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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)
Minimum Minimum
Functional Spaces Quantity Dimension Remarks
Waiting area 1 Careful attention to ventilation required
to minimize nosocomial transmission of
TB
Registration/triage 1 1.5m x 1.5m
area (2.25 sq
meters)
Medical records/HMIS 1 1.5m x 1.5m
(2.25 sq
meters)
Consultation–exam 3 minimum + 1 3.0m x 3.0m Consultation-examination rooms used
rooms for every 250 (27 sq meters) for ANC, family planning, OPD, EPI, MCH,
additional HIV+ under-5, TB/DOTS and HIV services.
patients
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
Reconfiguring space
Patient flow and waiting time
Internal linkages
Confidentiality / privacy
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
Installing solar panels in Rwanda
Digging boreholes in Nigeria
Main
Illustrative Designs Public
Access
Existing building
linha de cobertura Roofing
6 7,0 6 6 7,0 6
1 6,9 2,0 4,0 6,9 0,0 1
4 2
Examination Room Nr 2 Examination Room Nr 1 Group Counseling Reception
6
6
3 3 3 3 3 3
0,0
0,0
0,0
0,0
0,0
1,0
1,0
1,0
3,0
3,0
3
3
1,2
1,2
3,0
1,2
9
9
9
2,8
2,9
3
3
1,0
1,0
1,0
3 3 3 3
1
0,0
0,0
0,0
9 3 2 9 4,3 1 6,8 1
6
6
2,1
2,2
2,0
2,2
2
2,9
linha de cobertura
Waiting space Waiting space
2,0
Farmacy Covered verandah with seats Covered verandah with seats
3,0
0,0
0,0
15,2
1,1
2,1
9
4,5
4,0
1
linha de cobertura do alpendre de espera
1,2
9
3
4,0
3
1,0
3
Waiting space
3
Covered verandah with seats
3
3 3
1
6
1 9 9 1,1 1
1,2
6 1 6 2,3 1 2,2
3,0 2,9 2,3 6,9 2,0 6,9
3,0 33,7
3,0
Illustrative Designs
How many visits/patient?
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
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
How many visits/patient?
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 600 150 30
patients are f/u
If > 5 patients/day 500 125 25
are new
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.
