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

Interviewer: Today is the 18th Nov 2018 and we are seated at the nurses’ office room at LRRH.You are a pharmacist?

Respondent: Yes,

Interviewer: Ok I just request you to be loud so that I can hear this when am transcribing then remember there is no right or wrong answers and your opinions are very important and we shall keep it confidential, so we need you to be frank or honest as much as you can, ok so let me just know a little bit about you

How old are you?

Respondent: 25

Interviewer: What are your qualifications?

Respondent: I am an intern pharmacist ...but I graduated last year

Interviewer: You graduated last year?

Respondent: I graduated this year but I finished school last year

Interviewer: Wow! Ok and...

Respondent: Bachelor of pharmacy

Interviewer: Ok so you came here in lira this year?

Respondent: Yes, this year, since October 1st

Interviewer: October 1st? You have been here for?

Respondent: Making 2 months

Interviewer: 2 months? Ok and then, have you seen any RHD patient coming for maybe medication?

Respondent: The ones I have seen have been looking for medication, now that we don’t have a tent, they usually come to the pharmacy, and we are usually on exchange because in the pharmacy, we don’t have the drugs, and they have been reluctant but we have the laxatives like Laxis at maximum stock

Interviewer: So you said they have been coming?

Respondent: Yes

Interviewer: That is wonderful, ok then looking at the demographics for the patients that have been coming for treatment, which age group do they fall into? How do you describe them?

Respondent: I would say...

Interviewer: Are they young, are they old. Are they women...

Respondent: laughs, most of them ok from the observation, I have not been very observant but from my observation, most of them are ladies, yes and the few are the young kids

Interviewer: Kids?

Respondent: Basically there are many who are present

Interviewer: From your observation, are they in school?

Respondent: No, if they are in school, they didn’t go to the advanced level so far

Interviewer: Ok

Respondent: Probably past P.7

Interviewer: P.7?

Respondent: Not S.4

Interviewer: Not S.4? and then apart from RHD, which other common illnesses are you treating in the pharmacy?

Respondent: we always receive basing on what is in the hospital, so we treat the patients

Interviewer: And what is most common?

Respondent: What is most common I would say infections because we give out a lot of anti biotics but common among those is peptic ulcers, respiratory infection disease and then sexuality transmitted infection, then some rare cases like T.B infections.

Interviewer: Ok then, how often in a week, how many times do you get prescription for RHD?

Respondent: In a week? Hmm like twice

Interviewer: Twice ehh.

Respondent: Yes

Interviewer: So let’s say like 2 per week?

Respondent: Yes 2 per week

Interviewer: Ok then So is it mainly the adults who you treat for infections that you get or it’s the pedetriatic/children?

Respondent: Pardon?

Interviewer: Looking at the demographics, do you treat more children than the adults or more adults than the children?

Respondent: Overall on the desk, we treat more adults than the children because the ped ward is opposite almost half empty most of the time

Interviewer: What explains that? What do you think explains that?

Respondent: I don’t know exactly maybe it’s the facility or they lack residence because even in the emergency ward, you will and mostly see adults and I have never seen the kids there yeah and that is the matter

Interviewer: That is strange, I thought if you would ask me, I would think it is maybe according to the sick...

Respondent: Yes that would be the case but the statistics say otherwise because I haven’t gone there

Interviewer: Ok tell me about your training on RHD, have you ever had any training on RHD management?

Respondent: No

Interviewer: No?

Respondent: Honestly, I have not

Interviewer: Ok, maybe in school, did they ever tell you anything about management of RHD?

Respondent: Well in one of those classes when they were talking about clinical pharmacology, they talked about it

Interviewer: They did?

Respondent: Yes

Interviewer: Also you have some clue at least about it, about RHD?

Respondent: Not that the clue

Interviewer: It’s a clue eh..?

Respondent: It’s not just the clue, the clue will really be in details

Interviewer: Ok and then after the graduation, since graduating, have you ever had any formal training or workshops you have attended where they are talking about RHD?

