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

Interviewer: so tell me about your age; how old are you?

Respondent: I am 50 years old.

Interviewer: Tell me about your qualifications and where you trained from.

Respondent: I am a medical clinical officer, I trained from Arua School of ... by then it was called ‘school of clinical officers’ and that was way back; I qualified in 1995. Then I also did Health Education and Promotion at Nkozi University and that was in 2010-2011, and I got an Advanced Diploma in health Education and Promotion.

Interviewer: So how long? You said you have been qualified since 1995.

Respondent: Yes, since 1995.

Interviewer: So how many years are those?

Respondent: That’s about 25 years.

Interviewer: How long have you been working here?

Respondent: Here at Kajjansi?

Interviewer: Yes.

Respondent: This is my forth year.

Interviewer: 4 years!

Respondent: It’s in April that I am going to make 4 years.

Interviewer: So you have been working here for the past 4 years!

Respondent: Yes.

Interviewer: Okay. So this is the clinician’s room?

Respondent: Yes, this is the clinician’s room.

Interviewer: It’s where you see patients from!

Respondent: Yes, it’s where I see the patients from.

Interviewer: So tell me about the demographics of the patients you see here; what kind of patients do you see and what kind of diseases do they present with?

Respondent: Okay. It depends on the season; during this dry season people mostly come with cough, flu, fever, sore throat and skin infections, but when it’s the rainy season that’s when you will find that they come mostly with fevers and diarrheal diseases. We have a slum here called ... the hygienic condition of that place is not good that in during the rainy season we get the most diarrheal cases.

Interviewer: what kind of age groups do you usually have of the patients that come here?

Respondent: We have young children from let me say, 2 months up to 90 years, because we have a diabetic clinic on Thursday and Friday and also an eye clinic on Thursdays. So mostly on Thursdays the elderly come mainly because they know that there is a diabetic clinic where we test them; for the eyes, we do eye screening on that day. So on Thursdays, the elderly are many but on the other days you would find the children and middle aged.

Interviewer: Tell me about your training in RHD; do you have any training on Rheumatic Heart Disease?

Respondent: Just as a special training?

Interviewer: Well any training, whether in school or ...

Respondent: In school, we were trained; when we were in medical school we were trained about RHD but after qualification, I have not had any special training for Rheumatic Heart Disease.

Interviewer: So you have not had specific training!

Respondent: No.

Interviewer: But you had some training during school!

Respondent: During school, yes.

Interviewer: But after that you haven’t!

Respondent: Yes.

Interviewer: Okay. So have you received any training since graduation? I mean since graduation when you became a medical officer?

Respondent: On what?

Interviewer: On Rheumatic Heart Disease.

Respondent: No, I have not.

Interviewer: You haven’t! So how many patients of Rheumatic Heart Disease do you often see in a day, week or month?

Respondent: huh, it’s very rare. Here! It is very rare, or maybe sometimes, let me say in a year I can see maybe two.

Interviewer: In year?

Respondent: Yes.

Interviewer: What about patients who come with Acute Rheumatic Fever?

Respondent: Acute? The problem with that is that sometimes we miss them because people come with fever, they come with a sore throat, and they come with maybe general body weakness ... Because when I auscultated the heart sound, I was hearing some murmurs. So what I did, I referred that patient Uganda Heart institute. I think that was last year.

Interviewer: That was last year!

Respondent: Yes

Interviewer: So what is the average age of patients you usually see with Rheumatic Heart Disease? Although you see them rarely, what is the average age of patients you usually see?

Respondent: They are just young people, like in 20s. Most of them are in 20s.

Interviewer: So most of them are in twenties! Are they working or not? Are they in school or?

Respondent: They are working and also some are students. Most of those we have seen are students.

Interviewer: What kind of symptoms do they usually describe?

Respondent: Some of them come with fevers, headaches, sore throat and then the general body weakness, and because of the sore throat that’s why they have painful swallowing and so on.

Interviewer: Okay. So generally, what about follow up and adherence; for those you have seen although they are few, do they usually adhere to treatment?

