• Ensuring access to thoughtfully designed, safe, and well-equipped facility infrastructure is an important step to providing high-quality primary health care.

    Despite their importance, gaps still remain in ensuring sufficient facility amenities, safety precautions, and equipment. An important step for prioritizing health infrastructure needs and priorities is to gather data that describe current conditions, including what health care systems and facilities are lacking in addition to what they have. Assessment tools that can be adapted to specific country contexts have been developed to measure the critical areas of service availability, readiness, and provision. As more countries take part in these assessments, the data they gather can be used to help prioritize facility infrastructure needs as specifically as in a single health care facility and as broadly as in a whole region. Researchers at The Water Institute compiled data for an array of indicators of health center environmental conditions and standard precaution items from 78 LMICs, representing 58% of the total population of LMICs and 129,557 health care facilities between 2007-2016. These data found that 59% of health care facilities lacked reliable energy services, 50% lacked piped water on premises, and 33% lacked improved sanitation facilities on premises 6. Further, nationally representative data from a subset of six countries showed that only 2% of health care facilities provide all four of water, sanitation, hygiene, and waste management services. There were statistically significant inequalities in coverage by urban versus rural setting, managing authority, facility type, and subnational administrative unit 6. The study also looked at indicators of environmental conditions and standards at health facilities – including water, sanitation, hygiene, energy, and waste management – and found that more than half of facilities were equipped with disposable syringes (85.2%), latex gloves (76.5%), appropriate storage of sharps waste such as sharps boxes (74.7%), disinfectant (e.g. chlorine solution for decontamination) (63.6%), safe disposal of sharps (63.6%), appropriate disposal of infectious waste (60.9%), and soap for handwashing (60.8%). Conversely, fewer than half had appropriate storage of infectious waste (39.3%), alcohol-based hand disinfectant (29.5%), sterilization equipment (26.8%), and guidelines for standard precautions (26.2%) 6.

    A lack of appropriate facility amenities and sufficient safety precautions and equipment exposes people seeking primary health care, the facility staff, and health care providers to greater risk of infection and disease. This can happen through contaminated water, hands, food, medical equipment, inadequate sharps and infectious waste disposal, and potential for unsafe blood transfusions. 6 Inadequate facility density and distribution can create issues for a patient’s geographic access to care and a health system’s ability to deliver services. 

    Finally, funding, particularly through capital investments, is necessary to ensuring sufficient resources for designing and equipping PHC facilities. Find more on funding for PHC in the Health Financing module, forthcoming.

  • Facility amenities: Facility amenities are the features and utilities that enable primary care facilities to be ready and able to provide quality, person-centered primary health care 1. Basic amenities include electricity, safe water, exam rooms with auditory and visual privacy, light sources, sanitation facilities (toilet/latrine: flush/pour toilets to piped sewer system or septic tank, pit latrine, composting toilet), communication equipment (cell phone, landline telephone, and/or shortwave radio), computer with internet or network connectivity, and access to emergency transportation 789.

    Facility density: The number of primary care facilities per number population. Some indicators base the facility density per 10,000 people, others by 5,000 or 100,000 1.

    Master Facility List: A Master Facility List is a complete listing of health facilities in a country, both public and private. It is composed of a set of administrative information and data that identifies each facility – such as facility codes, names, types, ownership or managing authority, location, address, and contact information, geographic coordinates, and operational status, as well as services offered, human resources, and infrastructure details such as number of inpatient beds – and is used as a standard mechanism for uniquely identifying health facilities and allowing for information to be compared across time and across data sources for individual facilities10.

    Standard safety equipment: Standard safety equipment are the materials needed to support primary care service delivery and reduce the risk of transmission of bloodborne and other pathogens from both recognized and unrecognized sources 111. They are the basic level of infection control precautions which are to be used, as a minimum, in the care of all patients 11. These include basic safety tools such as sterilization equipment, safe final disposal of sharps and medical waste, sharps boxes or containers in exam rooms, waste bins with lids and liners in exam rooms, surface or environmental disinfectant, single-use standard disposable or auto-disposable syringes, bar or liquid soap along with running water or alcohol-based hand sanitizer, latex gloves, and guidelines for standard precautions against infection 7891213.

    Standard safety precautions: Standard precautions are established processes that require health care workers to assume that the blood and body substances of all patients are potential sources of infection, regardless of the diagnosis or presumed infectious status, in order to provide a high level of protection to patients, health care workers, and visitors 14. Standard precautions include the following practices: hand washing and antisepsis (hand hygiene); use of personal protective equipment when handling blood, body substances, excretions, and secretions; appropriate handling of patient care equipment and soiled linen; prevention of needlestick or sharp injuries; environmental cleaning and spill management; and appropriate handling of waste 14.

