you also join the bandwagon of being helpless. The other thing is that even the administrators or the politicians those ones in charge of financial control they didn’t know really the magnitude of heart diseases, they usually get to know only when you are when they are burrying one and by then also when they say you have a heart disease, most people think you are going to die so they tend to even spend less on you and they think now once you have a heart disease, it is some kind of a charity which has to come and pay for your treatment short of it you have to die ,some kind of a misconception trend which has been there though the treatment cost has been high ,then there are those ones who may want something done, they come to the hospital early before the heart failure has gone worst , then they are told they may need those days, we didn’t have any surgeries done much in Mulago but right now Mulago is doing a lot but still some people instead of going to Mulago, because of lack of knowledge they still think that they have to go to India for the operation because they think it is only in India because they lack the information ,so there is complete lack of knowledge and information in the community about heart diseases and rheumatic heart disease to be specific there is really a huge gap in information there and the resources to use for making diagnosis like as I said earlier on we don’t have diagnostic equipment to be used so most of these patient initially we were referring them to Mulago to at least do for us an Echo may be once a year and that is it the rest you use your clinical judgment. Then the other thing is that you have some patients when they improve they don’t want come back then also you have some patients who after you see them, you are sure they will come back, they travel away like others they go to Sudan to look for money and by the time you are seeing them next they are very sick or they have gone to the lake side like Amolatar for fishing the next time you see them they are very sick. Then those ones who actually are in town some of them the they are really without parents and those ones you only see them once in a while when they appear back in heart failure and also we didn’t have preventive activities going on to actively look for the patients who are exposed to this streptococcus so they are identified earlier and treated, we don’t have actually a protocol which is supported by the government and to actively look for it and diagnose, it just the way they do for Malaria, because for malaria you have RDT quickly microscopy you have the diagnosis for rheumatic heart disease sort eee swabs of the throat , transporting it to Kampala I mean some of the facilities like for culture and all that is missing and most hospitals don’t have them except for teaching institutions. Yeah

Interviewer: Okay and then okay now according to you as a health worker, which barriers do you face in taking care of them?

Respondent: It is just about, one for those who come the barriers I find is that first of all they come late so there is a problem of diagnostic tools to be used ,number two the drugs they are probably there in inadequate amount or not there, number three people who get trained during the time they are in the unit they may get transferred they may get moved to another place, they may retire they may opt for another job, that interferes with the institutional memory of those who you can use for treating these patients because you can’t treat them alone. And then the other one is in the data collection and use most times patients come, we do all that we have to diagnose, investigate, treat, they go home and it is not captured anywhere and they go home so it creates an illusion as if the patients are few because there is poor data capturing by the health workers this is partly because Rheumatic heart disease is not given special attention like things like HIV where the data cannot be missed anywhere, if you give somebody treatment for HIV they won’t miss it but for rheumatic heart disease they will look like it is some other condition and so there is no special data collection systems for heart diseases that has been there. It has been bundled up with other diseases and data use has not been there therefore most times when it comes to budgeting you find the data is scanty and people don’t even pay much attention in buying the drugs for rheumatic heart disease or buying the reagents to make the or prioritizing the diagnosis of rheumatic heart disease and also when it comes to the community aspect as a doctor you hardly hear any group coming to talk about rheumatic heart disease except from Uganda heart institute I have never had any genuine group that comes to tell me about rheumatic heart disease and how we can prevent and so on and so forth and then there is an aspect where people think that heart diseases is supposed to be referred yeah most health workers think that it is for other people it is not theirs it’s for some selected few and they perceive it is if it is for some people it is not theirs so the way it is treated also creates a lot of challenge and because there is no some kind of cohesion and then lastly those ones those one the patients we see the mortality is high and sometimes the patients start to correlate the death of another person to be like to determine their prognosis and yet it is a difficult different thing basically yeah. Yeah that is I think what is there

Interviewer: I don’t know If you, you i think we already talked about this the barriers that you perceive these patients face, yeah you mentioned a few of them so just briefly do you think the administration and leadership of the district is doing well?

Respondent: Doing well in what aspect?

Interviewer: In terms of health Respondent. I don’t know

Laughs, okay what hasn’t the district the leadership in the district not done well what do you think they are not doing well?

Respondent: they have not prioritized the heart diseases that’s one thing I know that’s the part they have not really prioritized prevention diagnosis and treatment of heart diseases

Interviewer: So why do you think they haven’t really prioritized it so much?

Respondent: I think there has been less emphasis put on it I don’t know whether it is the money or what I don’t know I don’t know I can’t speak for them I don’t know but they have not done really much about it may be they themselves also they really need to be informed about the magnitude of the problem may be they also don’t know I don’t know may be data use is poor so they can’t really whatever figure out the burden as such.

Interviewer: And then about the funding of health care in general and then with RHD in particular, are you happy about it?

