Operations Manual: Infrastructure

1. 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.

2. 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

3. 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 ???

4. 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

5. 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

6. 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?

7. 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

8. How much space is needed? Preliminary estimates are adapted from WHO guidelines (WPRO manual cited earlier)

9. 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

10. Reconfiguring space • Waiting area • Triage • Clinical consultation • Counseling (HCT, adherence, other) • Lab / sample collection • Pharmacy / dispensary • Outreach / linkages / transportation

11. Reconfiguring space • Patient flow and waiting time • Internal linkages • Confidentiality / privacy

12. 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

13. WHO Guidelines for the Prevention of Tuberculosis in Health Care Facilities in Resource-Limited Settings

14. 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

15. 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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18. Illustrative Designs

19. Illustrative Designs

21. 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.

22. How many visits/patient?

23. 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.

24. How many patients/room? These are maximum figures. Assumptions include: • Patients receive triage, registration, counseling, pharmacy, and laboratory/phlebotomy services elsewhere; • The clinical visit includes a history, a targeted physical examination, and adherence assessment; • The clinician completes appropriate documentation during/immediately after the visit; • The functional work day is at least 6 hours long.