Relevant resources

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Designing safety-net clinics for innovative care delivery models California HealthCare Foundation, 2011

The design of the physical environment plays an important role in improving health care quality, work efficiency, and cost-effectiveness. Clinic design can have a substantial impact on the effectiveness of innovative care delivery models, but guidelines are limited. This white paper identifies key characteristics of the physical environment design for new care delivery models and provides preliminary design recommendations.
Tags: Guidelines, Facility design

Design solutions to improve healthcare access and outcomes – a case study on population health at Adelante Healthcare, Mesa, AZ. The Center for Health Design, 2017

This case study explores one of the first US health care facilities specifically designed to support patient-centered medical home model and population health by following the principles of evidence-based design. The facility was designed to accommodate multiple PHC-oriented clinical and community services in one location. Quality research, routine data collection, and performance evaluation allow staff to continually adapt the setting and programs through which they deliver health care.
Tags: Facility amenities, Facility design

The Center for Health Design Insights & Solutions. The Center for Health Design, 2019

The Center for Health Design is a US-based research, education, and advocacy non-governmental organization that focuses on evidence-based healthcare facility design. The Center develops and shares best-practices tools and resources for improving healthcare environments, including research reports and issue briefs, interviews, case studies, design strategies, lessons learned, key point summaries, and webinars for topics including population health, safety, noise, technology, and infection control.
Tags: Guidelines, Facility amenities, Facility design

Service Provision Assessments (SPA) The DHS Program, 2019

SPA surveys were developed for national level monitoring of health systems. They look at (1) the availability of different health services in a country; (2) the extent to which facilities are prepared to provide health services; and (3) the extent to which the service delivery process follows generally accepted standards of care. They are conducted in a nationally representative sample of health facilities, covering all types of public and private health service sites.
Tags: Data collection tool, Facility survey, Facility amenities, Facility design, Standard safety precautions

Profiles of Health Facility Assessment Methods International Health Facility Assessment Network, 2008

This report profiles several of the main instruments used for health facility assessment at district and national levels and considers their management utility, including cost and frequency of implementation. It is meant to give users a better understanding of the major assessments and the reports produced based on these assessments’ findings. It can also be a helpful aid to determining goodness-of-fit for some of the potential facility assessment tools.
Tags: Data collection tool, Facility survey, Facility amenities

Service Delivery Indicators (SDI) The World Bank, 2019

Service Delivery Indicators is an African-wide initiative that tracks measures of health service delivery. Within health facilities, these include availability of equipment, drugs, and infrastructure. The survey is conducted every two years, designed to fill gaps in the data landscape until standardized facility surveys are repeated with predictable frequency. The indicators are standardized, to allow comparison between nations, across subnational boundaries, and comparisons over time.
Tags: Data collection tool, Facility survey, Facility amenities, Standard safety equipment

Creating a master health facility list WHO, 2013

This is a practical guide for how to develop and maintain a Master Facility List. The guide describes itself as “a complete listing of health facilities in a country (both public and private)” including administrative information and information that identifies each facility. As a prerequisite for conducting more detailed assessments of service delivery such as the Service Availability and Readiness Assessment, this is valuable guidance on the main considerations and components involved in the creation of a Master Facility List.
Tags: Guidelines, Facility survey, Facility amenities

Improving infection prevention and control at the health facility: interim practical manual supporting implementation of the WHO Guidelines on Core Components of Infection Prevention and Control Programmes WHO, 2018

This manual offers practical guidance, tips, resources, and examples to support guideline implementation, drawing on current evidence for infection prevention and control (IPC). It focuses on the development of a sustainable action plan, informed by the local context, to enact the guideline recommendations. It also explains how to integrate and embed IPC within a health care facility’s structure and daily activities.
Tags: Guidelines, Facility amenities, Standard safety precautions, Standard safety equipment

Operations manual for delivery of HIV prevention, care and treatment at primary health centres in high-prevalence, resource-constrained settings, chapter 5: infrastructure. WHO, 2008

This chapter focuses on infrastructure interventions important for improving infection control, particularly for decreasing transmission of HIV or tuberculosis. It highlights essential infrastructure requirements – such as space, privacy, and water, sanitation, and hygiene – as well as those needed in each area of a health center, and explores how to develop an enabling physical work environment using quality management approaches.
Tags: Guidelines, Facility amenities, Standard safety precautions, Standard safety equipment, Facility design

Practical Guidelines for Infection Control in Health Care Facilities WHO, 2004

This guide provides detailed information about infection control practices and programs, environmental management practices, and care of health care workers. The guidelines were developed to help infection control practitioners with management of infection control and prevention and to ensure that staff and managers fully grasp the importance of infection control programs.
Tags: Guidelines, Facility amenities, Standard safety precautions, Standard safety equipment

