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) Functional Spaces Minimum Quantity Minimum DimensionRemarks Waiting area 1Careful attention to ventilation required to minimize nosocomial transmission of TB Registration/triage area 11.5m x 1.5m (2.25 sq meters) Medical records/HMIS 11.5m 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.

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

16. Installing solar panels in Rwanda

17. Digging boreholes in Nigeria

18. Illustrative Designs

21. 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?

22. # visits/month# visits/week# visits/day Panel size = 100 patients If 50% are on ART66173 If 100% are on ART100255 Panel size = 250 patients If 50% are on ART167428 If 100% are on ART2506313 Panel size = 500 patients If 50% are on ART3338317 If 100% are on ART50012525

23. 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?

24. How many patients/room? # visits/month# visits/week# visits/day If majority of patients are f/u 60015030 If > 5 patients/day are new 50012525 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.