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

Interviewer: Today is the 18th Nov 2018 rather and we are seated here in the nurse’s room at LRRH. We shall give you 003, health worker 003.So doctor before we start, I just want to know more about you

How old are you?

Respondent: Am 30 years

Interviewer: 30 years?

Respondent: Yes, am an intern doctor in lira regional referral hospital?

Interviewer: And how long have you been working here?

Respondent: I have now worked here for two months

Interviewer: Two months?

Respondent: And I am here for one year

Interviewer: You are here for one year?

Respondent: Yes

Interviewer: Ok and so when did you qualify, when did you finish?

Respondent: I finished in 2018

Interviewer: In this year?

Respondent: In this very year

Interviewer: 2018

Respondent: Yes 2018 may, in May 2018, that’s when I qualified from Makerere University, college of health science

Interviewer: Congratulation

Respondent: In Bachelor of Science in medicine and surgery

Interviewer: ... did you go for the party

Respondent: Our graduation will be on January, around 20th January and everyone is invited

Interviewer: And ... will be number one

laughs, ok, good to hear that and then let’s look at the demographics of the patients that you see, what are the common illness that you have treated since you came in?

Respondent: Since I came in?

Interviewer: Yes since you came in

Respondent: Since I came in, right now am in the main medicine ward, but I also go cross to the female medicine ward and sometimes at the emergencies, yes to look at the distribution, disease distribution, I see more of liver disease in the elderly people, liver disease is very common, hypertension, PUD also being very common but in children I have noticed RHD, RHD is one of the problem in children and sickle cells disease, those two stand out

Interviewer: These two stand out?

Respondent: Yes, in children although sickle cells is more but we have seen common cases of RHD in children, actually on my very first day here, I got a child with RHD and I was running around to see how to get help then I had to do echo, I had to do what..., those things are not done here at the hospital, then I noticed there was a project here that was doing that and that helped

Interviewer: Ok good

Respondent: But subsequently I kept getting in touch, but common among children

Interviewer: Which other age group do you see with them?

Respondent: RHD?

Interviewer: Yes

Respondent: RHD in early adulthood, I have seen it in 22, twenties early, I have not seen it in the elderly, middle age adults, I have not yet seen it there

Interviewer: You have not yet seen it?

Respondent: Yes

Interviewer: Ok, before we get there but we are just on track ok so let’s talk abit about the, your RHD training and management, have you received any training during school?

Respondent: At school as one of the topic

Interviewer: Yes

Respondent: In internal medicine

Interviewer: Yes

Respondent: We went through many cardiac conditions like RHD was one of the Topics, that we came across, also during the affluent prayers, we would actually come across patients

Interviewer: The patients?

Respondent: And we would be taken through but not as a special course or a special training but the knowledge I was using was basically what I came with at school and then with the help of my supervisors around but am not trained in the disease in particular

Interviewer: Ok so does that mean that after your graduation, you have not yet had any training?

Respondent: After my graduation of course I haven’t

Interviewer: Not yet...

Respondent: I had a period of about 5 months where we were just waiting for internship, you get it, in that period, there were trainings with the ministry of health which I went through but the one I went through was something to do with haemorrhagic fever, Ebola management, Marburg and the rest, those were our training CBC infections control

Interviewer: Right

Respondent: Yes

Interviewer: So you have not had any training on RHD?

Respondent: But on this, no...

Interviewer: Ok

Respondent: Not yet

Interviewer: And then in a day, how many RHD patients do you normally, typically see?

Respondent: If am to say in a day, on average I can say maybe one

Interviewer: one?

Respondent: Yes ok so where I am, I can see only one, so in a week, you could say maybe 3 also

Interviewer: And then are they usually outpatient or inpatients?

Respondent: They usually come as referrals from health centers, you know if their symptoms worsen, they have tempted to be treated and they fail

Interviewer: Hmm

Respondent: But when they reach here, we actually realise they don’t come with the diagnosis of RHD, they come, they come with you know somehow being managed with malaria, malaria but not the coughing, respiratory tract infections, they come when they are badly off, doing badly so they come here, so it’s usually from here that we notice, we are dealing with RHD here.I have not yet received a patient who has come with RHD as a diagnosis from down

Interviewer: You have not seen?

Respondent: From the health centers, usually we discover from here that we are dealing with RHD

Interviewer: So what are the normal, usually which symptoms do they present to you when they come?