Respondent: Health care funding has been poor and they usually emphasis key priority areas then priority of course is based on each and every institution what their priorities are and you can only set something to be your priority if you know the problem if you know the magnitude of the problem and as I told you earlier on, the data use in data collection capturing, collection, recording analysis and use of in the hospitals concerning heart diseases is extremely poor so it doesn’t really reflect what is on the ground and of course as you know there is a trend now that where the money is put that’s where you have more data collected for you and other places where money is not put data will not be collected and it will appear as if it is not there when it is there and for us at the front line medical personnel treating these patients we find them but to them it is not a big issue because they have not taken a deliberate step to look for these cases record them and holistically handle it according to the disease burden.

Interviewer: So you feel we have a big problem with the record system?

Respondent: Record system terrible, the financing system terrible

Interviewer: And it could be affecting the financing

Respondent: Exactly it is affecting also because once you don’t, once what is not recorded it means it is not done therefore the same principle applies to them when it comes to budgeting.

Interviewer: Okay

Respondent: So they look as if it is not a big problem but it is

Interviewer: I get it

Respondent: Then what about the health workers are you happy about the numbers the qualifications that you have at the hospital

Health workers are few health workers are pretty few and they are very demotivated and they also lack knowledge in managing most of these cases of heart diseases and as I told you most people run where there is money so where you don’t get allowances for the activities, you don’t go there so cardiac diseases you don’t see allowances so no one wants to go where there is no allowance. HIV program you find people there, TB program you find people there

Interviewer: Because there are allowances?

Respondent: Because there are allowances for people who get involved in those activities

Interviewer: So you think there should be motivation of people?

Respondent: There has to be more motivation for these groups leave alone finances, first of all they need training they need to be motivated and they need to be followed up, you need to know where they are, they need to like follow what they are doing, they need to do for them refresher training but otherwise the staff levels we have is critically low and worst they keep switching them from one area to the another you will find you trained this time in heart diseases tomorrow they are in maternity doing antenatal care and ,and you can’t really stop them from that but ahh most of these staff have to be oriented in that direction they need to be trained actually refresher training and courses is vital for them and I would preferably choose a model of having like a selected people who get more training in care of cardiac patients more of a specialized way of keeping the nurses in one area such that it becomes also difficult for people to keep them moving randomly so if Uganda government can take that module where you say you want cardiac nurses you only study cardiac nursing and special training even if you go to another district or another hospital you just join the group of people who are managing cardiac diseases on that side just the same as those ones who manage children ,those who manage neonates ,those who manage diabetes, those who manage hypertension I mean those who manage accident and emergencies there has to be some kind of a structured way of doing nursing than the approach we use now because the approach we use now does not encourage excellency it encourages mediocrity you get more of everything and nothing in detail.

Interviewer: Alright, and then how do you perceive the quality of care the health workers are giving?

Respondent: The quality, okay before I think it was terrible and I think out of ten I would give it 30 I mean out of 100 I would give 30 and that is 30% I don’t really think they are giving the care which these people deserve truthfully I may even give less but with the program which is going on now for this detection of rheumatic heart disease by Uganda Heart Institute down here it has first of all it has relieved us of the burden first of all getting the patients investigating these patients ,giving them medicines, following them up, recording, it is as if they have removed some one heavy load away so it is for now being done by the research group but the only trouble is when the research group leaves they will leave those patients to who? Thank you

Interviewer: Laughs, okay and then the waiting time, okay how best do you think the quality of care can be improved?

Respondent: The waiting time, okay quality of care the most important thing is actually, it should be by these refresher courses for people to know how to detect the cases to start with, number two diagnostic tools to be used for diagnosis of rheumatic heart disease cases it has to be available. For the last 2 years somehow we have been getting fresh air because we are using the v scan that is courtesy of a research but soon it will go back to what it was because now we can do basic scans we can detect the cases but as soon as they take the machines back we are back to where they found us except that we will have the knowledge and we will sit back and do the same thing that we were doing before treating on guess work then there has to be a special clinic really for we like opening cardiac clinic specifically so as these patients are given the attention they deserve just like HIV patients so as you know who to be seen first, seen quickly, say no, who to refer, who to stay, who to admit in that way if we can have a system that would have them seen in the out patients or their own clinic well and good. Then also to improve their services there are areas like the cardiac beds you hardly find a cardiac bed in the hospital apart from in the in the ICU which are few beds the other ones they behave as if they are cardiac beds but they are just modified cardiac beds they are just beds and others don’t even lift the cardiac beds are lacking including even the resuscitation tools things to resuscitate cardiac patients emergency cardiac drugs I hardly see any, I hardly see any apart from a few you get from the theatre you don’t see any out you don’t even see emergency cardiac trolley or whether basic life support trolley or advanced life support trolley with cardiac drugs things like defibrillators I mean all those things, tools to use with drugs and all that zero. It’s just by the name that it should be there but those are the things that would probably if they are there would improve the quality of care otherwise we are practicing almost a half like bush medicine emergency medicine in the bush.

