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

Interviewer: This is a qualitative study. So basically, as I have given you the consent form, this study is to determine how to provide better care for Rheumatic Hear Disease. It is building a case to invest in Rheumatic Heart Disease and control in a limited resource setting and as you know, when we are doing research there are no right or wrong answers. We just need to know what happens on ground. So please be frank and share your opinions. The data we gather is confidential; we won’t link it with your identity to any of the reports we produce. So tell me about yourself; age, qualification and your training.

Respondent: I am Doctor ..., 30 years old, Bachelor of Science in Medicine and Surgery and I work with Wakiso district Local Government.

Interviewer: Where did you train from?

Respondent: Kampala international University.

Interviewer: Okay, thank you so much. How long have you been qualified?

Respondent: Its now two years.

Interviewer: And how long have you been working in Wakiso Health Center IV?

Respondent: I have been here for almost a year.

Interviewer: You are a government worker?

Respondent: Yes.

Interviewer: So you have been working at Wakiso for almost a year!

Respondent: Yes.

Interviewer: So tell me about the demographics of the patients you see in practice and the commonest illnesses.

Respondent: We see patients from neonates up to old ages but we commonly see patients with upper respiratory tract infections, infections which cause fevers like malaria and skin infections normally in OPD. But we have certain illnesses that are separated, like non-communicable diseases like hypertensions and diabetes on different days. We have an HIV clinic where we see clients and we have a post-operative ward where we do Caesarian sections. So we do most of the cases and those we can’t isolate, we refer to higher places where they can get better specialists.

Interviewer: These patients that you see, tell me about their age groups; what specific conditions are common in different age groups? For example, 0-5, the young ones and teenagers. What common illnesses are in the different age groups?

Respondent: Commonly, if I start with the neonates, it is normally neonatal sepsis. Then outside neonatal period, 1 and 2 months to 5 years, they commonly present with upper respiratory tract infections, pneumonias, cough, and then sometimes with other fever conditions like malaria and febrile convulsions. Then from around 6 years to 15, they normally also present with upper respiratory infections, cough sometimes those fevers, flu and malaria. Then the adults like I told you, we have many with HIV, so there’s no separate group of ages. With hypertension, our patients are always above four years and we also have a few with diabetic children. I think we have one day a week where we carry out DM clinics; we can have one or two in a week that we see, so we find that most of the hypertensives are about 40 years. HAART clinic is general, then as I told you, the labor suite are normally for mothers.

Interviewer: Okay, thank you so much. Tell me a little bit about your training in Rheumatic Heart Disease; have you received any training in school about Rheumatic Heart Disease?

Respondent: It was not specific, just the normal lectures. There wasn't anything specific about it.

Interviewer: Okay, was it like a course unit or it was like when you do a problem based learning where they give you a topic to research on? How was it?

Respondent: Some topics I can’t remember what we did for that, but I do remember we did problem-based and others in lecture, but I do recall we covered that although am not sure if it was under problem-based or lecture.

Interviewer: Okay. So since you graduated, have you received any training in Rheumatic Heart Disease?

Respondent: No.

Interviewer: You haven’t!

Respondent: We haven’t.

Interviewer: Okay, so in Wakiso Health Center, how many patients with Rheumatic Heart Disease do you often see in maybe a day, week or month?

Respondent: Particularly for the time I have been here I have not diagnosed any patient with Rheumatic Heart Disease. It’s not that I have not seen, I just can’t confirm. But it takes time to diagnose that kind of condition because sometimes you feel that someone has heart anomalies, irregular heartbeats but then you have to refer that patient for confirmatory; you can’t just diagnose that this is Rheumatic Heart Disease because maybe of some abnormalities like irregular heartbeat. There are other things you have to investigate and confirm to get the diagnosis.

Interviewer: In training where you able to see any during your training?

Respondent: Yes.

Interviewer: During?

Respondent: My internship.

Interviewer: You saw but since you came in Wakiso you haven’t seen any specifically?

Respondent: Yeah, I have not seen to confirm to myself that without reasonable doubt this is Rheumatic Heart Disease.

Interviewer: Which means that they have the symptoms but you have not yet confirmed that they have Rheumatic Heart Disease?

Respondent: Yes.

Interviewer: Are those in-patients or out-patients?

Respondent: Out-patients.

Interviewer: They are usually out-patients! Okay, thank you so much. Now, as a medical officer what is your understanding on the causes of Rheumatic Heart Disease?