Respondent: No I have not heard because before I came here I was working at the facility not a clinic, so we usually had CMEs but RHD has never been discussed

Interviewer: Has never appeared? Ok do you think it’s necessary to have one? Or do you find it necessary?

Respondent: Yes it’s because when you are working at the pharmacy, the patients come, at least you should have an idea about every disease because the patient will come and will say I have this, you have to know how to distinguish, is it RHD, is it a cardio myopathy, is it hypertension, and is it cardiac malfunction, so you have to know about a little bit of everything so that you can know which drugs to give and distinguish because they differs

Interviewer: Ok so currently what are you following? You just follow what the doctor have prescribed?

Respondent: Currently I give based on the duration of the drugs, I always have to consult, why you are giving this one which is longer than it should have been

Interviewer: Ok so do you mainly see the inpatients or the outpatients that mostly come?

Respondent: RHD patients are mostly outpatients

Interviewer: They are outpatient?

Respondent: Yes

Interviewer: Ok and then so according to you, what is RHD? What do you know about it, what is that you know about the disease

Respondent: Not so much

Interviewer: Hmm

Respondent: I know that it involves the heart and the heart controls the body system to pump blood and that blood should come out

Interviewer: And then what could be causing it?

Respondent: Not so much, not so much actually

Interviewer: Are you aware of the link between sore throat and getting RHD, have you ever heard about it?

Respondent: Not really but you can tell me now...laughs

Interviewer: I cannot tell you because I need to know what you know and why we are asking you is because we want to see the gap so that people can be given

Respondent: Ok

Interviewer: The necessary training

Respondent: Ok

Interviewer: Could you be knowing how it can be prevented or how we can prevent RHD

Respondent: Me personally before I am a professional, like taking the real life styles, drink a lot of water, enough exercise, eat well or eat right ,if you do all those, you will get a lot of nutrients, so they should eat right laugh...take enough exercise, that is in good condition, that is specifically for RHD patients

Interviewer: You have mentioned some of the treatment you give for the RHD patients, what are the treatment options you know for treating RHD?

Respondent: Most of the time, the prescriptions I have seen, have come with drugs which also treat hypertension, so those are the ones I know. The prosomide to reduce the freedom of the system, the amlodipine, pelodipin which has not been prescribed because of its scarcity, I believe with the right medication and adherence to treatment, the patient could be where they could become way better because I don’t believe it’s a permanent damage to the system.ok, it may not be completely reversed, but it can be prevented from worsening and wasting other tissues of the body.it has to be both sides, early treatment but also early administration

Interviewer: And so tell me about your encounter with these patients, when did you see the last patient? How long ago?

Respondent: Let’s say last week because this week I have been out of the pharmacy

Interviewer: So it was last week? And was it a female...how did this patient present, was it a kid or an adult

Respondent: An adult, I think she was incultivated

Interviewer: So what drugs was the patient taking?

Respondent: I think it was transvelon

Interviewer: Ok and then...so you told me that most of the RHD patients are women, most likely not many years of school

Respondent: Yes, women and children

Interviewer: But do they tell you if they are working or not?

Respondent: No

Interviewer: Do you think that they are aware of the link between sore throat, acute rheumatic fever and RHD? Do you think that they are having a clue?

Respondent: Normally i don’t think so because there has been screening and sometimes it actually shocks the patient, the person came in fine in the morning, she looks just fine and well, so just get done with this thing and go home, you tell them we may actually need to do another test, they are like what is wrong with me.I feel fine, I feel normal, I can walk home, am busy am walking so what are you talking about

Interviewer: And then you as a pharmacist, do they ever come to you to ask question that you feel that if you had the information about them, you would give them in this station?

