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

Interviewer: So today is the 9th of November 2019 and we are seated at the doctor’s plaza and we are interviewing participant WH006. Okay, so thank you for giving this time to talk to you. Just to remind you a little bit is that we are looking for different ways we can improve care for our RHD patients and there are no right or wrong answers, what we are interested in are your views. So we ask you to be frank and share your opinions with us. Your data is going to be kept confidential like we told you and we are not going to link your identity in any of the reports we produce. Can we go ahead?

Respondent: Yes please. It’s okay.

Interviewer: Can you tell me a little bit about yourself, how old are you sir?

Respondent: I am 35 years.

Interviewer: And what are your qualifications?

Respondent: I have PLE, Senior four, Senior six, Bachelors, masters and Masters in Internal medicine and a little training; minimal training in cardiology.

Interviewer: Okay. Nice to meet you.

Respondent: Nice to meet you too.

Interviewer: Okay, so where did you train from?

Respondent: In Mbarara University

Interviewer: How long ago did you qualify?

Respondent: For a doctor, 10 years ago. As a specialist physician, 6 years ago.

Interviewer: Wonderful. So when you look at the demographics of the patients in your practice, what are the common illnesses and who are these patients you see?

Respondent: Well it’s hard to tell but they are so many patients. Well, for me in my line of specialism I tend to see more of non-communicable diseases although when I am doing general, I see a lot of HIV, malaria, streptococcus, TB. But in my area of specialization I do a cardiology clinic, so I see a lot of heart failure, hypertension, RHD and diabetes.

Interviewer: Okay. Wonderful. So by age group which is the ... ?

Respondent: By age group the majority I see are in the youth bracket and a few elderly ones. Especially for the non-communicable diseases, I see elderly ones with heart failure and hypertension. But for these other diseases of RHD, they tend to be any age but majority between 20 and 40 years.

Interviewer: 20 and 4o, for RHD!

Respondent: Yes but I have seen elderly with RHD.

Interviewer: Okay. Then those ones with RHD, are they school or working. The majority.

Respondent: The majority, I cannot point majority because I would have to have figures to know whether it is the majority, but I can say many of them are in school and also a good number are not.

Interviewer: Okay. So let’s talk a little bit about your training in RHD; have you received any specific training during school?

Respondent: Yes, I received training during a cardiology fellowship about RHD, and I have run with colleagues RHD clinics at the heart institute and also here. So that’s the basic training that I got.

Interviewer: Wow, that’s good. So where did you train from?

Respondent: Like I told you, Mbarara University for Bachelors and Masters. Then I went to Uganda Heart Institute in Kampala where I studied most of the RHD knowledge that I have.

Interviewer: So how often do you see RHD patients? Is it per day, a week? How many can you say in week?

Respondent: In a week I see like 2.

Interviewer: Like 2. Do you see outpatients or inpatients?

Respondent: Yes, most of them are outpatients.

Interviewer: Okay that’s good. So I am interested in what you were taught, what are the causes? What do you understand to be the causes of RHD?

Respondent: I understand streptococcus to be the cause of RHD and I also understand that it comes usually during early childhood like 3-5 years, teenage; early exposure to sore throat. So what I know is that the sore throat usually the one which is streptococcus maybe treated insufficiently or maybe go away on its own but there’s an element of molecular mimicry. Like to simplify it, the immune system of an individual will recognize with infection and try to fight it, but what I might call a body accident; the body will also produce a mechanism which will target other organs accidentally. So mostly, it will target the heart valves. Remember it was trying to clear the sore throat but many years later, the immune response attacks the valves of the heart, but it can also attack the joints and brain. So that’s what I know as the cause.

Interviewer: Okay. So you have answered my next question, I will not ask it. So what can done to prevent RHD?

Respondent: Quite a lot of things but the first one is to promptly diagnose and treat sore throat and treat it adequately with penicillin. But that is treating a case, and then the other thing is to prevent cases. One of the things is to avoid overcrowding of our children especially kids at school; nowadays they crowd in one room like this one. You find like 20 kids in a dormitory and if one has a sore throat and it is contagious and they will all get it. So reduce congestion and reduce poverty levels as well because if there was no poverty, children would be brought for screening for sore throat but because of poverty, they don’t.

Interviewer: They don’t bring them!

Respondent: Yeah

Interviewer: Okay and then what were you taught are treatment options for Rhd?