Respondent: They usually present with high fever, you find they usually come with high fever, tachacicadic, you know breathless, some of them are in failure already, heart failure already with difficulties in breathing, not so much coughing but with difficulties in breathing, you know with heart failure with its symptoms, difficulties with breathing and some cough there but yes, also some of them with articulation

Interviewer: Ok and then let’s look at what you have been taught, what is your understanding of this disease? RHD?

Respondent: From school, my understanding right from class is that RHD is haematological related and to begin with what professor used to tease us was that this problem is the problem of the third world countries, yes, it’s the disease of the poor, they get respiratory tract infection and they may get neglected or don’t treat it aggressively and they end up getting the problem, the problem comes from what we call a genetic mimicry, the organisms usually streptococcal, that has the ability to induce the immune activity in the body, that immunological activity may result into the formation of anti-bodies against the organism, however these anti bodies or the organisms, they target, these targets on the organism may resemble some structures of the body system, one among them is the valves, could be the kidney, can be the joints, so at the end of the day, these anti bodies end up attacking both the organism and the body structure, therefore leading to RHD,with all its symptoms

Interviewer: Ok and then could you be, are you aware of the link between the sore throat and RHD?

Respondent: Yes, usually because the streptococcal is always along the respiratory tract, so it starts with the throat, it starts with the throat, if not treated well with proper anti biotics, it can translocate into the circulation, then from the circulation the issue now starts in the immunological relations

Interviewer: Were you told about how to prevent RHD

Respondent: Yes, we got to know that sore throat should not be treated, you know reluctantly, it must be treated aggressively with proper anti biotics but given the system oh...of course we would, we would with a sore throat, and we would think of sore throat, we would do microbiology of the cell but usually treat our patients systematically here die to exhaust irritations, we can do the microbiology test to find out which organism exactly we are dealing with, then we must prefer ah... broad spectrum anti biotics could be good like broad spectrum respects anti biotics say amoxixaslin clastic as to be able to cover maybe as our first line but like I told you in my first statement, it’s the disease of the poor, in most cases these drugs must be expensive, a little expensive and people just end up with the local herbs and they think it can go with that, then they end up being a problem

Interviewer: Do you know of any local herbs that people around here normally use for sore throat?

Respondent: Here they normally tell me they boil, they boil lemon leaves, then squeeze in it also the lemon,make some coco just to try and sooth the sore throat and cough of course I don’t know if it works for them but it just seems to me as if they end up with us to the hospital

Interviewer: Do you usually get patients coming in with sore throat? Is it a common tradition that is here?

Respondent: It is not, it’s not usually for patients to come complaining that they have a sore throat, they come when maybe I don’t know maybe because this is a regional referral hospital, they become when maybe its pneumonia, they are coughing badly they come with difficulties in breathing and they have tried with their cough elsewhere, it has progressed away from sore throat

Interviewer: So why that sore throat is is not taken like seriously?

Respondent: One, I think people have many problems that they try to ignore health conditions, they would want to try and pay attention to other things, they start paying attention to health situations when now the condition is worse but usually I think, I think according to their responses because usually we get patients when they are very sick, they come here when they are really very sick and when you ask them, they tell you how they have spent a long time home without getting help .one of it is not attaching much care or concerns to health but also the issues of economic problems but in most cases when you ask them, they tell you they come from very distant places, the distance from where are residence to the hospital usually it involves costs to transport themselves, am sure it’s one of the problem.

Interviewer: The issue u know going to the health Center and you don’t get the drugs, these drugs they rarely just buy, sometimes they don’t get the drugs also available in the hospital day and they get reluctant to go to the health Center or to seek care but if you don’t have the money and you know you are going to hospital and what you need is not there, sometimes you end up trying local herbs, they delay to seek care

Ok and then talking about drugs, if you look at this facility here in the hospital, how are stocks?

Respondent: Stock for RHD drugs, antibiotics are available, we have anti biotics ciproproxline are available. when it comes to others because when it comes to RHD, you are going to have cardiac issues you are going to have issues with inflammation, So there is too much limitations in terms of the availability of drugs, drugs are very limited, very, very limited like if you look at the management, you may need a steriat, you may need a steriat to manage to clear the patients, I have not at any time ushered a steriat since it’s never in and they are usually not in stock ,Asas you might just need an Asas or aspirins, also its always out of stock because those are the first line drugs that get always out of stock, I don’t have the explanation for that but they are usually not available

Interviewer: Stock out!