Respondent: The way I understand Rheumatic Heart Disease; it mainly starts with infections in the group A Beta-hemolytic streptococci which affects the upper respiratory infections, then leads to auto-immune reactions which affects the heart which then causes valvular problems, which are micro and then you get micro deficiency, then stenosis, and then end up with heart failure.

Interviewer: Okay. You as a health officer, are you aware of the link between sore throat and Rheumatic Heart Disease?

Respondent: Yes please.

Interviewer: How do you know that link?

Respondent: Because the group A beta streptococci I have talked about will affect the upper respiratory tract infarctions so the body in means of trying to eliminate the bacteria, it will also cause an effect on the valves of the heart. So it will be an auto-immune reaction because the body will be the one destroying the valves as it tries to destroy bacteria from the throat so then you get problems from the valves.

Interviewer: Okay, thank you very much. So, what were you taught can be done to prevent Rheumatic Heart Disease?

Respondent: So, me what I remember is, one; treating the upper respiratory infections as fast as you can by giving proper diagnosis and giving antibiotics to patients. Then after that diagnosis of Rheumatic Heart Disease, maybe we can give them prophylaxis antibiotics like pen-v, like penicillin-V to the patients for a specific period of time depending on the stage of presentation of the patient.

Interviewer: Anything else?

Respondent: That’s what I know.

Interviewer: Okay, so according to you, what can be done to treat? What were you taught can be done to treat RHD?

Respondent: First all treatment depends on presentation of the patient after doing your confirmatory tests, so you have to treat to eliminate the bacteria itself. For that one, you give penicillin-V and then also benzyl penicillin can be a start dose. Then if someone has presented with urethritis, then you can give anti-inflammatory like acetyl salicylic acid and then that’s when you can give the dose of steroids. Then if it presents with pericarditis, then we follow the protocol of heart failure and manage according to what the patient has presented. Then if someone has presented with St. Peters rash, then you give anticonvulsants like sodium vulgate. If it fails, you can go to Pen-do and then give preventive measures thereafter.

Interviewer: Okay. Now are there aspects of Rheumatic Heart Disease management in which you need more training?

Respondent: Yes.

Interviewer: Like which ones?

Respondent: One; diagnosis.

Interviewer: Explain diagnosis. Which specific part of diagnosis do you want training in?

Respondent: In diagnosis, some of the symptoms we might be talking about them but we have never appreciated them to the patients, and sometimes you may see them but not know that they are the symptoms we are talking about, like the St. Peters rash. I have seen some in videos but not on a patient myself, so if you get maybe a patient and you look at it, because you may be seeing them on a patient but you don’t know that it’s what you have been reading about. Maybe the skin presentation; I have also never appreciated it on a patient. I mainly base on the history and yet sometimes patients have even forgotten if they had an upper respiratory infection. I base on history like heart irregularity and then I send for more investigations. So at least if I get more training in those symptoms of the patients, then it can be good for me.

Interviewer: What other diagnostics do you need training in to help you as a health officer?

Respondent: Interpretation of the ECG. I know a bit but I need more on how to interpret those electro-cardiograms so that I can relate them to the presentation of the patient.

Interviewer: Anything else, maybe about the x-ray or echo-cardiography?

Respondent: Yes maybe just x-ray you can. They all present with cardio-maggoty because I know people who have been in this field; the people of heart institute know features which can help you to interpret. So at least if someone can equip you with the skills on how to diagnose a person, then it can be easier for you to do others.

Interviewer: Okay, so according to you, what is your understanding on the long term prognosis of RHD?

Respondent: The long term prognosis, I think sometimes it’s poor.

Interviewer: Why poor?

Respondent: It is a poor, one; because sometimes when you have Rheumatic Heart Disease, you end up with heart failure and the prognosis of heart failure, we know it’s almost around five years depending on the stage of heart failure, which is sometimes not good. Two; most times we the health workers may not give the proper care and advice because you find that they are supposed to take prophylaxis, but you find most them are not taking prophylaxis as they are supposed to. Sometimes it’s on patients; you tell them to come for injections but ... because, I remember during my internship in Masaka you could tell the patient to come back for injections but wouldn’t come back or even come back after two years only to tell you (by the nurses), "we told that patient to come for injections but now he has come back after two years with heart failure!” So probably it can be the disease itself and sometimes we health workers can contribute due to lack of knowledge. Then it can be patient-based if he has not done what he is supposed to do or take advice seriously.

