Operations Manual: Infrastructure Manual is designed for staff at existing PHCs, so the primary focus of this chapter is on adapting/enhancing existing.

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.


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


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 ???


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








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?


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


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.








Reconfiguring space

Waiting area

Triage

Clinical consultation

Counseling (HCT, adherence, other)

Lab / sample collection

Pharmacy / dispensary

Outreach / linkages / transportation

Reconfiguring space

Patient flow and waiting time

Internal linkages

Confidentiality / privacy








WHO Guidelines for the Prevention of Tuberculosis in Health Care Facilities in

Resource-Limited Settings















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Illustrative Designs

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?


# 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


If 50% are on ART 167 42 8

If 100% are on ART 250 63 13


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 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.

Operations Manual: Infrastructure Manual is designed for staff at existing PHCs, so the primary focus of this chapter is on adapting/enhancing existing.

Documents

minimum space

optimal space

informal space

visitmore space

group educationmore

hiv services

clinical services

integrated servicesdesign