Respondent: They are always stocked out, of course if you want to handle, if you have issues of cardiac that you want to do, you are limited to a particular formulation, if you want your, I you want your... if you want your Vito blockers, you may have only eplocanol available other than these kind of drugs are still a problem here, when you are to manage RHD, you need a whole package to manage this situation, so they have to buy, you have to ask them to buy and there become is a problem, go buy they will tell you they shall buy, you come back, and they have not bought No money to buy, the patient is detoriating, the joints are getting inflamed, the deformities are beginning, you get it! The fevers are running high, you, you try with your anti biotics, you try it but inflammations are flaring, you get it! So it’s a challenge

Interviewer: Now what can we do?

Respondent: Now I think it start with how to empowering people economically would be the way to go but of course it’s a long, long way to go but in like a short term, arrangement maybe you would encourage that the hospital be stocked with all the necessary drugs because they are not even very expensive, somehow in most cases like if you want a steriat, usually like cortisol steriat, they are not usually very expensive but you find this people are already broke, they don’t have money to buy so we can stock them ourselves, vendecine of course is there, vendecine penicillin but it’s also out of stock in most cases, it’s also not expensive out there

Interviewer: Ok, thank you. How, during your school years were you taught about the treatment option for RHD, of course I have heard you talking about the drugs

Respondent: Yes the different options?

Interviewer: Yes

Respondent: You see we were taught ,of course we answered those questions, we know the root cause now, we want to attack the bacteria, of course now in the heart the bacteria is not there, it’s now the anti-bodies against so we give vendecine peroxylaxis monthly dozes of vendecine depending on the ages, of course now we treat the symptoms that are coming with these anti bodies deposited, yes we can deal with the bacterial infections with anti-biotic broad spectrum preferably with penicillin best interactors and then we deal with the inflammations caused by the anti-bodies. we tend to, since we know there is anti-body production, we want to supress that process so we use cortisol steriat to suppress them and give ASAS for inflammation and the fevers we try to bring it down to respond and if there is candidiasis, we go and give them, if there is a heart failure, we give them heart failure arrangement inter blockers Castrol blockers, so that we try and lower the pressure and also reduce the heart rate

Interviewer: Ok, thank you, so what is your understanding about the long term prognosis of RHD? , looking in your own understanding

Respondent: My own understanding is that if managed properly and effectively progress is good, prognosis is good, we can reverse the articulation, we keep giving them this anti- inflammatory, the cortisol steriat also for some times, also as we do physio therapy, they will always get up and with our monthly Benzathine Prophylaxis, we try and prevent the organisms from continuing to grow. yes they probably, the Benzathine penicillin, yeah, the prognosis is not very bad if managed early, if the heart, if the heart is not badly affected but of course if we delay and the valves are now badly damaged the heart is badly damaged, then the prognosis might not be good because it might involve that you do valve replacement or transplant which is not a good thing, it depends on when you come in and how far the extent of the damage to the heart valves

Interviewer: Ok, wonderful! Then let’s talk about the encounters with RHD patients, do you remember the last patient you worked on and how long you are...

Respondent: Right now I still have one, I think I have two, Right now on the ward, you saw it’s still a fresh thing

Interviewer: Yes

Respondent: And I expect anytime

Interviewer: Yes, give us a picture of how these patients presented and ...

Respondent: These patients presented at emergency department with a very high fever, uncontrollable cough, and cough with joint pains, generally weak so at the emergency, the person who was there made a diagnosis of pneumonia and the patient was actually referred with pneumonia. So being on the ward, I received the patient and he is actually 15 years old and they were coughing, they were breathless and I immediately first put him on oxygen, then when I started my clinical exams. I saw this patient was remitting a joint criteria for rheumatic diagnosis of RHD, they already had ah...hydratory hytheritis with even spinal deformities, very high fever, the cicardia, the heart murmurs were already there, so I called for help as I told you, echo here, we don’t have as a hospital, so I came, asked for help from the project. Then we did the echo, first we did a throat swap, the rapid test was positive, so I knew I was on the right track, echo was also significant yeah so then we sat up together, we started the treatment, and the patient started improving. Now he has improved, what he is left with is the physio therapy not yet, what am left with is the physio therapy then I discharge him

Interviewer: Ok, good to hear that. then, so you said you mostly see children with RHD

Respondent: Yes, Mostly children like between 10, ages between 10 and 20

Interviewer: and 20?