Respondent: laughs, talking from my experience especially from my place here, natives from here, well am not from here, so there is a big problem from language barrier, so if they don’t understand English, spending on them, asking questions, so usually you have to get the intermediary, you may have an interpreter or you ask them to tell you back in English, then you explain, then we get it back, so it’s basically, getting back to the person. When you look at it on both sides but some of them by the time they come, they just want to get the drugs

Interviewer: And they don’t ask questions

Respondent: Yes, unless it’s you to involve them with the information, you tell them take these drugs take lots of water

Interviewer: So how do you explain those things especially now that it’s not your native language, you have to tell the person to drink lots of water, do this, how do you do it, how do you manoeuver

Respondent: I have been borrowing extra man power

Interviewer: laughs

Respondent: I always ...that’s why am friends with Jenifer, Linda and jafess

Interviewer: So in the morning when you start working

Respondent: In the morning I always greet them

Interviewer: They can help you?

Respondent: Yes

Interviewer: laughs

Respondent: Ok

Interviewer: And then if you look, do they ever describe their symptoms to you when they come?

Respondent: No, they just come to pick the medicine

Interviewer: When they come to you, do you get it but that’s not the area, no I will leave that that is not for you. And when they come back do they present their empty packets to you or they take them back to the nurses

Respondent: I have not seen any coming to pick medicine with empty packet, not really

Interviewer: They don’t come? Do you have a good sense of their follow up and their adherence to their medication?

Respondent: Since most of them are outpatient there mostly because the inpatients are given the interim report given when the doctor has prescribed, which medication have they changed from, so you can give a sequence, if the patient has been having ampicillin, then they went to ampliclox, then maybe the doctor prescribed genta, the Ceftriaxone, so at least you have a rough record of what was given and at how much, but the outpatient is mostly a single paper, laughs, the diagnosis, treatment and then they go, they usually don’t come back, I know

Interviewer: Do they ever mention any barriers to getting care to you at any one point in this facility.

Respondent: I will not say they have communicated it out but I will cease to identify, somebody tries and prescribed the right drug not being on our reception medicine desk facilities, so here you know it a referral, we only provide a decisional ditties, the medicines are cheap, safe, it’s effective, it’s affordable and we always give to many patients, very many drugs fall under those brackets and they are first line, we always give second line and third line maybe the alternatives which are affordable and its like it can be better, if you give like spinalatol,you may never find it here, kavendilol,you will never find it here,

Interviewer: So some of the patients have to fend for it?

Respondent: Yes you may have to write a prescription that has maybe like four drug then you get only one like hypertension, that one has dephedipin and amlodipine, so if it’s not one of those two, then it’s up to you maybe plus captopril and phroximide

Interviewer: So how do you think we can overcome that, why is there fem medicine on...

Respondent: It’s a government facility, so you need to cater for that of the patient, that one I don’t think its going to be rectified any time soon because we also at times, we run out of these essential medicine

Interviewer: You do?

Respondent: Yes

Interviewer: Like how long do you take before you get another stock?

Respondent: Usually they delay like depending if the drugs are ah...the contribution is really high and need is high, we and we stock, like when we have a delay, usually we request other facilities which is half way here to get them here, yeah, at many times we have gotten medicine from Kitgum, most times we have been giving medicine to Aduku an Barr and some health facilities

Interviewer: Have you reached to some extent where you spent like 2 weeks without any drugs and also maybe even when you asked for them to give you some, it takes some time to reach Respondent when you ask for drugs from outside, the delivery is not more than a week

It can take a week or without?

Respondent: A week or within the week depending on the process because we have to write a letter, get it stamped by the director, scan it, send it, follow up on a phone, organise the transportation ,then you get it from there, so that’s why deliveries delays

Interviewer: So what happens to those patients who comes within a week when you are still processing the drugs

Respondent: We tell them the drugs is still out of stock, that is the first thing, we advise them to purchase it from the nearest pharmacy before the come back because otherwise, we don’t have much to do.

Interviewer: Ok, for those drugs that you basically don’t stock here, on average for an RHD patient, how much do you have to spend outside to get the drug?

Respondent: On an average, I think if we don’t have the drugs I have prescribed because If I give it a channelled look and also give it directive, hopefully without an ACE inhibiter laughs...like I have to record roughly ok, a minimum will have to be 15000/= because they are not going to take those drugs for like a month because it’s usually for a short period of time

Interviewer: Wow!