Interviewer: Okay, anything else?

Respondent: Um, yeah I think if everything is done in the correct way, we can have a good diagnosis if we follow what we are supposed to do.

Interviewer: Which is?

Respondent: Like, if you do early diagnosis of the patient, then initiate what you are supposed to do like counseling and prophylaxis of the anti-biotic you are supposed to give to the patient. I think we can try to stop the poor prognosis of the patient.

Interviewer: Now tell me about your encounters with patients with Rheumatic Heart Disease; that is, in training and at your work place. Do you remember the last patient you saw and how was that visit? How did this patient present?

Respondent: The last patient I saw with rheumatic was during my internship. That patient came with heart failure and I think that’s what the patient was talking about were signs of heart failure; difficulty in breathing, swelling of the lower limbs and arthritis. Otherwise, we were just managing it as a heart failure by that time.

Interviewer: Okay, the patient already had Rheumatic Heart Disease, so you were treating the complications!

Respondent: Yes.

Interviewer: So what do you think has been the average age of those RHD patients you have been seeing? Where they working, in school or not?

Respondent: I can’t remember whether they were in school or not but at least the two patients I have properly seen that they have heart failure, because I have seen heart failure secondary to Rheumatic Heart Disease, both of them were less than twenty years old. One was around 15 years and the other girl was around 18 years, but less than twenty, around there.

Interviewer: So do you think those patients are generally aware of the link between sore throat, acute rheumatic fever and Rheumatic Heart Disease?

Respondent: I don’t think they are because even some health workers don’t know, so I don’t expect those patients to be aware.

Interviewer: So you think the patients don’t know because the health workers are not aware?

Respondent: Yes. Because, most times like the way you see Uganda, they are not like those countries where patients read a lot. There are a few patients that can read a lot because it’s us who read and give that information to patients, so if you find that 30 of us are not aware, then you expect around 70% of patients are not aware. First, they should empower us the health workers and then we can empower the people.

Interviewer: So just to remind me, what kind of symptoms do these patients describe when they come in? Those you saw, you told me they came with heart failure?

Respondent: Yes.

Interviewer: Difficulty in breathing?

Respondent: Difficulty in breathing, Apnea, couldn’t sit on bed, swollen limbs, swelling, abdominal distension and arthritis. That’s what the patient would tell you but when you check, you get irregular heartbeats.

Interviewer: So according to you, do you think those patients are good to follow up and adherent to treatment? Were they good to follow up?

Respondent: Yes. They must be followed up.

Interviewer: But do they go for follow-up?

Respondent: No, the health workers or patients?

Interviewer: The patients.

Respondent: They don’t, that one I can’t lie to you whether they follow the treatment prescribed or not, but during the hospital we could try, but when you discharge them you don’t know.

Interviewer: Which means you are not aware if they are adherent to treatment or not?

Respondent: Yes.

Interviewer: And it means the one whom you told me came in after two years and if you did an earlier follow up, they were not able to come back on that follow up date!

Respondent: Yes, the challenge which I saw is if you follow in the medications they were taking, you find that they weren’t there. Then if the medication is not there in the hospital then why would you follow up a patient in the village if they are telling you they don’t have money to buy the drugs? Sometimes you find that you need a medication but the patient has to go and buy at the pharmacy, so the challenge begins exactly at the hospital.

Interviewer: So what sort of barriers do the patients commonly state to getting care they need?

Respondent: The first one is about seeing health workers. In Uganda, seeing a health worker is not easy except if the health worker also left. Coming here, you realize that someone is in line, like that one with a heart failure must go to OPD and yet he has difficulty in breathing, so he is seated in a chair and is going to wait for 5 hours when nobody has seen him. So I think what we have to improve is, I don’t know how we can do it, but it is the health worker to patient relationship or our attitude at places of work. Because, you find that sometimes there are many people and there’s only one person and in some places you find that there are no doctors. Sometimes you find patients have to travel long distances. Leave alone Kampala where there are many health centers, but when you are deep in the village, someone tells you I need to use 20,000shs - 30,000shs on boda to come to the hospital, but then he reaches and there’s a problem getting medication. So he decides, “next time let me try my herbal medicine and see’

Interviewer: Which means we as health workers become barriers to patients coming to seek treatment and our attitude also towards patient management!