Respondent: I have seen most of them. I think there was only one who was less than 10 years because night duty is always long but mostly between 10, I can recall 3 with 15 years, 14, and 15

Interviewer: Ok

Respondent: Yes

Interviewer: And then could you be knowing if they were in school or out of school children

Respondent: They are in school children

Interviewer: They are in school children?

Respondent: They are actually in school children

Interviewer: Ok and then do you think they know the link between sore throat, acute rheumatic fever and RHD

Respondent: That is where there is a problem, there is so much knowledge gap in terms of health, they don’t know, exactly they don’t know at all, When you ask them, have you ever suffered a sore throat? They will admit it to you, did you treat, no it went, it went but now finally am getting cough again, yes but there are knowledge gaps. It’s somehow the knowledge gap, they don’t have that knowledge

Interviewer: Ok, and for them, what symptoms do they describe to you when they come?

Respondent: For them the symptoms they describe to me is the joint pain, general body pain, they say general body pain and stiffness in the body, stiffness in the body with swellings, yes and cough of course fever is getting high, they try with anti biotics and then they go down and being breathless, failure to breathe

Interviewer: So generally are they following their follow up and adherence to the things you tell them to do and the drug taking?

Respondent: The follow up according to me I think its zero, there is zero follow up according to me, ok as me , I have never tried to follow up because, we need the scope of plans, so and I don’t know whether there is follow up elsewhere

Interviewer: But do they adhere when you talk them

Respondent: Then adherence, we try and encourage them at the discharge to try and adhere but I can’t ensure, I can’t know what happens when they go home, especially that these drugs has to be bought, so I don’t know, you write but I don’t know whether they buy it but I think they buy it because I have no seen re-admission yet in this period of two months, I haven’t seen that

Interviewer: You have not seen any re-admission of RHD?

Respondent: Yes

Interviewer: So what sorts of barriers do they commonly state, barriers to getting care that they need, what do you think stops them from accessing the care

Respondent: The barriers start with the economic status, distance from where they stay to the facilities and then you know poor economic status, funds to put into transport, buying drugs and the availability of drugs in those centers is another problem. In those centre they have very, very limited and they get out of their stocking

Interviewer: And then when you are discharging, am sure there are certain things you tell them to do or not to do

Respondent: Yes

Interviewer: Right, do you think they obey them?

Respondent: They rarely, they are but you see laughs. I can talk to you, most of the patients have been found to be patients of the very low class status. Even their ability to comprehend the information is very little, their ability, their capacity to understanding what you are talking about is very, very limited because before you choose, and you decide to discharge them. They want to go home, yes I don’t but you try to explain to them because we want since the ailment comes with articulation problems, it requires continuous you know physio therapy, rest and prophylaxis treatment, yes, continuous treatment of any other symptoms that comes like I told you the knowledge gaps like their ability to understand. I have not tested it, I have not gone to do research to find out whether they adhere to some of these but in my own thinking, in my opinion, I think they neglect, they don’t get, they don’t find time to pay attention towards this disease.

Interviewer: So when you give them appointments ah... I don’t know if you have given some to come back maybe you have been here for two months?

Respondent: Yes, 2 months

Interviewer: 2 months? Have you had to give any to go back for appointment?

Respondent: Yes

Interviewer: How was the turn up, did they turn up?

Respondent: Yes fortunately they come back

Interviewer: They come?

Respondent: Definitely they come, if you stress to them the importance of what you are telling them, they come back, you write it on their discharge form,

Interviewer: You have just answered what I was going to ask that why do you think they come back for their appointment, so it is stressing of the ...

Respondent: It’s the emphasis

Interviewer: emphasis that you put on?

Respondent: Yes

Interviewer: If you attach a lot of emphasis?

Respondent: Yes

Interviewer: They will come back

Respondent: Yes they will come back

Interviewer: What else do you think motivates them to really come back?

Respondent: To really come back?

Interviewer: Yes

Respondent: You know the horrific status you find the patient usually at the peak of the disease, they get helpless and you think yes, we are losing the patient and now seeing this patient come back to life and able to live, walk, I think that also sends signal to them, so they want to listen to what we tell them to come back

Interviewer: So when they get better, then they are encouraged to come back?

Respondent: The only thing I told you, yes, they are encouraged to come back, the only thing I am not sure about is the day today information you give them that daily dozes do this, give this physio therapy, give these drugs, go buy them that is what I don’t know whether they do but come back, they do come back

Interviewer: So those that come back, have you encountered, why do you think some people don’t come back for their appointment?