Respondent: The first treatment is usually penicillin. Yeah Penicillins. Whether you give them PEN-V but we would want to see what stage is the RHD; how much has it done so far? So we would do an ECHO, a simple scan so that I can see that really is the RHD there? Is it mild or it is severe? How many valves are involved? Is the patient in heart failure or not? So from there, you make a decision; if it is mild or if there are early changes, because there are also early changes, what we call early rheumatic changes. When you do an ECHO it could be that. Then that one is a case of follow up; you advise promptly to treat the sore throat. Okay?

Interviewer: Yes.

Respondent: Or you give some shots of Benzathine penicillin, they will come back and you repeat the ECHO, and interestingly, some of them regress. You find those changes have gone back in the very early stages.

Interviewer: Wow.

Respondent: But when you have an established disease, now that is a permanent diseases, a severe one because heart failure will need medicine for 3 things; the first one is to prevent recurrent sore throats to make sure you don’t get more injury. The next one is to treat heart failure in case people have heart failure or prevent changes, what we call remodeling of the heart, the heart may dilate or fail. Or those who are already in heart failure, you treat heart failure. But ultimately, they need surgery, those who are already severely sick they need surgery to correct the valve or replace it. You put a new valve.

Interviewer: Wonderful. Wow! So what is your understanding about the long term prognosis of RHD?

Respondent: If caught early, if the disease is diagnosed early the prognosis is good actually, I told you some may regress. But here in our experience, majority are discovered late, the prognosis unfortunately is not good; it is very bad. We have a lot of cases where you can’t do much and they can’t afford surgery or they’re too late for a new valve. You know even putting a new valve, when you are too late, you will not even be managed.

Interviewer: Why are they coming late?

Respondent: It is because of challenges with diagnosis. As I told you, it is not easy to link this sore throat to the problem of the heart. Even majority won’t know that they had a sore throat. Imagine if you get a sore throat and you are 3 years old, or 5 or 10 years old and it goes a way, so now they come in with non- specific symptoms and they are in the village and there is not enough knowledge about it, so they are in heart failure, they’re having chest pain palpitations and they are lost. They are treated by many people because not everyone has ECHO to see what’s in the heart and the symptoms could be because of many things. So the diagnosis is usually delayed.

Interviewer: It is delayed!

Respondent: That’s the main problem.

Interviewer: Wow. You have said they don’t have the knowledge, how can we step up the knowledge?

Respondent: There are efforts already which have been made; we have had schools’ programs for sensitizations and also a bit of checkups to see how many. There was a study which was run around here. So there is some knowledge around here in schools.

Interviewer: Okay.

Respondent: Then there has been some campaigns, a few ones on radios right now and there’s also an advert going on to screen for Rheumatic Fever. So giving such knowledge generally improves people to start thinking about the heart and what can go wrong.

Interviewer: Okay, that’s wonderful. So do you remember the last patient you worked on for RHD?

Respondent: I remember.

Interviewer: So how long has it been?

Respondent: Yesterday.

Interviewer: [laughs] could you briefly tell us how that visit was? Who was it?

Respondent: It was a follow up visit and it was a good news of RHD regression.

Interviewer: Wow.

Respondent: Which I don’t see many times, so this was mild Rheumatic Heart Disease with mild micro gurgitations. It was diagnosed this year in January, so I followed up after 6months so that was July there, the symptoms had reduced but we still maintained PEN-V penicillin. So the patient came back yesterday and we did another ECHO, and RHD changes on the heart had disappeared.

Interviewer: Wow. How old was this?

Respondent: This was a 30 year old lady. It is one of those which am very proud of.

Interviewer: Wow, that’s wonderful. So do these patients know the link between sore throat, ARF and RHD, at all? Do they have a sense of, do they know that?

Respondent: The ones who come to us are referred via ELT doctors here. The unit doctors explain to them that “you have recurrent sore throat so you could be having RHD, so go to physicians, cardiologist or whoever for further screening.” Those ones come knowing and they are the ones who usually comply to treatment very well. But the ones we diagnose usually who come in late, they don’t know actually.

Interviewer: They don’t!

Respondent: So the majority don’t know.

Interviewer: They don’t even know that.

Respondent: Yes.

Interviewer: Okay. What sort of symptoms do they usually describe to you when they come?

Respondent: They come with easy fatigability, (they get tired).

Interviewer: Yeah, they get tired all the time.

Respondent: Body swelling, they come with chest pain, they come with palpitations, so those are the four main symptoms. But there are those who come with a cough that is not going away; they have treated the cough and it is not going away but when you check the heart, you find the problem is from the valves.