Respondent: Yes, that one is very true because I experienced this one time: I had a man with heart failure and needed an x-ray but even before writing an x-ray, even reaching there alone is a problem. He can’t even move 5 steps! So sometimes you don’t even have couches at the hospital to carry patients. So you reach there and the people want money to do the x-ray, which is government thing by the way! They even chase them from there, so you just find the man puzzled on the way and doesn’t know what to do because our attitude is a big challenge, before you even look at other things.

Interviewer: So that is what the patients usually tell us. So now you as a health worker, what sort of barriers do you perceive these patients face in getting the care they need?

Respondent: First of all, sometimes they tell you or you see the same problems but some of the barriers are about medication; we totally lack medication, not only for heart failure but also in other conditions. An example I can give you is that sometimes in a health center like this, we might have obstructed labor and you don’t have these anesthetic drugs here, gloves, not even a syringe or even a bottle of normal saline, but you are there and you can work. So patients come to the hospital, for example, I was in Kiryandongo some three years back and you could get patients with arthritis and much as you want to give them some furosemide, it’s out of stock in the hospital. So the biggest challenge is medicine, and it chases away patients because when the patients come to the hospital, there is no medication. So one stays there for a week and you tell him to buy furosemide, but you find out that he doesn’t even have food to eat. He won’t come back because he sees there’s nothing in the hospital, because good you diagnosed, but you haven’t given me anything! You say that I am hungry but you don’t give me food, so why should I come next time? Two, workload for health workers; you find the workload is too much. I can give you an example of OPD; he has to see more than 100 patients, so most times he stops listening to patients’ problems. He just says; what is the problem, headache? It needs time to diagnose most of those illnesses and understanding patients' problems but if the patients are many, then you will stop looking at most of the things. Just taking the pulse can tell you about the patient’s case even if the patient hasn’t told you anything, but if you have 100 patients, you can’t have time to look at someone’s heart because they are all complaining and you can’t chase them. So you have to look at them all.

Interviewer: So tell me about the local health system barriers for example, what are the factors you usually get as regards to administration and leadership at the district in your provision for care? Like, by the time you get to the hospital, the administration should have done so and so. So what do you think is the barrier in the administration that hinders your care to the patients the way you would have done it?

Respondent: Maybe for me, if I talk about the leadership, the challenge I get is the way they deliver medicine to us. Most times I think we are not involved properly; you find that the drugs they deliver are most times not the exact drugs we want for certain conditions, because I think they should be delivering drugs according to the conditions we see in the unit. But sometimes, you find what they pack for a health center in Kimwanyi is what they pack for Wakiso, but I don’t believe we see the same conditions. Because, sometimes you find we have drugs for conditions and they are getting expired yet you don’t have these conditions, and they will do the same next year in excess. The other problem is between political leaders and health workers. Like, we have more of those health centers so the politicians don’t get time to come to the health unit to understand how the unit runs or works but then they misinform the public. So instead of coming, they (public) just hate the facility because of what the politicians have said. They can come and tell health workers that everything is in the hospital and that you shouldn’t buy anything when they have brought only two boxes of gloves in the theater which are even going to ...

Interviewer: Those are politicians saying that?

Respondent: Yes. Like when they have been making tables (kimeeza) and they talk to the patients.

Interviewer: A ‘kimeeza’ is like a political rally!

Respondent: It’s like a political gathering in the community and they talk a lot of things, but instead of coming to the health unit first and understand such that when you make your ‘kimeeza’, when people bring up something then you react with information on the ground. But for them, they react and make comments without coming on ground to find out what’s happening to the facility. You find that you don’t have things to use but people can’t believe because for them they saw a track bringing in medication, and yet you are telling a patient to go buy something. So it becomes a problem to us to do our work, not only in RHD but generally.

Interviewer: My next question is funding for health care in general and Rheumatic Heart Disease in particular; are you aware of any funding in the health facility for the different health conditions and Rheumatic Heart Disease in particular? Are you aware of any funding in the hospital?

Respondent: Yeah. Generally, it’s a government hospital where we work so most of the things, the drugs and payment of the workers comes from the government. But we have other stakeholders that help with other things, like for HIV, it is Mildmay. Then there are these non- communicable disease like hypertension and diabetes; I think they are for the Uganda Virus Research Institute. There’s IDI that deals in circumcision in the unit.

Interviewer: IDI is Infectious Disease Institute?

Respondent: Yes, they help us with circumcision but with Rheumatic Heart Disease, it might be there but I haven’t heard about that.