Respondent: Sometimes I think because of transport issues

Interviewer: Transport issues?

Respondent: Yes, issues of no money to transport the child and even when they are here, they try to make call to fund their bills, what they eat and some drugs they buy, so at the end of the day when they get back home, it becomes a challenge given their status, I think that is one of them. I don’t want to attribute it to the negligence but I think I want to attribute it on the capacity to come back and take care, that is why am telling you that even the day to day care, I think it becomes a challenge because I think there are usually large families out because now others also have to eat, what to drink and other basic needs. They tend to ignore health issues, so basically and the late presentation in the hospital

Interviewer: You said they don’t really take health a priority that is why they come and present late?

Respondent: Yes, because I think they try local remedies, because they try chances, they give it to chance, they delay to present and probably shared negligence to health related issues might also be one of them and then also the ‘’big animal’ ’poverty, poor economic situation that is eating us

Interviewer: That is eating...laughs

Respondent: Yes

Interviewer: Ok and then let’s look at the local health system barriers here, what is not working for you on your side here in lira hospital, you want to do this but you are let down

Respondent: sorry to say this but investigations are so limited, investigations are so limited here in lira hospital. Investigations are done outside the hospital from private settings and yet we also discovered that not all private facilities give correct results from the investigations, so you can’t investigate properly

Interviewer: So you said that you don’t have, you don’t have a ECG machines?

Respondent: Now here if I am to point out, the only thing here is the ultra sound and x-ray. for a CBC you can’t, I can’t do a CBC within, we can’t do echo, I can’t do CT, I can’t do...of course CT is now too much to ask but I can’t do a CT,I can’t do any electrolytes, you get it! I can’t do any microbiology related investigations. You don’t think of a culture or of chemistry or any other things, I don’t think even just of a gram stain of course I can’t analyse urine laughs, so I don’t know why those challenges are persistent but that is the picture, what I can only do is an x-ray and ultra sound, those two are not enough to investigate the patient and they are far from helping the patient, so that’s one of the barriers, another barrier to help would also be the series of those I listed. Being a regional hospital, people come from very far and when they come here, they find it hard to maintain themselves, you want to keep the patient but the attendants have nothing to eat, they have nothing to help them, so that becomes also a barrier, that becomes a barrier coming from the side of the patient

Interviewer: ok

Respondent: Patient’s side

Interviewer: In Mulago, patients gets some food, Are patients here given food in the hospital?

Respondent: They are not given food, food is not there

Interviewer: There is no food, you are to cater?

Respondent: There is no kitchen working because even me, I don’t eat food here

Interviewer: laughs...even you, you don’t eat food?

Respondent: laughs...

Interviewer: laughs...I thought it was across because like in kawempe where I work, you get food

Respondent: We don’t get food here, we have been trying with the director on that, we can’t be hungry

Interviewer: So when you look at funding for health care

Respondent: Funding for the health care I think it’s still far below the belt, funding for health care is still below

Interviewer: And then for RHD care?

Respondent: For RHD care becomes very serious, indeed it turns out to be like a luxury, they will not because if they cannot provide those others, food and the rest, singling RHD might be a long way to go, for health, for the hospital and for the ministry or for the budget ok, to take care, it will be a challenge, to me i think so unless your justification but I see it as a problem

Interviewer: And then let’s look at the administration, how do you look at it?

Respondent: Administration, I have not paid much attention to the issues of the administration much in this period of 2 months. But so far I see administration is there, there is no gap, I don’t see the gap because I see the director is around, all the offices are occupied ,the SPNO is there, the heads of departments are there ok so they can be there. What happens in the administration is not just people occupying the offices, work going on and that is a sensitive part that someone had to talk about

Interviewer: So in case you need something to ease your work and you raise the issues to the administration, what is the response?

Respondent: What was the response? The response is simplified to lets work within our means, its simplified to that level, just we use what you have available, what you don’t have, patients can go do it.if they cannot, if the miss schedule are not within, you refer to the national referral and that’s why we can refer patients just for INR to Mulago with far bleeding issues

Interviewer: Ok taking it to a higher level leadership within the district do you see any concern for the health issues?

Respondent: At the district? Yeah, at the district I have not yet broadened my...,I don’t know because I have only been here for a short period of two months, in a short period of time to know how they engage at that level. I have not yet taken time to study their engagement and development about our matters

Interviewer: How about health information system, medical record system at this place when you look at it, is it working for you?