Interviewer: Okay and are they good at follow up and adherence?

Respondent: Yes and no, and it varies from patient to patient. So I will categorize them.

Interviewer: Okay.

Respondent: I will say the ones who have support like social support, family support come back and the ones who are alone don’t come back. I have seen that case clearly.

Interviewer: So social support like what?

Respondent: Social support makes them comeback but without that, they go away and they get lost, and then we discover them on the ward in heart failure admitted.

Interviewer: Oh! They come back when ... ?

Respondent: Yes. When they are very sick and in heart failure. So you say “eh! This one was our patient of RHD. ”

Interviewer: So part form social support, what else makes some people comply with the drugs?

Respondent: Well, when they have pain, unfortunately, when they have pain they keep coming and complying for that period when they are in pain, with bad symptoms, but as they get better, they disappear then they come back when the symptoms come back. That is what I have seen.

Interviewer: Okay. And then um, so to then when they come back especially in heart failure, what excuses do they give for having not come back?

Respondent: The medicines. You see the medicines in the hospital, some are there and some are not there. Those who are not in the RHD program may not get and for me I also work in private sectors and other places, so there the medicine is expensive.

Interviewer: So it’s the medicine.

Respondent: The medicine is expensive! So they take. Then others get tired of medicine because it is daily, then the injection is painful. This Benzathine penicillin is terrible, you know it.

Interviewer: Yes.

Respondent: it’s like the one of syphilis if you have ever got it, and it is terrible, very terrible! And the technique of injecting, not every nurse knows it. So some nurses, sorry to say, inject it badly or poorly or they don’t put pain killers or Lignocaine there. So the patient says “ah, I am not going back for that painful injection”

Interviewer: Okay. And then um, now let’s look at the local health system barriers that you are facing. You are going to tell me which ones are working for you and you tell us why and those which ones are not working for you and you tell us why?

Respondent: Yes.

Interviewer: Let’s look at the administration and leadership in the district, is it helping you do your work with our patients?

Respondent: I don’t know much about the administration at the district.

Interviewer: You don’t know?

Respondent: Yeah, I only know the administration at the hospital. Because a regional referral hospital is semiautonomous; we are under the central government, Ministry Of Health more than the district. We seem to be above the district; the DHO I think doesn’t have a lot of say, so I don’t think ...

Interviewer: Okay. So let’s talk about the administration in the hospital.

Respondent: It is very good.

Interviewer: Is it supportive?

Respondent: Yes it is because working together with the heart institute, it is the one really responsible for the cardiology clinic together with the university. So heart institute, Mbarara University, MarieStopes and Ministry Of Health. So there’s coordination really; it is the same angle that we managed to the ECHO machine. It the ECHO which does a lot of diagnostics, you see that? Then there’s an RHD program. So our place is organized because we have a specific RHD clinic on Fridays and then we also a general cardiologist clinic in Tuesday. So if a patient comes when it’s not a Friday and they are sick, they can still be assisted. So the system is good.

Interviewer: Wow, that’s wonderful. Now when you look at the funding of health care, how is it? Is it working for you?

Respondent: I don’t know much about funding for health care but what I can say, salaries are paid on time.

Interviewer: That’s good!

Respondent: So I have no reason to say in that regard, well maybe the drugs; if some patients may not get the heart failure drugs, then that may be an issue.

Interviewer: Are they getting them?

Respondent: They get some like Lasix and Captopril but if you want more, others you might not get them like the Losartan. But if you want Atenolol, captopril, Lasix you will get. So I could say it is 50/50.

Interviewer: 50/50. So for those they cannot get at the hospital, how much can they spend for a month?

Respondent: Unfortunately, the drugs which are not available are the most expensive ones. So the ones that are on are what we call the essential drugs from the Ministry. They may not be very efficacious for these cases who are in heart failure, so you may want to bring back the injection fraction, blah. So if they have to buy, it is very expensive.

Interviewer: Like how much?

Respondent: They can spend like 100,000shs a month if they are in heart failure. That’s a lot of money, 100,000shs seriously! It is a lot. It is actually more that 50% of their earnings because if you take the earning of people here, it is like 200,000sh-300,000shs.

Interviewer: Okay. So what do you have to say about the funding of RHD in general? In particular.

Respondent: Funding of RHD it is lacking, I am sorry to say. Because, we should look at it in a holistic way, now there’s RHD clinic, we won’t go into the details, but what if the RHD research clinic closes? Because like any other project, it has a timeline, it has to close, what will happen? These patients will fall back to the general cardiology all of them and the medicine which we are getting for RHD, the follow up and sometimes the phone calls to bring them back , I don’t know about transport refunds but I know about phones calls and follow up will be lost. So the funding should be sustainable, what I see is there right now it might not be sustainable. So funding is not enough.