Respondent: yeah, they adhere to treatment because what I usually do is that when I maybe give them amoxicillin and so on, because I may sometimes give them PFStat for maybe five days, when they have completed treatment I usually tell them to come back and then I review again. When I see that there is improvement, I tell them to ensure that if there’s more or the symptoms persist or if they get that same sore throat within 1 or 2 months, so when they come back again, what I do is to just give them Benzathine.

Interviewer: So what sort of barriers do they usually or commonly state to taking the care they need?

Respondent: Here the barrier, in most cases is that sometimes they are mismanaged. Because, somebody can come here with maybe a sore throat but you give an antibiotic with no Penicillin in it! But we also attribute that to maybe lack of enough knowledge for some of the staff. Then the other barrier is that they sometimes come when we don’t have any antibiotic in the facility. If you had come here last week, because we got our supplies on Friday, but if you had come here on Wednesdays, we didn’t have Benzathine, Amoxillin and even Septrine was not there. I think we had only remained with a few stocks of ampicillin injections. That also brings about the issue of mainly the supplies.

Interviewer: So the main issue you have is mainly the supplies!

Respondent: Yes.

Interviewer: Because my next question was like; what kind of barriers do you perceive they face in getting the care they need? And like you said earlier that the main issue they face is when they come here, sometimes the drugs are not there.

Respondent: Yes

Interviewer: So besides that, do they find the health workers there all that kind of stuff?

Respondent: In most times we are there, because we ensure that there is staff at the facility 24/7.

Interviewer: Mm?

Respondent: Yes

Interviewer: Okay. Now I am going to ask you about the local system barriers; which of these pieces is not working from you and why? I am asking about administration and leadership at the district in regards to RHD.

Respondent: Okay, the district ... because I am sure what they would have done maybe, because you are telling us that at the Uganda Heart Institute there are many cases from Wakiso, and I am sure that when they go for these National Health Assemblies, some of these findings are shared and the DHO attends. So I think from attending those health assemblies and they find out that we have many cases at the Uganda Heart Institute, I think they would have come and informed us about it, but they have been informing us about immunization and so on. However, with the heart, if they had informed us about it, I think we would be vigilant and if you see any patients with sore throat to make sure that they get the right treatment, or that instead of giving them other antibiotics without Penicillin, we make sure that everyone ... because sometimes you may find that maybe it is the nurse who is seeing the patient, we ensure that we empower them also. So the district had that weakness but good enough you came on board and educated them and they called us also. So I am sure that we are also on board now.

Interviewer: So funding for health care in general, how do you see funding? How do you see funding of this health Centre in general and in regards to RHD?

Respondent: The funding, like government for example, for us with supplies and so on, the government puts money in National Medical Stores and the funding was not good because for this financial year, they have put there 22million for the whole financial year!

Interviewer: For this facility?

Respondent: Yes, just for this facility.

Interviewer: For these number of patients!

Respondent: Yes, 22 million, but they have promised us that in the next financial year, we shall get the health Centre IV kit and they would have increased our funding from 22 to 150 million. So I’m sure that come this July this year, I think the funding would have improved.

Interviewer: But that’s in general.

Respondent: Yes.

Interviewer: But in budget is there funding for Rheumatic Heart Disease?

Respondent: Yeah, because now when they went for the procurement plan, what they were emphasizing is that they looked at non-communicable diseases. They told us we have to ensure that we plan for those diseases like hypertension, diabetes, and screening for cancers and so on, and also Rheumatic ... I am sure Rheumatic Heart Disease will be taken in that same category.

Interviewer: So health workers; how many health workers do you have here? What are their numbers, qualifications and how long do the patients take to wait?