Respondent: Yes, we have a record office, let me show you how it flows, we have an outpatient, we have an emergency department, so from the outpatient for these requiring emergency, management and possible admission, they come, they open for them a file from record office. Now at the record office, all patients’ information is kept there, it’s usually hard copy and I think digital computer

Interviewer: You call it digital?

Respondent: I think they have a computer system

Interviewer: Ok

Respondent: Where they keep some information about the patients, what I know is we have a record office where patient’s information are

Interviewer: Just in case I wanted to go today and I just look at the RHD that they saw from January- November, will it be possible to get the information?

Respondent: That needs a trial, we need to try the system, I need..., I haven’t checked but I need to find out like I told you, office can be there like this record office but that does not be the thing there but the activity there, are they going on, are there, is there capacity to do the right thing, are people doing the right thing, that detail I need to find out but for the structure, the organogram, I see the structure is there, I don’t know whether it’s giving, its doing what it’s supposed to do

Interviewer: Why I’m asking is because we find some health facilities, you just reach there and then you have the boards

Respondent: Boards?

Interviewer: Statistics

Respondent: Statistics of this...you are right, those statistics, that feedback, that information is not available, you cannot go to my office and you are able to see on boards the disease patterns or distribution of the disease and easily. I don’t know whether that information is at the records office but at my level, it’s not available

Interviewer: Ok, do you have, could you be having guidelines and protocols for RHD care here?

Respondent: Not yet

Interviewer: Not yet?

Respondent: Not yet

Interviewer: Do you have CME’s here?

Respondent: We get here CME’s

Interviewer: Have you attended any of the RHD training?

Respondent: Not yet, the CME’s we have attended are mostly to do with gyne, to do with gyne issue and other emergencies, RHD not yet

Interviewer: Not yet ehh...? Will you find them important if at all?

Respondent: Yes, it would actually be very important to give capacity to health workers, start with the health worker capacity to have knowledge on how to manage it and also how to maintain the patient. After the treatment, how to keep the patients, it’s very important if we could have the training

Interviewer: So would you go for having the protocols for RHD and guidelines?

Respondent: Yes, but do you think, I would go for if you asked me, I would go for CME’s to create, to increase, to raise these people’s suspicion index, you need to raise these people’s suspicion index because I have found, I told you of one who went through the emergency department and reached to the ward and he was getting treated of pneumonia without anyone thinking of RHD, that shows the knowledge gap, so you raise the suspicion index then you bring the material for people who already suspicious of the disease or is aware of the incidence of the disease. Then materials will help, so the protocols are there, how to manage, the outcomes and how to advise these people subsequently after hospital stay, now at home, how they should take care of themselves, home care and the rest of it, those ones now would benefit those who are already with the highest suspicion and are knowledgeable about this disease.so if you asked me, CME’s first then eventually protocols and guidelines, would be coming

Interviewer: Ok did you talk, do you have ah...how are your stocks for heart failure drugs, anti-coagulations drugs and then the BPG

Respondent: Heart failure drugs especially congesting heart failure?

Interviewer: Yes

Respondent: We have stocked phroximide, we are stocked with phroximide but that goes along with spironatol but when it comes to hypertensive drugs, they are usually not available, they are out of stock. I have always, a part from propanol as the inter blocker, the rest they have to buy

Interviewer: Why do you think that it’s always like that?

Respondent: I don’t know, I don’t know, I think, I think it still goes back to the budget allocations to help, most of the drugs we have are for the basic care, basic care, you know for the serious treatment, patients have to go and buy,

Interviewer: And buy for themselves?

Respondent: Yes, for instance the hypertensive drugs are hard to find in the pharmacy

Interviewer: In pharmacy?

Respondent: In the hospital pharmacy, it’s very hard

Interviewer: So looking at the system here, the local health system here, what has worked for you?

Respondent: What has worked for me?

Interviewer: And why?

Respondent: And why

Interviewer: Yes

Respondent: Ok, as like I told you, as an intern doctor, what has worked for me is my working relations with the senior staffs and the supervisors, it has worked for me because I make decisions that are verified, some cases corrected and for me that works for me and also the drugs for basic needs are always available, in most cases, they run out for a short while the deliveries are made, when they are made, at least they are sure of having basic needs which are substantial to buy anti biotics to start with as you think of out there yes and space because with that space you can do your work

Interviewer: Ok for the things you have mentioned, what has worked for you?