Interviewer: Okay. And let’s look at the health worker force, how are the numbers and qualifications that you have?

Respondent: The numbers now and qualifications, we have 2 physicians with some cardiology training with one in the cardiac patients’ clinics. It’s fair for now because when you are 2, one can even afford to be off today, this week and the other works or you work together one on the ECHO machine and the other treating the patients. For now, it is okay but it also because of the help of RHD (study), the second clinic will close as soon as the RHD clinic study stops. Then in terms of other cadres, we also have senior health officers, doctors who are trying to specialize in internal medicine, they help us. Because we have taught them so they help us. Because this is a teaching hospital, I think the workforce is good for the doctors.

Interviewer: Waiting time for our patients?

Respondent: Waiting time for our patients varies; if we have many patients in the line we prioritize those ones who are very sick. So whether you have RHD or not, if you are very sick you will be seen. So waiting time will be on average about an hour. Unfortunately, if are dealing with an RHD case, it takes a lot of time on the ECHO machine; it is a tedious exam but if I am dealing with hypertension, 10 minutes and I’m through.

Interviewer: You are done!

Respondent: Yeah, but to study a valve in an academic way because we are in a teaching institution, it will you take a lot of time.

Interviewer: It takes a while!

Respondent: So the next patient to come after one rhd patient, it will be about minimum of 30 minutes and maximum 1 hour.

Interviewer: Okay, thank you. And then when you look at the quality of care that you are giving to these patients, how is it?

On average, it's above average. Reason being this being a teaching hospital, I think we tend to follow protocols so it's above average. We may lack some few things but it's above average here.

It's above but it's not yet there at 100.

Respondent: It is not at 100 because of patient numbers.

Interviewer: Okay.

Respondent: So sometimes you have to wash through and finish the line, so there you don’t do what’s the ideal. You just do the basic that you can and that will be above average.

Interviewer: So what is that that you can't do especially on busy days when you are working?

Respondent: On busy days you may not do a full ECHO.

Interviewer: Okay.

Respondent: You may do just a basic ECHO and that one affects quality. Let's say if you are studying micro valves, you want to see in details how much RHD has done to eat from the base to the valves themselves to the tips and surrounding areas and you score, you do what is like a weekly score. But when you are in a hurry, you just say severe Mitroscenosis and you put micro valvular ending.

Interviewer: Without scoring!

Respondent: but you do not score; you be like, “I want to finish” because it takes a lot of time. You may not calculate the Pulmonary Pressure because it takes a lot of time but you must see severely, this rheumatic and it is schiznosed. We diagnose and you just go. So that is slightly average above average and not ideal. The other thing which might be lacking is patient education; so we shall do diagnosis and send to the nurse to treat or to dispense the treatment. But if we had few patients, we would sit with the patients and say “look, we found this and is because of this." So if a patient hears it from the doctor and they may believe it better. And I don't know why, but they tend to believe it better when they hear it from the doctor than a nurse or a second person that simply says, “The doctor said ABCD.”

Interviewer: Okay, wonderful. Let's look at the medications; how are the stocks?

Respondent: I really don't know about the stocks.

Interviewer: Anti coagulation, the heart failure drugs?

Respondent: I want to tell you that I don't know about the stocks.

Interviewer: Yes.

Respondent: We write and you go get or don't get. So we don't know.

Interviewer: Eh, So you don't know much about that.

Respondent: Yes.

Interviewer: But for the diagnostics you said have said you have that.

Respondent: We are doing well; we have ECHO which can do a detailed study of what you want.

Interviewer: Are they paying for the services?

Respondent: If they come among the general patients they pay. If they come among the RHD study they don't.

Interviewer: So for the general, how much do they pay?

Respondent: For the ECHO?

Interviewer: Yes.

Respondent: They pay 70,000shs

Interviewer: Okay. Can many afford that and what do they do when they can't?

Respondent: Well they complain but if they are really poor, there’s a waiver that comes out of bureaucracy to the hospital to waive. So they can't afford in general because 70,000shs, and I told you already 100,000sh is a much. So 70,000sh is close to 100,000shs. It is not really affordable but they struggle.

Interviewer: Let's look at the health information system you have and the medical records systems, how are they?

Respondent: Well again I say that for those who are in study, the information is good.