Respondent: Yes

Interviewer: And then which other barrier do you think is...what else is hindering these patients from accessing care why do you think they don’t come

Respondent: I don’t want to say it in a bad way but most of the time people don’t want to come to the hospital unless there is a problem, a problem they have noticed if I feel pain, pain is not going after 2 days, then maybe I need immediate attention. if I wake up feeling fine, I can eat, I can walk, I can do all that, why do I need to go to the hospital, so that’s why some patients have been surprised patient as they get shocked at their actions, their system is not exactly as they think it is. Yes so there is need for sensitisation and health awareness, telling them actually that this thing that maybe killing you slowly, actually be treated very fast and getting back to normal without you going through this documental effects

Interviewer: Ok, have you ever had about any sensitising campaigns around here about RHD?

Respondent: Not really

Interviewer: Do you have CME’s here?

Respondent: Yes, every week

Interviewer: Every week? Have you had CME’s on RHD management?

Respondent: No, the one we had was on ok there has been kind of on and on depending on how the hospital is but it’s been on every Thursday, we had one on bespatter haemorrhage, we had one on mulateral sensation the last one we had was on sprain brain damage and how to navigate it and that’s what we basically discussed

Interviewer: Ok so and RHD management?

Respondent: Maybe not yet, maybe it was done before I came in

Interviewer: before you came in?, so what do you think would stop someone from adhering to drugs, you give them the drugs, you tell them to take like 2 in the morning and 2 in the evening for 30 days, what would stop them?

Respondent: Sometimes it’s a variety of factors really, one is the pill burden because the person you are giving 1 drugs2 X2 right that is four drugs already for day and so probably they have 3 drugs and one day there are probably 6 tablets, some of them have different frequencies, some of them is 1x2,others is 1X1,so he has to remember that ah...but that is also navigating what one is doing during the day, what kind of job he has, most of the locals here have subsistence sources of income ,selling food stuffs from the garden, tomatoes, onions, things go on basically, so navigating that and walking around the medicine. You start feeling feasible, usually if the medicine is home, so if you tell them to take 2X2, you have to set a reminder for them if really they are to do it

Interviewer: Why do you think some of them don’t come back for reviews?

Respondent: Like I said before, the patient came, he was feeling fine and they are not noticing exactly the difference, so for you to notice, for him to exactly know the difference, it is for him to come back and do the review again, probably they sacrifice a day to do that, the other time we lost a girl ,so survival verses about spending a lot about their life because some it’s frightening sometimes, so you have to choose to really, I am feeling fine but I need the medicine. Ok I need the medicine but I am not feeling too bad about myself, I really need to make that money, what should I really do? Go make the money, if you feel unwell again

Interviewer: Ok good, let’s look at the local health system barriers here, which cases are not doing well for you?

Respondent: which one?

Interviewer: As you are doing your work here, what is not working well for you, what you would want to be involved, which area so that you can do your work well?

Respondent: There need to be..., as a pharmacist, I would say a fresher course

Interviewer: A fresher course?

Respondent: Yes, fresher course on the use of drugs especially in anti biotics because the way they are prescribed, are having, you have to re do the prescription because most of the time, we are in the pharmacy full day, Monday to Sunday, Monday and Tuesday is, we are have patients over load like after all the work is done, we have a long line and each ward they have like, they brought all the files at once, so you find medicine for like 12 files. Surgical has brought another 12 files, you have to go through all of them, you have a long...you want to leave this patient and get them done and get to go, you don’t have time to think through what you are writing. So there is need to prescribe. So last week we actually had to move from the pharmacy to the ward to ask who wrote this because they wrote a prescription for, the diagnosis was without so much examinations. They made the diagnosis based on what the patient explained, abdominal breakdown, general weakness, then the person wrote Ulceration mild, as in how do you do ulceration mild just by mere looking, so the diagnosis was PUD plus PID then another person wrote Pluservicitis, then they wrote 7 drugs, five sets of them being anti biotics IV CEF, IV genta and doxycycline, Cipro, metronidazole, nystatin and omeprazole

Interviewer: But you are lying, is that true?