Interviewer: So you have not heard about funding for RHD?

Respondent: No, I haven’t heard.

Interviewer: So about the healthcare workers, tell me about the numbers; how are the barriers of their numbers, qualifications and the quality of care they provide? How is it a barrier to provision of care? Do they provide the quality of care that’s needed for workers?

Respondent: Those ones we have.

Interviewer: How about the numbers?

Respondent: They are few compared to patients. I think because the number of people who are supposed to be in health centers was paused before and people have not taken time to review, for example, our midwifery unit has three qualified midwives to work there, but that’s where you have a post-operative where you have expectant mothers, antenatal care which can get more than 80 mothers a day and a labor suite which can deliver more than 5 mothers a day. So you have a very busy ward. Now if you have three (midwives) and one is at antenatal working on 80 mothers, do you expect her to take the correct thing even if she’s qualified? You have one in post-operative, one in labor suite with two mothers, then who do you think is working at night and who is going to be off? That’s one of the biggest challenges. So when you go to other departments, like I told you, we currently have 2 medical officers in the unit and two clinical officers. We have a theatre which is operating and it’s very busy, then we also have non- communicable diseases. So this means that some units where there are supposed to be a medical officer, you just get a nurse to be there and yet you wanted someone more than a nurse to be there. So we have limited numbers.

Interviewer: So what you are saying is that with the few numbers of health workers, it affects the quality of care you give to the patents. Although they are qualified, they are few and this means that the quality of care they give to patients is poor because of the patient numbers.

Respondent: Yeah.

Interviewer: So what about the waiting time?

Respondent: It depends on the unit where you are. As I told you, at the out-patient department it will take some time because you may find two consultation rooms and yet the patients are many. So you have to take a lot of time; there’s no doubt about that. Another challenge is that if you are in other departments, even what to use is a problem! Like I told you that if I need to do something, I need to tell a patient that you go and buy this, and then they say I don’t have money.

Interviewer: So tell me about the health system barriers in regards to medications. You were telling me about medication particularly benzyl penicillin, anti-coagulation and heart failure drugs; do you have them?

Respondent: Yes, we have. Like for example, benzyl penicillin, but it gets out of stock sometimes. They do bring for us but after sometime we run out of stock.

Interviewer: Which means that they give you a good number to handle your patients? You have no issues with that?

Respondent: The issue with what?

Interviewer: With all the drugs.

Respondent: For the issues, we have. Maybe those of family planning don’t have (issues), but the rest do. For family planning and ARVs, the drugs are ever there.

Interviewer: What about the anti-coagulants?

Respondent: I have not seen anti-coagulants in our unit.

Interviewer: Which means that’s a hindrance! Like, when you get an RHD patient there will be no way to provide care without those medications!

Respondent: We just refer.

Interviewer: That’s a Health Center IV for goodness’ sake, so for someone to come to the heart Institute, they would have to get the initial care they need before they reach there. Sometimes they get sick in the night, you have those kind of things at least they need they such that they get the care they need.

Respondent: Indeed, they get it.

Interviewer: So tell me about diagnostics for example the cardiography and those other types of ...

Respondent: First of all, we have the laboratory so it’s good we can do all things. But for these things of culture, we don’t do.

Interviewer: Culture and sensitivity?

Respondent: Yeah, we don’t do. ECG, even a mere ultra sound we don’t, or even the ECG I can't even comment now!

Interviewer: Do you have an Echo Cardiography?

Respondent: No, we don’t.

Interviewer: Then that’s also a barrier!

Respondent: Yeah, that’s what I told you that when I get a patient and I feel they need it, I write and tell them to go and do ECG.

Interviewer: So tell me about the health information system at the hospital; how are those systems interlinked? Okay, tell me how the medical records system is generally. How is your record keeping? Do you have a register where you keep them or an electric way of saving information?

Respondent: I think record keeping is good because they particularly have a person who is supposed to do that in the unit, and then every unit has a book in which they record each and every patient they see all their demographics, diagnosis and treatment they have given and the registration numbers of a patient. Then data is got by that records person, summarized, saved electronically and then at the end of the month, he has to give a summary of what the patients we have in each unit and conditions, and then sends to the district. So I think the record system is not a big issue.

Interviewer: You said every different unit has a book where they register the patients!

Respondent: Yes.

Interviewer: Are those different medical systems interrelated or integrated in a way that you are able to access information from the different units?