Interviewer: Why?

Respondent: Because they have the papers that are already pre-signed to get the information that you want and there’s a channel of information to even consult work to get and follow. That one among the study, they are good. Those ones who are not in the study, the general cardiologists, we keep in our book. We have two registers one if you are going to do the echo we register you, second in the Computer we put results then actually there’s a 3rd one for the general clinic for the nurse to keep track. But it may not go to the details of the hospital, I don't know how often it goes because it stays in.

Interviewer: It stays in your place!

Respondent: Yes. Unless the hospital records person comes looking for them.

Interviewer: Do you have specific registers for ARF and RHD?

Respondent: Those in the study have while those who are not in the study are in the general cardiology register.

Interviewer: okay. do you have guidelines and protocols for RHD care?

Respondent: Those in the study, yes. Those not in the study, is part of the general cardiology.

Interviewer: It is the general cardiology. Okay.

Respondent: And it is like this clinician’s discretion when RHD has been assumed properly, understood and mastered. So we assume that really every doctor should understand the protocols we treat very well.

Interviewer: Yeah, because sometimes they need to refer back will they be available?

Respondent: Yes. The good thing is that I have told you that at least 2 physicians have some cardiology training.

Interviewer: Okay, that’s good. So for all the things I have mentioned, administration, funding, health care or workers, the numbers, medication, information flow and protocols. Let's look at the things which are working for you. You said the administration is okay!

Respondent: It okay. It is trying.

Interviewer: Okay. Funding for rhd?

Respondent: In the study yes, outside the study, no.

Interviewer: The health work force, you said you have?

Respondent: For the doctors yes, the nurses no, because we only have one nurse in the clinic.

Interviewer: No! For the medication you couldn't say much because you said you don't know.

Respondent: I don't know!

Interviewer: At least for diagnostics you have.

Respondent: We are doing fairly well.

Interviewer: Okay.

Respondent: Even though it's a bit expensive.

Interviewer: For the health information you said um?

Respondent: It is 50/50 because we gather the information but I don't know what happens to it afterwards.

Interviewer: Okay. The guidelines and protocols?

Respondent: We don't have the official protocol for those who are not in the study. For those in the study they have.

Interviewer: Okay, wonderful. So let’s look at the last set of question; we are looking at your perceptions about patients out comes. Generally do think our patients are getting the care they need?

Respondent: Yes and no. Yes, because they get the diagnosis, the first part of care and get basic treatment.

Interviewer: They get basic!

Respondent: Basic treatment where I mean we give Penicillin, we give the PEN-V, the Benzathine and a few anti-failure drugs. But I want to tell you that RHD is a surgical disease; many patients who come to us with heart failure need surgery and on that we score zero because they don’t get the surgery. Are you getting me?

Interviewer: Yes. I am getting you.

Respondent: Because if it’s already RHD giving you heart failure, even you give them Penicillin for whichever amount, it won’t get cured. They still need the surgery to repair the valve or replace it. So there we score very badly.

Interviewer: So what do you do for those patients?

Respondent: We talk to them about moving to the Heart Institute because that’s where they can get the surgery. But I also know the waiting line for those who need surgery at the heart institute is very long. It is very long because surgery is expensive, the little time I was there, most times patients were waiting for camps, those who have money. And again I told you also that if your case is so advanced you are not encouraged for surgery, you are a candidate for palliation and that is very bad for RHD. But if you have heart failure from RHD, it means your RHD is already advanced and medicine will not cure you; you will take them to slow its progression or stop you from having heart failure for some time but you must get surgery to be cured but we don’t have the surgery here. And let me tell you also, when you tell somebody to go to Heart Institute, Mulago- Kampala from here in Mbarara, that is a death sentence; they fear there, whether you tell them things are going to be okay, they fear.

Interviewer: What do they fear in Mulago?

Respondent: It’s a new place; somebody has never been to Kampala and then the fear of money. They say “eh, to operate the heart is expensive.” Then they also have some hearsay about heart surgery, maybe relatives who were operated and died. So they say, “eh when they touch your heart, you will die” Unfortunately, some cases may be true, maybe someone died after heart surgery so if somebody hears about it they misunderstand it. So there’s a big fear for going for surgery.

Interviewer: Okay. So that means the communities these patients stay in also contribute to the attitude they have!

Respondent: Definitely they contribute! When you ever tell someone that “you are going for heart surgery” or they need heart surgery, huh, they are already devastated because when they go back to the community and they say” I went and saw the doctor he really diagnosed the disease that I have heart problem and I will need operation/surgery” then they will go for herbal medicine.