Respondent: I have the picture the support it because I had to take the picture

Interviewer: laughs, Wow!

Respondent: Yes, it’s in family planning unit, you wonder are we treating the patient medically or we are trying to give them a condition so that they keep coming back because we can’t prescribe 6 anti biotics in just one system, two of them being IV’s so for that I had to mutually go there and ask who is treating and what is the criteria for treating like this because most of those actually out of the 7,omeparazole being out, so being 6,you could actually give 2 of them and the patient will actually be fine. Ok maybe if we need to supplement because if it was PUD and PID but you don’t need to give 6 of them

Interviewer: Just out of curiosity, was that one a doctor?

Respondent: I was told it was a sister

Interviewer: Ok

Respondent: Yes

Interviewer: Wow!

Respondent: We had to rectify that on another day when you are very tired with lots of patients, you don’t have a clear mind to literally do that, you just tell everyone to sit here, you do the rest if you are really tired, you just displace and until you discover with 1.2,3,4,5,6 anti biotics for one system, what is the diagnosis, so you need to check, so there is maybe need for refresher course and the right treatment

Interviewer: So it’s a refresher course, patients overload ah..., what else?

Respondent: The patients overload may not really be a problem or a hospital because the pharmacy is always there

Interviewer: How many people are there?

Respondent: In a normal day we have like two people there, two people managing

Interviewer: On average how many cases do you get, like how many?

Respondent: Managing the whole hospital, it’s an inpatient pharmacy and also outpatient

Interviewer: So on average, how many 5 statute

Respondent: In a day?

Interviewer: Yes

Respondent: That is interesting because I have never counted but it’s over like 100

Interviewer: over 100

Respondent: Yes

Interviewer: Wow!

Respondent: Because the other thing is we have an inpatient pharmacy here and also the outpatient pharmacy but an inpatient pharmacy is free out of the hospital because they transferred it, so they have to go to the mental side so they give patients the prescription, they have to get out of this side, go round, then walk to that side and get the medicine, sometimes the pharmacy is also closed that side because patient’s medicines are not there so most of them just come here.what is working here is also working for those ones from that side

Interviewer: Wow! Any other challenge you face

Respondent: The others is basically managerial, drugs being out of stock

Interviewer: The stock out of course

Respondent: Yes

Interviewer: ok and then let’s look at the administration and leadership, what is your take on that? How have you seen the leadership here?

Respondent: In the hospital or in the pharmacy In the hospital and in the pharmacy, let’s start with your department, how is it running?

Pharmacy department, it runs smoothly because you always know who is working and who is off and who is not there, in case he is out, they let you know, you may fill in for them because last week I was out of this supporting some things so someone had to fill in for me, so when I came back, we had to exchange

Interviewer: Ok, so how about the general administration

Respondent: The general administration of the hospital, we have the supervising pharmacist who always comes back and ask because during a normal week, not a normal week laughs, normally on a typical week yeah, it’s the usual patients, medicines you give out but we usually have the internal evaluation, presenting complains, how the patient is reacting to this drug, there is always a problem with gentamycin and with the fresh batch they brought, people reacted to it abit but we had to try and find out. Some people reacted but then after doing some close observation, same people who were reacting to it were given the same drugs, there was no reaction, so maybe it was just spiking of the medication but same drugs, same dozes

Interviewer: Ok then, let’s talk about the funding for health care in general, what is you take on it, what is your opinion about it, what do you have to say about it?

Respondent: The funding, well we actually try to do our best laughs, we actually have to do our best because we don’t have everything that we possibly need or probably want but we have the basic to keep the hospital running, we are trying to navigate things laughs

Interviewer: And then for the RHD particularly, at least you told me that there are some you don’t get, you only get the essential drug and then, so what can be done, do you know if there is anything we can do to improve the...