Service Availability and Readiness Assessment (SARA) WHO, 2019

The SARA assessment was developed to assist countries in assessing, mapping, and monitoring services availability and readiness at health facilities. The reference manual includes planning for the necessary steps and factors that must be in place in advance, the data collection process, and the core instrument and indicators index. The implementation guide focuses on the practical steps to implementing the assessment, including budget, sampling, adaptation, guides for data collectors and supervisors, and data processing, analysis, and output.
Tags: Data collection tool, Facility survey, Facility amenities, Standard safety precautions, Standard safety equipment

Standard Precautions in Health Care WHO, 2007

This “aide-memoire” is a reference brief for standard precautions in health care including maintaining a safety environment, hand hygiene practices, personal protective equipment, and respiratory hygiene and cough etiquette. It is for health facility planners, management, and staff, with reminders both on the process (appropriate hand washing) as well as the environment (e.g. encouragement around promoting a safety climate and education of health workers, patients, and visitors). It could be posted in public locations and referenced for planning purposes.
Tags: Guidelines, Facility amenities, Standard safety precautions, Standard safety equipment

What questions should be considered to begin improvements?

The questions below may be a useful starting place for assessing facility infrastructure in your context and determining whether it is an appropriate area of focus and how one might begin to plan and enact reforms.

Has primary health care facility density and distribution in the country been assessed? Are there documented targets for optimal health facility density and distribution to meet population health needs?

 

Having good, up to date information on the ratio of primary care facilities to the population, how the ratios vary between urban and rural settings, how facilities are distributed across regions or districts, and how facility distribution compares to population distribution can inform infrastructure planning and prioritization 1. Regular data collection using reliable sources can also provide information on geographic or facility-level disparities in facility distribution or facility amenities, an important starting point for improving equity in access. For more information on geographic access from the patient perspective, see the Geographic Access module.

Does your country maintain a Master Facility List?

 

One of the challenges of using multiple data sources and tools to collect health services information is making comparisons across surveys and synthesizing a wide breadth of data. A Master Facility List “creates a standard mechanism for uniquely identifying health facilities, and allows for information to be compared across time and across data sources for individual facilities” 10. A Master Facility List is also a fundamental requirement for detailed assessments of service available and readiness, including the SARA (Service Availability and Readiness Assessment) 10. The process of creating a Master Facility List involves establishing institutional arrangements (a coordinating group and an implementation plan); determining what information to include in the List (facility, administrative, and service information); identifying data sources and populating the List; filling in gaps and updating the list; and managing, maintaining, and disseminating it 10.

Are your country’s PHC facility design and planning considerations specifically focused on team-based care and patient-centeredness? Is facility design responsive to patient needs?

 

Quality PHC requires much more than basic amenities and safety equipment. Design considerations focusing on patient-centeredness, efficiency, workflow, and the tasks of health care workers can be incorporated from the start. Design considerations around safety include planning for infection control, patient movement, fall prevention, medication safety, behavioral and mental health risk, and security risk 15. Equity and environment of care requirements include ensuring size, layout, and functions of facility structure meet diverse care needs of patients 16 – for example, ensuring patients who are elderly or who have trouble walking on stairs have alternative ways to access waiting rooms and facility spaces. It also includes accommodating patients, visitors, physicians, and staff – for example, making sure facility spaces are large enough and have seating for more than just one or two people. Other important aspects include basic physical environmental considerations, such as ensuring appropriate ventilation and air flow through facility spaces, using windows, fans, or air systems as appropriate, to satisfy comfort and safety needs. Planning and design requirements include designing to reduce sound and noise, to help patients and visitors find their way through the facility (including clear signage), and emergency preparedness and management 15. Design considerations that support team-based care provision, improving workflow and incorporating new technologies, can also improve quality of care and patient experience 2.

More information on team-based care can be found in the Team-Based Care Organization module.

Does your country track the proportion of primary health care facilities with all of the identified standard safety precautions and equipment in place?

 

Data on variation in availability between subnational areas and facility type can be timed to inform planning cycles. Determining the physical availability of services can be a useful starting point for prioritizing where to begin with improving service delivery and to inform facility-level improvements 56. After determining which facilities have low coverage, for example, facility managers, infection prevention and control practitioners, and program managers can collaborate in identifying solutions to make improvements. An intervention study in Kenya found that after portable handwashing stations and simple drinking water stations with drinking water treatment were installed, and health care providers were trained, the stations were used in a sustained way even though there was no access to piped water 6. Collecting information using reliable sources that are updated regularly is integral to getting the full picture of safety precautions and equipment - and using data to drive action.  

Does your country engage in any surveys tracking service availability and facility amenities, such as the Service Availability and Readiness Assessment (SARA), Service Provision Assessments (SPA), or Service Delivery Indicators (SDI)?