Interviewer: Laughs, Okay, what about the medication do think they are available?

Respondent: The medications I,

Interviewer: Benzathine and anticoagulation medicine?

Respondent: With the program from the heart institute this research they have been there for those patients but before that and am quite sure even after that if there is no, no any post program planning done for those patients we will go back to where we were where drugs are procured.

Interviewer: What about in the hospital

Respondent: Drugs are few

Interviewer: In the pharmacy

Respondent: They are there, few, if it is brought but greater majority as said earlier on it is out of stock for most part of the year.

Interviewer: Okay

Respondent: Yes

Interviewer: Ahh, you talked about diagnostics being available

Respondent: Diagnostics are not available but right now we are riding on the back of the researches being done in the hospital by heart institute so that’s what we are benefiting from by sending those patients there but of course once they leave we go back to square zero

Interviewer: Okay, and then do you have guidelines and protocols for RHD care?

Respondent: We are using the national guide the national guidelines the one from Heart Institute but of course me as a doctor I use other two guidelines the one for American Heart Association, the European Cardiac Assoc society I combine those ones to use but we have our guideline by Uganda Heart Institute that it is used and is working well.

Interviewer: Okay that’s nice, lastly, we talk about perception of patient outcomes generally do you think that they, they are getting the care that they need especially surgery?

Respondent: No, no

Interviewer: Why is that so?

Respondent: I think it is finances, these patients, the surgical aspect, most of them you refer some of them need more advanced surgeries and they need to be referred may be to India because of lack of tools to use from that side of heart institute so they tell them that they need to be sent to India but the cases that end up in Mulago where they can do with the tools they have ,they have actually been doing them and, and with really I would say with 100% good out comes, those ones they have done I think they have scored almost 100% I haven’t heard any scenario where they have failed okay may be they are there but the failure rates of those ones I have sent has been zero so those ones

Interviewer: Okay meaning they are doing well

Respondent: Yes it’s only those they have deferred because of the reasons of the tools to be used on them

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

Respondent: The safety concerns is that they don’t know who is supposed to be like their main source of help so sometimes when you send them down there to the clinics I mean in the health centers for them to be injected some times they think they may be injected by someone who doesn’t know how to inject properly so it is issue to do with pain they may inject without lignocaine the pain attributed to the injection that’s basically their worries of course the safety concerns of the surgeries to be done which are done in heart institute they are usually minor because it is not a safety concern it’s more of worries whether it can be done because most of these surgeries were not done in Uganda so they would only be concerned whether it can it can also be done now in Uganda that’s all.

Interviewer: Then do you have you do you think there are preventable deaths that occur in the hospital?

Respondent: A million, too many.

Interviewer: Why do you think so?

Respondent: Why do I think so, when you come with heart failure and you don’t have a basic drug like Lasix and you die from volume overload is that death from a cause you cannot prevent?, Isn’t it so?

Interviewer: Yeah

Respondent: Yes, so, there are deaths which you can prevent, patients come with heart rate over 160 you don’t have IV drugs to slow the heart rate down they end up with stroke or a myocardial infarct just because you can’t slow it down yeah they are preventable causes really .

Interviewer: So due to lack of medicines and supplies

Respondent: Medicines and yeah medicines and supplies to be used including diagnostics ECG for example not there in the hospital apart from the one of the research it’s not there it can’t be done

Interviewer: I see

Respondent: So you make a lot of diagnosis from ECG alone but if you can’t make that diagnosis then you die you will die from something they would have stopped, so there are a bunch of people who die from preventable causes, yes

Interviewer: And do you think there are patients who dying in the community without presenting to the hospital?

Respondent: A bunch of them because I have gone for burials and when they talk you can co relate the history to the cause of death and you can tell this is from a heart disease ,you can tell, so many die there

Interviewer: And why you think those ones are actually not coming to the hospital?

Respondent: It’s partly poverty, partly ignorance, partly lack of information of services offered, partly because of frustration, social issues at home, transport or partly the services are not available where they stay, they have to trek a long distance to the next best place where they can get a doctor like you see most doctors now are only found in health Centre 4s and hospitals even health Centre 4s the doctors are not available and even if they are available they may not be I mean they may not be I mean more, more, able to comprehensively handle these cases yeah they are not competent enough.

Interviewer: Thank you so much now in your opinion what are like give me one or two most important things ministry of health could do to improve out comes

Respondent: Ministry of health, let them improve diagnostics and then supplies of the drugs and then diagnostics, supplies of drugs then they, they need to prioritize heart diseases just like the way they prioritize other diseases where there is priority they put funds and where they put funds there are results you don’t put funds no results.

Interviewer: Okay, thank you so much, do you have any other thing to say?

Respondent: Nothing.

Interviewer: Nothing, okay, thank you so much for accepting to participate in this interview ahh your views will really help us in making care of rheumatic heart disease better.

Respondent: Alright, good luck

Interviewer: Thank you.