Respondent: Yes, you can access information from that unit although I have not seen people trying to access it a lot, but if you want it’s there.

Interviewer: So do you have specific registers for specific conditions? For example, patients who come with hypertension and DM, do you have specific registers for them?

Respondent: Yes, like we a have specific register for TB. Like I told, we have non-communicables, so the book is there.

Interviewer: What about registers for acute rheumatic fever and Rheumatic Heart Disease? Do you have those too?

Respondent: I don’t think so.

Interviewer: You don’t think so, because you have never seen them?

Respondent: Yes, I have not seen them because I would have seen them if they were there.

Interviewer: Do you have guidelines and protocols for Rheumatic Heart Disease at the hospital?

Respondent: No, it’s not there?

Interviewer: So what are your referral pathways in case you have received a patient presenting the symptoms you have described?

Respondent: When I get a patient, I just refer directly to Uganda Heart Institute.

Interviewer: [laughs]

Respondent: Because for me I am close, but if I was far I would send to a regional referral hospital. At least it’s in Wakiso where I know you cannot get any disturbances.

Interviewer: Now, I need to know about the local system enablers; what motivates you to come from wherever you come from to work?

Respondent: The most important thing is the calling, and when the patients improve, there’s a way it feels in the heart; you feel so happy. Other things are additional but the important thing is seeing the patients feeling better. Because, you can’t treat a baby of four months but if you see the baby who had convulsions and fever improving, you feel so nice. In addition to that, our administration doctor who works for us is a very good man and very welcoming. You have to talk when you have problem, so we work as a community and when at work, you feel like you have reached home. There’s no big issue in the unit.

Interviewer: Which means the leadership at the hospital has enabled you to be able to provide your care!

Respondent: Yeah.

Interviewer: And has the district done the same?

Respondent: Even the district has no big issues. Normally we take long to communicate to the district, but it’s mainly the in-charge who communicates to them if there’s a problem and they will communicate if there’s a way to solve your issues in your place. Even when they are not around, they have been able to solve our problems.

Interviewer: So according to you, do you think the general funding enables you to provide the care that you need to the patients?

Respondent: No, they are not because funds have to be pushed first in training those health workers. Because now, patients with rheumatic heart failure and fevers may be bypassing the health workers but maybe the health workers can’t recognize. So there must be specific funds for training health workers to understand, and also put the diagnostics in place to help the patients because if these two are not there, you might think that you have no rheumatic heart patient in Wakiso when you have like ten of them!

Interviewer: So what you are saying is that to you, the funding is not enough!

Respondent: Yes.

Interviewer: So, I was saying the health worker numbers, are they working for you?

Respondent: No, they don’t. Like I told you, we are few. Someone can come here and say that they are sick or that he left home with severe headache but he has been sitting here.

Interviewer: So you are saying the health care numbers don't enable you to provide the care the way you need to!

Respondent: Because, for example, you may go to the unit when the doctor doing the operation hasn’t reviewed the post operatives and yet he has those he operated on back for review, and then they are called to the OPD because sometimes they call you when they have a patient but you sometimes fail to go there because you may find that you have five caesarian sections. So you tell them I will come but by the time it is seven, you have to go home, then you say I didn’t see the patient which they called you for.

Interviewer: Which means the numbers also affect your quality of care; they don’t enable you to provide the kind you want!

Respondent: True.

Interviewer: Do you think the medicine provided to the facility like Health Center IV enable you to provide your work the way you want to as a health worker?

Respondent: No. Maybe if you have that benzyl penicillin, you can start somebody on that antibiotic as you refer the patient, or you may give a prophylaxis. When the patient has received treatment from somewhere and they refer to us, we can give that continuous prophylaxis but as I told you, the challenge comes when the drug is not there because the patient can find no drugs on the unit.

Interviewer: So the health information systems, do they enable you to provide the care you need?

Respondent: With that one, at least there are no big issues.

Interviewer: So you told me earlier that you don’t have guidelines and protocols of Rheumatic Heart d Disease!

Respondent: In the hospital, we don’t have.

Interviewer: Tell me the perception of patient outcomes; do you generally think the patients get the care they need or not.

Respondent: They don’t get the care they need.

Interviewer: Why?