Interviewer: They go for herbal medicine!

Respondent: Yes because they believe that “ah, heart surgery is too much; you are going to die. I better take this herbal.” They have a lot of perception then them for herbal medicine.

Interviewer: So when these patients tell their families that “I have RHD” are they encouraged? How are they ...?

Respondent: They are shattered.

Interviewer: They are shattered!

Respondent: Me I have seen from experience; you tell somebody “your child has RHD” and you tell them what RHD is, general information, they are shattered. They start thinking that maybe they are cursed because there are not many people who get RHD how come only few get RHD. Then they start getting second opinions from very many people, unfortunately they get messed up by some people so where. So it is very bad news.

Interviewer: Do they specific local herbs they use if they don’t come?

Respondent: There are some famous herbs over the radio and a lot of adverts. Some herbs are maybe what, some people say they treat everything; diabetes, hypertension, heart disease, cancer and everything. So even if someone hears that one, even if I don’t mention names, it is even on the radio.

Interviewer: Because in Kampala especially in Buganda region, for sore throat there’s what they call omwetango that’s the common herb.

Respondent: Omwetango here is used for constipation.

Interviewer: They use it for constipation! Is there anything they use here for sore throat?

Respondent: They use eucalyptus leaves, you make juice. Because that eucalyptus treats flu, it is actually real, it helps with flu. So some people run to it for sore throat.

Interviewer: Okay. So doctor do you have any patients’ safety concerns and quality of care ... Of course quality of care we handled, did you see any practice and you feel that it is putting their health at risk?

Respondent: Maybe anti-coagulants; Warfarin. In the study there’s ease of measuring INR, but outside the study, we are in the dark. We move in the dark.

Interviewer: You don’t know?

Respondent: We move in the dark. We monitor it once a month when the patient comes back and you see there are some patients who don’t tolerate this simple 5mg of Warfarin and it’s the one available, the 1mgs, 2mg are in Kampala. So here we do 5mg, 10mg, 7mg and you are not going to see a patient next or another week; you will see a patient after one month or 2 months or wherever they come back. That puts them on at risk yet they need the warfarin.

Interviewer: Why is that here you have 5mg?

Respondent: It’s what is on the market. You see the market forces of pharmacies, you will not stock 1mg when many clinicians only know 5mg. The 1mg and 2mg of warfarin are newer, so when you stock them they will expire.

Interviewer: Okay. So have you witnessed any preventable deaths occurring in the hospital? Surely you look at this death and you say “no, no”

Respondent: Not really. The ones I could say were preventable are these patients who get lost to follow up and then they come back when the heart failure is advanced, they have arrhythmias, they are so dilated, they have clots and you have nothing to do about it. So those are the preventable deaths but not those that have not been diagnosed because of the availability of the machine, it has done magic, tests you know what you are doing. It is very straight forward.

Interviewer: Okay. So do you think there are patients dying in the community without ever presenting to the hospital?

Respondent: Very many. I told you the problem is herbal medicine.

Interviewer: Herbal!

Respondent: Yes. It is very terrible; it keeps a lot of people at home drinking and drinking, and then they even reach a point of dying there. Then others get lost in lower health units, health center IV may not have much knowledge about it so they could diagnose these people even with TB, can you imagine! Because they have cough that doesn’t go away or because they have other issues, they may not diagnose RHD.

Interviewer: So the last question, in your opinion, what are the two most important things Ministry Of Health should do to improve the outcome of our patients?

Respondent: Increase awareness through many programs, either radio or community visits or health education to know that RHD is real and at least we know we can prevent it by ABC. So let them increase the health education. It’s in many ways; it is in the communities among health workers, and even in schools. Can you imagine 100 pupils in primary residing in one dormitory or even 200, because the school has 300 students? So something has to be done by the Ministry of Health and Education jointly because people get exposure from that. Then after that, we shall also need to make available the services because when you already got the disease, you need to be treated early to slow its progression. Then to cure it, it is with surgery but then let the valves be made available because valves are the ones that make heart surgery expensive. Those are the two things.

Interviewer: Okay. Thank you so much. Anything else before we finish?

Respondent: Well, I just want to thank you for this opportunity and to tell you that RHD can be eradicated too.

Interviewer: Wow. Okay, good to hear that. Thank you so much for your wonderful views. We are going to use them with a couple others to see how best we can come up with a strategy of improving the outcomes of RHD.

Respondent: Thank you.