Respondent: Okay, now in this facility we have 32 health workers. Okay, 30 because 2 are cleaners. So its 30 health workers and 3 of them are on study leave. So we have got 2 senior clinical officers; we are two, and then we have a Senior Nursing Officer. With the nurses, we have 2 Nursing officers; one is nursing and one is a counselor. We had a midwifery nursing officer but she left; she went to nursing school and is now a tutor. Then we have like 5 enrolled nurses including those with enrolled psychiatry. Then we have like 4 Enrolled Midwives because of the heaviness of this facility. Then we have got a Dental officer, etymology officer, we have a Health Educator. Good enough our health educator is also a clinical officer by training, so she also helps us when we are clerking patients. Then we only have 3 Nursing Assistants but we make sure that we don’t allow a Nursing Assistant to see a patient; we make sure that we have a nurse or a clinical officer around all the time. Nursing Assistants are usually at the dispensing side, immunization and so on.

Interviewer: So which means that according to the numbers of health workers you have, you are not badly off!

Respondent: We are not badly off.

Interviewer: So the medications like Benzathine penicillin, anti-coagulation and heart failure drugs, do have those?

Respondent: We don’t have. We Benzathine but we don’t have these anti-coagulation drugs because, even Aspirin is one of them but we don’t even get Aspirin.

Interviewer: You don’t get Aspirin from NMS?

Respondent: We don’t; this facility doesn’t get Aspirins.

Interviewer: What about the Warfarin?

Respondent: Warfarin, we don’t.

Interviewer: Is it because it’s a Health Centre IV or?

Respondent: It’s a Health Centre IV but getting the supplies of a Health Center III.

Interviewer: Wow!

Respondent: Now even in our hypertensive clinic they (patients) just buy Cardiac Aspirin. Because if it was there we could have been packing for them, but the rest like Nifedipine and so on, we give them.

Interviewer: So one of the main issues you have is supplies!

Respondent: Yes.

Interviewer: And they give you Benzathine but in limited amount!

Respondent: Yes, they give us in limited amounts.

Interviewer: Because you are at a different level but getting drugs of a different level!

Respondent: Yes.

Interviewer: Okay. So Health Information and medical records; how is your medical records system, integration within the facility for in and out patients? Do you have registers?

Respondent: We have registers.

Interviewer: Medical registers?

Respondent: Yes, medical registers in all the departments.

Interviewer: And how do you save your information or data?

Respondent: Which one? The monthly or?

Interviewer: For example, now you are seeing patients, where do you keep your data?

Respondent: Now this information is put in a register and after the register is full, we have a place where we keep all the registers. The Health Information Assistants keeps them.

Interviewer: Okay. Do you have an electronic system where you keep all data or you only use the books?

Respondent: The electronic is done for the reports; after extracting the reports, we put it in the system. Then the electronic for patients is only done at the HIV clinic; from there we have a computer where we enter all the details.

Interviewer: Only at the HIV clinic?

Respondent: Yes. That one we use it.

Interviewer: Do you have any registers for Acute Rheumatic Fever?

Respondent: We don’t have a special register

Interviewer: You don’t have specific registers for specific patients?

Respondent: No, we don’t have; it’s a general register.

Interviewer: Okay. Has the health ministry provided any guidelines or protocols for Rheumatic Heart Disease and care?

Respondent: No, not yet.

Interviewer: Okay. What are the local health system enablers? Which of these pieces is working for you; Perception of patient outcomes? Generally, do you think the patients are getting the care they need or not?

Respondent: They do. Now when a patient comes, I can see that patient very well, I even health-educate the patient very well and tell him/her what they are suffering from, give a prescription and also health- educate. For example, for sore throat I can say, “I am going to give you these antibiotics but there are other things you can do like using salty water which can work.” Then I take them to get the injection, pain killers and so on. But sometimes when the supplies are not there, I can do all this, but at the other side where they are supposed to get the medicine, that’s where the charges comes in.

Interviewer: So that’s when they have to buy the medicine?

Respondent: Yes.

Interviewer: So this means that the patient would have got the care but would not have got the medication!

Respondent: Yes, but sometimes maybe when I write Benzathine, sometimes when they buy it, they bring and we inject them.

Interviewer: Tell me patient safety and the quality of care concerns; do the patients feel safe? How is their quality of care? Have you had any incidents where ...?