Respondent: Because as I told you, the number of health workers, for example if I operate on a patient I need to monitor him every fifteen minutes. So if I don’t, the patient doesn’t get the care he deserves to get and for sure no one will observe that patient because we are very few. So the patient is at risk; anything can happen when you don't know. Because, imagine coming here and sit for four hours when you have a pneumonia killing you or a heart failure where you can’t breathe! So even if you treat such a patient, he can’t say you have given him the care he deserves. Because, by the time someone leaves their home and comes, he has a problem.

Interviewer: Which means the waiting time for the patients becomes longer!

Respondent: Yes, the waiting time is a problem and even the interacting time with health personnel becomes very short because of the numbers. As I told you, if you have 180 patients, it is very difficult to sit and listen to that patient properly because as a minimum rule, you are supposed to clerk that patient for 45 minutes, but if you are one and given 180 patients a day, you will see 15 patients. So by the time you see 100 patients, you have given each patient like 3 minutes. So have you examined the patients? No! Because, I may come when I don’t know that I have a heart failure, so it’s you to listen to me and tell me. Despite you treating the fever, it doesn’t mean I have received care. Two, investigations; as I told you, sometimes you want to do common investigations but the patient goes to the laboratory and find that it’s not there, like for an ECG, he has to travel this side just to do it. So I don’t think the patient will get the care they wanted.

Interviewer: So tell me about patients’ safety; are the patients safe with the quality of care you give them?

Respondent: Like in terms of?

Interviewer: Like a patient comes to you with a different diagnosis or symptom for example difficulty in breathing and fevers. When they come to you, are they safe in your hands that they will get the care they need?

Respondent: I think they are because we have qualified staff. The only thing that can change that is the numbers that may not provide services on time. Then absence of medicine because I might diagnose someone with heart failure and difficulty in breathing but I don’t have furosemide to give. That would be the challenge but in terms of safety, when the health workers have the resources to use I think there’s no problem there.

Interviewer: Have you had any preventable death at the hospital?

Respondent: Preventable death from rheumatic or?

Interviewer: Rheumatic Heart Disease and generally.

Respondent: So many times.

Interviewer: Why?

Respondent: You have said preventable or?

Interviewer: Preventable, like patient comes and you as a health worker you think this death would have been prevented.

Respondent: I hadn’t understood the question. I have not. We have not had that one.

Interviewer: You have not had any preventable death? Like dying according to things that as a health worker you would have been able to treat?

Respondent: There’s one kid who died because of lack of oxygen that time. We wanted oxygen but we didn’t have oxygen, so we had to refer although it was referral without oxygen. We would have put the baby on oxygen and then we refer but we didn’t have oxygen.

Interviewer: Then you lost the baby!

Respondent: We lost the baby, even getting an ambulance is a problem because we don’t have a working ambulance.

Interviewer: Do you think patients are dying in the community without presenting to the hospital?

Respondent: I think so.

Interviewer: Why?

Respondent: I think for me it comes in two things; as I told you, the attitude they have about us. Sometimes they think that even if I go to that place, those people are very rude; you reach there when you are dying but someone says, "Who has sent you there?" If I go to the hospital, there’s no medicine; they just tell me to buy and yet I don’t have money, so why can’t I just die from here? And three, it is the misinformation from local herbalists because they sometimes misinform the public a lot from the TVs. They teach them a lot of things like to just smear this or that once and it disappears, or that one can cure diabetes and hypertension and that by just swallowing two things, your diabetes is gone. So even the patient will remain there taking those herbs.

Interviewer: So as a health worker what in your opinion are the one or two things the ministry of health could do to improve patient outcomes?

Respondent: One, I think is to improve the health worker attitude towards patients although I don’t know how they would do that. I don’t know if they have to get someone to ... I don’t know, but health workers need to improve their attitude towards patients. And two, it is increasing the number of health workers and what they have to use in health facilities.

Interviewer: Okay. Anything else?

Respondent: Maybe also equipping health workers with listening skills, or maybe updating them because someone might have qualified ten years back and has never attended any CMEs and yet things have changed. For him, he is telling you those old things from ten years back! I think to also educate the patients to tell the community which services are available in nearby facilities because sometimes patients don’t know which services are available; they first go to private clinics and from there they are given treatment for malaria for every condition, and that’s when they come to the health facility when they’re badly off and after wasting all the money.

Interviewer: What about the training in Rheumatic Heart Disease?

Respondent: That’s the part that people don’t know. General training is needed because that’s where most health workers don’t know.

Interviewer: Okay, thank you so much.