Respondent: At least after basic education, the relations with the staffs

Interviewer: How about the numbers, are you comfortable with it

Respondent: Ohh! That is one of the thing that has not worked for me, the number are soooo big but with limited staffs and so ok,the numbers are very big, yeah and the staffing is small so the patient –doctor ratio is very small, sorry, it’s so huge, the other way round, the numbers are big

Interviewer: You said there is a gap in the staffing?

Respondent: There is a very big gap in the staffing

Interviewer: Where specifically?

Respondent: Especially the doctors, the number of doctors is very, it’s really very small, the nurses can be there, they get help from the nursing students, they can administer drugs but when it comes to the real clinical care of the patient, you need a doctor’s hand on the patient and you see when the numbers are big, you try to reduce on the number of time you spend with the patients and that causes a lot of problems in terms of making effective diagnosis and care to the patients, so you try to distribute your time to many people, you see this one briefly, they talk to this one faster, faster, you pick what you can do to save them, you start with urgent situation, you be with them, you don’t pay much attention or give enough time thoroughly to get the information that help the patient out of the problem leading to a longer stay in the ward

Interviewer: So in case of the RHD that are ..., have you ever referred any?

Respondent: I have not yet referred RHD patient because the ones I have managed, I have been able to discharge, so I have not yet

Interviewer: So do you have any guidelines in this on how to refer them?

Respondent: I haven’t gotten the guidelines

Interviewer: No guidelines?

Respondent: I am still using my piece of knowledge

Interviewer: Would you find them important

Respondent: Very important, very important to have these guidelines because you know guidelines help in simplifying on time you take thinking of what to do in this situation, you just have the outlines there and then you tailor the information very accurately to the patient, also your approach is well tailored, it guides you

Interviewer: Do you feel satisfied with what you went through?

Respondent: It is a struggle, it’s still a challenge

Interviewer: You know why we even ask the health workers this question

Respondent: Yes

Interviewer: It’s because it will require an integration just in case ah...the health workers thinks they are giving enough care, laughs, time and the other side the patients cannot

Respondent: If I cannot do a follow up, echo, I cannot do follow up, ECG’S, i cannot do you know do those other investigations to make sure the patient is out of danger then what is my right? I can’t be satisfied that I have done enough. I only base on the symptoms, the resolutions of the symptoms, ah... you go give us space

Interviewer: Can patients access surgery here, RHD patients?

Respondent: No

Interviewer: It’s not done?

Respondent: No, this is a referral

Interviewer: laugh

Respondent: You can IO’s, sometimes we can have a dysfunctional theatre and cannot do IO’s here

Interviewer: laughs

Respondent: We have not touched the heart valves, so it’s far, it’s far from that

Interviewer: Do you think there are some deaths here which occurred that surely would have been prevented?

Respondent: Very many because sometimes we can have very many cases that patients die of anaemia because we don’t have the blood bank. Patients die because they cannot afford the good antibiotics to...I give anti biotics to treat them, patients die because doctors sometimes are out of the station

Interviewer: Ok last bit that we are looking at, let’s look at the perception of the patient’s outcomes, generally do you think they get the care that they need here?

Respondent: We struggle with that aspect, patient satisfaction like I told you, you are the only doctor running around, the patients are looking at you, the whole day you are there you don’t have time to see them, after maybe after one day, I think patients satisfaction is lacking’ I don’t think they are satisfied

Interviewer: They are not satisfied?

Respondent: But as long as the symptoms are resolved they will feel happy.

Interviewer: So do you feel that they get the treatment that they need before they go away

Respondent: They get the basic

Interviewer: laughs, they get the basics?

Respondent: laughs, they get the basic treatment, I think they are not getting enough treatment that they deserve, even if they get it ,they delay in getting it but at the end of the day ,whatever they get ,it is helping them to go home

Interviewer: Ok, so what do you think causes it?

Respondent: That question actually would be best answered by those patients

Interviewer: By the patient?

Respondent: Yes, do you think..., do you feel, that is a perceptive because for me now, when I see you, yes, you are good enough to go home. I think you have gotten already what you need but the feedback should also be there and the drugs are available or nurses are not available to extend to the immediate needs of the patients, patients die because the required drugs cannot be found anywhere within like I had similar case, a severe hypertension, hypertensive crisis patient who could not get glabeterol IV and we could not save him immediately or even night hour, so there are so many deaths that would be prevented

Interviewer: That would be prevented?