Respondent: It used to be there in HIV (clinic) but we have now minimized it. Because, for instance in the case of HIV, the results had some issues but now days after counselling the patient, because those days when I had just come here, whenever a patient was tested HIV positive, anyone could know. But nowadays we have minimized that; we have counselors so we refer those patients there and they do everything there; you cannot know who is positive or negative. And even here for the other cases, we ensure that there is privacy; we sit with them here and do everything here, but for children, sometimes when they are many, sometimes the ward clinician sits the other side and the children sometimes are seem from outside there

Interviewer: Outside like in the corridor?

Respondent: No, not outside; I mean out there where we were seated. When we are two, one sits the other side and make sure that the adults are seated inside here while those with children, we see them from the other side.

Interviewer: Which means that your patients are safe their confidentiality is ensured!

Respondent: Yes, they are safe and their confidentiality is assured.

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

Respondent: Yeah, I think some of them die but we have got a VHT system and each VHT (personnel) is assigned a household. They ensure that they go to those households with patients and they are sent to facilities. Sometimes we have been, like now for TB, we oriented them one time and told them “whoever is coughing, make sure that they come.” Some of them (community members) were refusing but we involved the LC (Local Council). On time we had a multi-drug resistant TB patient, we referred the patient to Mulago but the patient took off and came back to the village. People from Mulago Hospital came here and they were looking for that patient, until the community sat and the Chairman told him “we are going to chase you away from the village!” So the patient had to agree and went back to Mulago. So our VHTs have helped us in ensuring that those people who are in the villages are sent here. They die but nowadays, with the improved VHT system, it is minimal.

Interviewer: So according to you, in your opinion, what would be the most important things Ministry of Health would do to improve the outcomes of patient care generally and Rheumatic Heart Disease?

Respondent: What Ministry Of Health can do?

Interviewer: What in your opinion are the one or two most important things Ministry Of Health can do to help improve?

Respondent: One, they should increase funding in the facility and with funding, so that we can also ... we have health inspectors and health assistants and they are people who do home visits and so on. So maybe if they increase funding, we can know that if we are having a patient A, B, C who is suffering from Rheumatic Heart Disease, so when we are going for those outreaches, we can know that in Location A if you have gone for maybe immunization, HCT and so on but there is a rheumatic heart patient around, after doing that activity, you can do a health visit; you can go to that home and see. Then it also helps the health educator when there is enough funding. Those days we had some funding and the health educator could go to the villages and do health education, and if the funding is enough, we can engage the health educator to move maybe to the sub counties, maybe when there is a council meeting; he goes and orients them. You know those people also have where they come from; so if you tell them, “If you have a sore throat please you go to the facility.” Some of them will go and be diagnosed early and maybe treat the sore throat which, because of the complications or side effects of the sore throat, will prevent you from getting them. So if we orient those councilors and so on, I think it will ensure that Rheumatic Heart Disease cases goes down. So, it is the funding.

Interviewer: What about training?

Respondent: I have told you about it already; we need funding and training.

Interviewer: And also dissemination of that information to the lower facilities.

Respondent: Yes, to the lower facilities. Good enough, you came late but there is a new policy which is coming called Result-Based Financing.

Interviewer: Yes?

Respondent: Through the Ministry Of Finance, Ministry Of Health and World Bank, our facility was assessed and we are through. So we have started the planning system for the next financial year and these are some of the things we are going to put in our work plan so that the health educator, in all his/her activities, we have to include Rheumatic Heart Disease. Because, with hypertension and diabetes, that one we did it and now we have like 500 clients in our clinic. So I think that if we get the funds, we are going to include Rheumatic Heart Disease such that when the Health educator goes out, he can educate the people so that they come early to the facilities and those who have the symptoms, they can come and we assess them and we see whether we retain them here or refer them to Mulago.

Interviewer: Thank you so much.

Respondent: You’re welcome.

Interviewer: Basically that was my last question.

Respondent: Wow, wow, wow

Interviewer: Thank you so much for your time.

Respondent: Thank you too.