 

Health facility assessment data are useful and important on their own, and can be additionally valuable in combination with population-level data 17. On their own, reliable, timely facility-based information provides insights about what is currently happening at the service delivery level with regards to input, process, costs, output, and quality. This allows for monitoring and improving performance at the facility and larger system level. Further, these performance and quality factors have an impact on whether and how people use available services 17. More information about the service availability and delivery assessments is available in the Resources section; many assessment tools are available online for adoption and adaptation at local or national levels.

Case Studies for Facility Infrastructure

Facility Infrastructure Senegal

In Senegal, a proactive approach to gathering data through nationally representative assessments has helped the country determine priorities for implementing changes to facility infrastructure and amenities.

Facility Infrastructure Sri Lanka

In Sri Lanka, a focus on equitable access to health care has led to comparatively high provision of basic health services, but at the expense of consistent quality of care – leading patients to bypass community health services. Facility infrastructure assessments and investment are helping to bring users back into the primary health care system.

PHCPI is a partnership dedicated to transforming the global state of primary health care, beginning with better measurement. While the content on this website represents the position of the partnership as a whole, it does not necessarily reflect the official policy or position of any partner organization.

References:

  1. Primary Health Care Progression Model Assessment Tool. PHCPI: 2019. Available from: https://improvingphc.org/sites/default/files/PHC-Progression%20Model%202019-04-04_FINAL.pdf
  2. Quan X, Joseph A, Keller A, Taylor E. Designing safety-net clinics for innovative care delivery models. California HealthCare Foundation, 2011. Available from: https://www.chcf.org/wp-content/uploads/2017/12/PDF-DesigningClinicsInnovativeCareDeliveryModels.pdf
  3. Gunn R, Davis MM, Hall J, Heintzman J, Muench J, et al. Designing Clinical Space for the Delivery of Integrated Behavioral Health and Primary Care. JABFM September–October 2015 Vol. 28 Supplement. Available from:https://www.jabfm.org/content/jabfp/28/Supplement_1/S52.full.pdf
  4. Gulwadi GB, Joseph A, Keller AB. Exploring the impact of the physical environment on patient outcomes in ambulatory care settings. HERD 2009;2: 21– 41. Available from: https://journals.sagepub.com/doi/abs/10.1177/193758670900200203?journalCode=her
  5. World Health Organization. Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies. Geneva: World Health Organization; 2010. Available from: https://www.who.int/healthinfo/systems/monitoring/en/
  6. Cronk R and Bartram J. Environmental conditions in health care facilities in low- and middle-income countries: Coverage and inequalities. International Journal of Hygiene and Environmental Health 2018, 221:409-422. Available from: https://www.sciencedirect.com/science/article/pii/S1438463917303760
  7. The DHS Program - Service Provision Assessments (SPA). Available from: https://dhsprogram.com/What-We-Do/Survey-Types/SPA.cfm 
  8. World Bank. Service Delivery Indicators (SDI) | Data Catalog. Available from: https://www.sdindicators.org
  9. World Health Organization. Service Availability and Readiness Assessment (SARA) Implementation Guide and Reference Manual. 2015. Available from: https://www.who.int/healthinfo/systems/sara_introduction/en/
  10. World Health Organization. Creating a master health facility list [draft]. 2013. Available from:  https://www.who.int/healthinfo/systems/WHO_CreatingMFL_draft.pdf?ua=1
  11. World Health Organization. Standard precautions in health care: Aide-memoire. October 2007. Available from: https://www.who.int/csr/resources/publications/EPR_AM2_E7.pdf
  12. World Health Organization. Infection Prevention and Control Assessment Framework at the Facility Level. 2018. Available from: https://www.who.int/infection-prevention/tools/core-components/IPCAF-facility.PDF
  13. World Health Organization. Improving infection prevention and control at the health facility: Interim practical manual supporting implementation of the WHO Guidelines on Core Components of Infection Prevention and Control Programmes. Geneva: World Health Organization; 2018. Available from: https://www.who.int/infection-prevention/tools/core-components/facility-manual.pdf?ua=1
  14. World Health Organization. Practical Guidelines for Infection Control in Health Care Facilities. 2004. Available from: http://www.wpro.who.int/publications/docs/practical_guidelines_infection_control.pdf
  15. Facility Guidelines Institute. Guidelines for Design and Construction of Outpatient Facilities. 2018. Available from: https://www.fgiguidelines.org/guidelines/2018-fgi-guidelines/
  16. Reiling J, Hughes RG, Murphy MR. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Chapter 28: The Impact of Facility Design on Patient Safety. Hughes RG, editor. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2633/pdf/Bookshelf_NBK2633.pdf
  17. Profiles of health facility assessment methods. Report of the International Health Facility Assessment Network (IHFAN). Arlington, VA, MEASURE Evaluation/USAID. 2008. Available from: https://www.measureevaluation.org/resources/publications/tr-06-36