Respondent: Well I don’t know if this will work but probably they should do like a special clinic because you may do you checking and giving out the medicine but you could give the prescription like I told you that their business Is just selling food stuffs like tomatoes and onions, you tell them to go and buy the drugs that is costing more than 10,000 shillings, they will usually debate like why should I really spend this much money when I have major needs like food, transport that I need to cater for, if I don’t cater for those ones, I may not survive but if am not doing too badly, so there maybe need to do a special clinic whereby boards should call their patients that they have their address earlier, that on this date and this month, we are going to do a review on all of you, then you can come with your medicine of their own, of course it may never be like this on the pharmacy and of course it’s a standing policy for management of health care

Interviewer: Ok and then, when you look at your numbers in your department, how are you finding the numbers of people you are working with

Respondent: The staffs?

Interviewer: Yes

Respondent: The staff yes that is adequate enough with the numbers

Interviewer: You are fine with that?

Respondent: Yes

Interviewer: That is good to hear, and then the waiting time of the patient before they are worked on

Respondent: The idea is before the files comes to the pharmacy, the doctor has done the review and like the doctor reviewed each patient because late in the evening and then it comes back in the morning because he has written everything and see whether to continue with the medication or he has improved or there is need to change his medicine, something like that. Now because there are very many, some times more patients in the ward and the ward round happens till mid-day, then they collect all the files at once, so you know medical wards. so depending on how soon the files come to you because if the file comes from a medical ward and you already came to your seat, we only work on them according to who comes first. Now for those ones who are emergency ward cases and the patient has come in, we first dispense that one then we can offer the files

Interviewer: Ohh and then how do you look at the health information or medical records here, how are the records kept here, are you happy

Respondent: Records, what do you mean?

Interviewer: If you have been working,

Respondent: Is it on point because its implication to treatment, it’s very easy to retrieve it even when you are dispensing medicines like this ah...majorly aspirins ,we may not only record it in our books but also in the patients file .we always write IV, the date which IV was given and at what quantity, so even if you are working till Thursday, that person working on Friday can know this drug was given, it should last them in this number of days and the next time they should be coming back, it should be on this date

Interviewer: Thank you, good to hear that, any areas which needs improvement via information management

Respondent: Record keeping, maybe making it digital laughs, of course that will make it a lot, for the pharmacy, but in the store, it’s already digital, so in case you want to retrieve anything, you just have to click on it and you get

Interviewer: So, let’s talk about the heart failure drugs, anti-coagulation drugs, the BPG drugs, the diagnostics like the echo cardiography here in lira hospital

Respondent: In lira hospital?

Interviewer: Yes, how are the stocks?

Respondent: first of all, the diagnostic test, I don’t think we have it here, they are mostly found outside there in a clinic close by where they do echo

Interviewer: The hospital does not have?

Respondent: They have been referred outside most of them

Interviewer: Most of them?

Respondent: Yes

Interviewer: Then the heart failure drugs, do you have them

Respondent: The heart failure drugs?

Interviewer: Yes

Respondent: we have a few drugs from the pharmacy, we have cardiac failure interblockers and ACE imputer, we only have a few of directives, and we have phroximide, receptive inter blocker, we don’t have them yes sometimes we don’t have anti coagulants

Interviewer: you don’t have.

Respondent: yes

Interviewer: Do you usually get stock out of those drugs?

Respondent: yes once in awhile

Interviewer: Once in a while?

Respondent: Yes

Interviewer: And you told me that it can take like a week before you get another stock, have you had an incidence when even the other centers don’t have drugs

Respondent: Yes, usually we monitor, we make an order based on the usage, So maximum stock, minimum stock, you have to have a good point, yes we are usually making a good point and we realised that the order would take a little longer than should have been the deliveries. We usually call the facilities by the time when we send a letter, you know, I want this quantity, what quantity they have to keep their facilities running and what quantity they will give you so by the time you make an order, you have a little to sustain you ah..to that point where you were organising the transport and stuffs

Interviewer: Wonderful

Respondent: So, you minimise time listening to them

Interviewer: And then if you look at the quality of care given to the patients especially the RHD patient, are you happy with it

Respondent: Well, am glad that they do the diagnostic test yes because once into treats and yes am really glad about that because by the time the patient comes to the pharmacy, you know exactly what is wrong with the patient

Interviewer: Ok, any missing..., is there any gap that needs to be improved on the care that is given?