Respondent: Preventable deaths occurring but not to allow, we try with whatever we have to save lives

Interviewer: How about the patient’s safety, do you have any concerns about their safety?

Respondent: Safety is broad, is it security, or it is health?

Interviewer: Yes in health

Respondent: How they are managed, the safety I would say provided the doctor is available and the doctor is knowledgeable, the patients are safe. For now I would think really that the patient are safe that is the reason they kept coming, flocking because they go back discharged some of them, the safety is...i think is at least above the belts, its abit fair, they feel safe

Interviewer: Ok, do you think that there are some patients who have died in the community without even stepping into the hospital?

Respondent: There are some deaths of arrivals, it is also in big number, I have also realised that private clinics admits patients when they see the patients are about to...they are failing to handle the conditions, they send patient here to die, they delay them in the private hospital

Interviewer: How about the RHD patients in particular, do you think they have some...

Respondent: RHD’s I haven’t, I haven’t heard of death on arrival or death due to RHD yet in this period of two months or maybe as time goes on but not ,I haven’t

Interviewer: what is your opinion? Give me two most important things ministry of health should do to improve on RHD outcomes

Respondent: Two things! RHD must be considered as a priority, it affects the young people, it affect the young generation and given that the country is aware, the larger population especially the upcountry is a poor population, once we attach that kind of importance to the disease, then we attach the budget specifically for RHD and when we are attaching the budget to the RHD, It means we start with the investigations at the hospital level, we should be able to investigate fully so therefore we must have all the services to investigate and then treat, stabilise the patients, so we look at the arrangements required, the drugs that we need for RHD and therefore that means we will have a department but RHD problems or cardiac issues or RHD finally where we can make it greater but not that it’s stopped, so that it is about within internal medicine that handle the disease, that is on the side of the government but also on the side of the health workers now, you asked for two right? , you need to empower, we really need to empower the health worker’s ability to manage RHD clearly without fumbling so that the diagnosis should be as fast as possible, I told you the prognosis would depend on the extent of the damage to the heart valves if this patient is really to do well, to overcome the world, the damage, the joints and sometimes it can even damage the kidney, so the capacity to diagnose requires the vicious circle of training of CME’s and protocols, then you will be able to manage

Interviewer: Last one, how about the other conditions, when you talk about RHD, how can we improve the outcomes of our patients

Respondent: On a broad scale, it’s largely a political will to attach all then budgets and importance to health must be prioritised, healthy community is a wealthy community, yeah so with that concept, it should start from the budgeting, the Maputo protocols of 15%,really was it Maputo or the Nigeria-Abuja, I think it is read by Maputo conference attaching 15% of your GDP to health is one thing that will address the insufficiencies in terms of facilities to use, to investigate, to treat, to counsel, to staff, to staffing all that requires a budget, you get it! Then now supervision, we need supervision in those hospital and supervision should not only be internal because internal can easily get compromised ,supervision should also control out, people should know that anytime supervisors and external supervisors can come and they want to know what is going on and people can be punished if found on the wrong side, so with budget on and the supervision ,because budget will address many things but if there is no supervision also, you will be sorry on the rock, both laughs...

Interviewer: Ok thank you so much for those ideas, we are going to put all these together with the rest we have got from other health workers and other groups and then we shall definitely forward that information to the concerned people to see how our patients are treated better and those who are not yet patients, then they gladly Care for our patients, any questions before we close?

Respondent: I was reading through the concept yes the project, this is a project?

Interviewer: It is a research

Respondent: It is a research project?

Interviewer: Yes

Respondent: How long is it?

Interviewer: We have two hands, she is directly handling quantitative and the qualitative is on, it might go on because we have four district to cover, we are going to Mbale, we are going to mbarara, we are going to Kampala and we have stared with lira, so we might run for the next one year and a half

Respondent: So when do I get my feedback because it says that there will be a feed back?

Interviewer: We will give feedbacks in case there are findings, new findings that would be having an impact on your work

Respondent: Ok

Interviewer: So that comes after we have analysed all the data

Respondent: That is after one year

Interviewer: laughs...one and a half

Respondent: One and a half?

Interviewer: And we shall disseminate the information, am sure when we are doing that we shall call your representatives

Respondent: That is ok

Interviewer: Ok and also use the publications to disseminate the information

Respondent: Ok

Interviewer: Thank you