operations manual: infrastructure manual is designed for staff at existing phcs, so the primary...
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Operations Manual: Infrastructure
Manual is designed for staff at existing PHCs, so the primary focus of this chapter is on adapting/enhancing existing structures, rather than designing and building new ones;
Goal is to identify specific challenges and empower staff to solve using local best practices;
Emphasis on flexibility, creativity, incremental improvements.
Operations Manual: Infrastructure
Quantifying space requirements
Reconfiguration to accommodate integrated services
Design and ventilation to prevent TB infection
Privacy, stigma, and safety considerations
Furnishing and equipment
Waste disposal, water, electricity, and communications
Operations Manual: Infrastructure
What guidelines exist for PHC infrastructure? District Health Facilities: Guidelines for Development and Operations. WHO Regional Publications, Western Pacific Series No 22, 1998.
USG guidelines (DOD, IHS)
WHO protocols re: hygiene/sanitation
TB/HIV guidelines
Other ???
Operations Manual: Infrastructure
What is different about HIV services? Increased time per visit
More space needed for counseling and other vital services (triage, appointments, group education)
More space needed for data and medical records
Increased need for linkages (internal & external)
Key issues of privacy, confidentiality, stigma, safety
Need for family-focused services
Need for multidisciplinary teams
Operations Manual: Infrastructure
Quantifying space requirements
Reconfiguration to accommodate integrated services
Design and ventilation to prevent TB infection
Privacy, stigma, and safety considerations
Furnishing and equipment
Waste disposal, water, electricity, and communications
How much space is needed?
NB distinction between minimum space and optimal space. Need to work within existing constraints/realities and to support creative use of both formal and informal space.
How many visits/patient/year?
How many visits/room/day?
How much space is needed?
A health centre providing HIV services to 250 patients can expect ~8-15 extra visits a day for clinical services. Assuming additional visits for lab, pharmacy, and counseling increases number to ~ 12-25 extra visits/day;
A single clinical consultation room, fully staffed and dedicated to HIV services five days a week, can accommodate roughly 125-150 patient visits/week;
Suggested “preferred” space = 3 clinical consultation rooms for outpatient services+ 1 additional room for every 250 patients enrolled in chronic HIV care
How much space is needed?
Preliminary estimates are adapted from WHO guidelines (WPRO manual cited earlier)
Functional SpacesMinimum Quantity
Minimum Dimension Remarks
Waiting area 1 Careful attention to ventilation required to minimize nosocomial transmission of TB
Registration/triage area
1 1.5m x 1.5m(2.25 sq meters)
Medical records/HMIS
1 1.5m x 1.5m(2.25 sq meters)
Consultation–exam rooms
3 minimum + 1 for every 250
additional HIV+ patients
3.0m x 3.0m (27 sq meters)
Consultation-examination rooms used for ANC, family planning, OPD, EPI, MCH, under-5, TB/DOTS and HIV services.
Operations Manual: Infrastructure
Quantifying space requirements
Reconfiguration to accommodate integrated services
Design and ventilation to prevent TB infection
Privacy, stigma, and safety considerations
Furnishing and equipment
Waste disposal, water, electricity, and communications
Reconfiguring space
Waiting area
Triage
Clinical consultation
Counseling (HCT, adherence, other)
Lab / sample collection
Pharmacy / dispensary
Outreach / linkages / transportation
Operations Manual: Infrastructure
Quantifying space requirements
Reconfiguration to accommodate integrated services
Design and ventilation to prevent TB infection
Privacy, stigma, and safety considerations
Furnishing and equipment
Waste disposal, water, electricity, and communications
WHO Guidelines for the Prevention of Tuberculosis in Health Care Facilities in
Resource-Limited Settings
Operations Manual: Infrastructure
Quantifying space requirements
Reconfiguration to accommodate integrated services
Design and ventilation to prevent TB infection
Privacy, stigma, and safety considerations
Furnishing and equipment
Waste disposal, water, electricity, and communications
Operations Manual: Infrastructure
Quantifying space requirements
Reconfiguration to accommodate integrated services
Design and ventilation to prevent TB infection
Privacy, stigma, and safety considerations
Furnishing and equipment
Waste disposal, water, electricity, and communications
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linha de cobertura
linha de cobertura do alpendre de espera
linha de cobertura
Roofing
Waiting spaceCovered verandah with seats
Waiting spaceCovered verandah with seats
Waiting spaceCovered verandah with seats
Existing building
Existing fencing
MainPublicAccess
Group Counseling ReceptionExamination Room Nr 2 Examination Room Nr 1
Farmacy
Illustrative Designs
Considering an “early” patient cohort – i.e., one in which the majority of patients have recently initiated ART - can assume that patients on ART are seen by a clinician every month (on average) and pre-ART patients are seen every 3 months.
Although there will always be LTFU and missed appointments, there will also be additional unscheduled ("walk-in") appointments for toxicity, acute illness etc; this calculation assumes that missed & extra appointments balance each other out.
How many visits/patient?
How many visits/patient?
# visits/month # visits/week # visits/day
Panel size = 100 patients
If 50% are on ART 66 17 3
If 100% are on ART 100 25 5
Panel size = 250 patients
If 50% are on ART 167 42 8
If 100% are on ART 250 63 13
Panel size = 500 patients
If 50% are on ART 333 83 17
If 100% are on ART 500 125 25
Using these assumptions, can estimate ~ 40-60 visits/week for each 250 patients enrolled in chronic HIV care;
These are clinical visits only (not counseling, lab, pharmacy/dispensary, etc).
Likely to be upper limits, as stable ART patients are generally seen less frequently as time goes on.
How many visits/patient?
How many patients/room?
# visits/month # visits/week # visits/day
If majority of patients are f/u
600 150 30
If > 5 patients/day are new
500 125 25
These are maximum figures. Assumptions include: (1) Patients receive triage, registration, counseling, pharmacy, and
laboratory/phlebotomy services elsewhere; (2) The clinical visit includes a history, a targeted physical examination, and
adherence assessment; (3) The clinician completes appropriate documentation during/immediately after
the visit; (4) The functional work day is at least 6 hours long.