Respondent: Maybe not necessarily about the care because maybe the general care information to tell, what the disease is about, what their chances really are because sometimes when you tell the person who has been taking the drugs for a long time that basically you are dying but have to keep them aware of it. You need to give the information to them. It should be good if you did that in the health clinic and give them all the information based on their questions

Interviewer: And then let’s look at the guidelines, have you had the chance to look at the guidelines and protocols for RHD care, anyway have you had the chance to look at them?

Respondent: I haven’t seen it

Interviewer: No? Would they be important to you if you have some CME’s

Respondent: Yes, because it’s a common condition compared to the 5 case every day, the frequencies is not so much

Interviewer: Do you think you would utilise this guidelines?

Respondent: This protocols, ok first of all... In case you are interested, it’s in place, you prescribe the right medication to the right patient in the right dozes, so the prognosis should be doing way better

Interviewer: We are about to finish by the way, let’s look at the local health system do you think it is working for you here in lira hospital, what has made your work easy when you are treating maybe the patients, the RHD patients and the other patients, so what are the pluses for lira hospital that have made your work easy?

Respondent: well, we have good health workers, we have doctors, we have relations, we have detailed health care in place, we have the doctors, the nurses, the midwives, we have the support staffs and we also have the shifts in between, so when one person is maybe working, you don’t get fatigued easily, we have people to help

Interviewer: Meaning that staffing is fine

Respondent: The staffing is fine

Interviewer: Then the administration

Respondent: The administration, they are quick to respond to queries and also find out exactly what went wrong and if the patient died, what was the cause of the death and what has been done up to that point, you would be doing best that you could. In case we are having a lack somewhere, how can we avoid it so that that incidence doesn’t ever repeat, so that always goes out very fast and then the guidelines are not here

Interviewer: You told me that you don’t have them

Respondent: On the ward recently there was a project and they gave out guidelines but with the British national format, actually with the latest version of 2018/2019, yes probably we need to sensitize people on reading them, they are there but they are not reading it

Interviewer: Ok just in case you want to look at the patients file, maybe on ward, would you find it easy to access that file or a patient who was seen like a week ago and then you need to go back and look at it maybe the things that were given

Respondent: Yes

Interviewer: How have you found that?

Respondent: Personally, it’s very easy

Interviewer: It’s easy?

Respondent: Yes because am part of that process, so if am to treat and diagnosing and am the one giving the medicine, I have to ask. so there are times I actually consulted the doctor because I worked on the patient given some of the diclofenac, the maximum dose is 150mgs when the doctor gives 75 mg times 3 daily, so that is 75 mg excess that day, so I picked for the patient to come and see the next period to be able to come to see the doctor, so I called and asked, this patient you saw and you got this diagnosis and you gave this treatment, the problem am having down with the treatment is the 75 extra milligrams (mg), Was the pain so severe and why are you coming up with this ok, then he may tell you, it’s a shorter course than what is required, I hope its just for today and then you will try to change it to a lesser doze

Interviewer: Ok and then the funding for the health care, is that one working for you here especially for the RHD patient since we are looking at RHD

Respondent: If it was for RHD we would be probably scoring negatives because we have roughly four drugs laughs. Yes the two of them being in the same categories and then the other one being a single category but for the health funding, we are trying what we can

Interviewer: Ok and then a little bit back to the health workers, do you have any specialists in RHD management?

Respondent: None that I heard of but I know doctors not specifically for RHD

Interviewer: Let’s look at the perception of patients outcomes, generally do you think that they get the care that they need here when they come here? Do they get surgeries here?

Respondent: Yes they do

Interviewer: They do?

Respondent: Yes

Interviewer: Then for the RHD patients, can they access surgery here for those who fall sick

Respondent: Not that I know much about it but I don’t think so

Interviewer: You don’t think so, and then if you look at the quality of care that is given to the patients and their safety, what do you have to say about that?

Respondent: Well unfortunately by the time some patients arrive because most of the patients we have here are referred patients, that means they have been to the local clinics, probably they have guessed what their diagnosis is, some arrangements have been made on the drugs and they have paid for it, then the condition did not get any better, so they say, while we have tried what we can and the patient is getting worse and worse, just refer her to the hospital, so sometimes if not most of the time, there have been crisis management of what was given or the diagnosis they didn’t find, sometimes it’s completely the opposite of what was not completely related to what was done. So you have to rescue that and then you start a fresh, ok sometimes the quality of care is on and off

Interviewer: Do you have preventable deaths that have occurred here, the deaths that shouldn’t have occurred?

Respondent: Yes, the patients sometimes are referred too late and what we can do is simply move smoothly because it has reached to the point of no return. Yes like for one coming and the BP is already hyper and they are already vomiting, sweating and unconsciousness, basically the best you can do is to check their blood pressure but again hold their crisis

Interviewer: But have you had deaths that shouldn’t have occurred because of the care you have given here?

Respondent: Here if the patient could have been ours and he could have been on the ward and everything, the only reason we would probably have besides of course the natural cause, the person has already been distinct. Yes sometimes it is because of the belief system, even right now there is a patient on the ward, yesterday they refused, and the care taker refused the doctor to give the patient any medication for the whole day

Interviewer: Why?

Respondent: Because they don’t agree on the medication, the medication is apparently making the patient weak or worse, so in case you do something in that case, it will be of course the care taker who will definitely say you killed the patient or you made the patient worse. But remember the patient will be in the ward and you are trying to get the patient on another level

Interviewer: So how do you deal with such cases, is it common or it’s...

Respondent: Yes it’s not common but the ones that they will really give you a run for you money, they are staunch, so unless you really tell them sometimes, you have to remind them who is a doctor and why they are in the hospital

Interviewer: In the hospital?

Respondent: Yes, so in case you be on management on a daily basis, let us agree on a day, then you have no drugs because usually we have to sometimes start all over again, sometimes they may get complications

Interviewer: So, from what you have you have said like someone who has high BP, then they are coming, does that means that there are some people dying in the community honestly without seeking care in the hospital

Respondent: Some patients come to the hospital as a last resort, it has failed elsewhere, lets us try here, sometimes it’s always the users, we have the emergency unit but sometimes we have the emergencies in another unit, like commits an abortion and the stuffs ,the patient comes and like in the gyn ward, someone tells you that I had pain in the morning and they have showed up about 8:00 p.m., so you wonder, so the whole day, what were you doing, yes, so you ask and to hear that they have been taking the smaller herbs, then you start asking, ok, that is all, what are complications that you should have been experiencing, it should have been done long time ago and then you see they have showed up

Interviewer: And then in your opinion, this is the last question, which are the two most important things ministry of health could do to improve outcomes of RHD?

Respondent: Sensitise the patients and raise awareness because personally I don’t know much about it so I cannot imagine how much the community does know about it, then me as a medical worker, I don’t know much about it unless it’s a unique local, then they really need it too much, they will know about it but generally not so much about it ,so there is need to raise awareness, sensitisation then besides that, also on the drugs to treat it because the drugs that come, most of the treatment drugs are to treat hypertension also maybe because it’s very common but then RHD is not hypertension. So there may be a social distinction which may be solved much on their own if that is rectified, it should be fine

Interviewer: Wow, beautiful, thank you so much for you time, any question before we finish

Respondent: When should we get the guidelines?

Interviewer: You said?

Respondent: How can we get the guidelines?

Interviewer: The guidelines

Respondent: Yes

Interviewer: We shall leave that to our bosses

Respondent: Is there how we could maybe get it

Interviewer: No, we shall talk to our bosses because at least some of the bosses I think can do something

Respondent: Because we may not be able to get the hard copy unless we know

Interviewer: Thank you so much for that information, surely that is something that has been heard

Respondent: But the soft copies, some of us have the smart phones to grab whatever

Interviewer: She will give you the feedback with time because she is in contact with us, thank you so much