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Ji Model Health Centre Published by: Council for World Mission British Council of Churches Edinburgh House 2 Eaton Gate London SWlW 9BL England Paper copies are 4.50 British pollnds. Available from: Teaching Aids at Low Cost Institute of Child Health 30 Guilford Street London WClN 1EH England Reproduced by permission Mission, British Council of the Council of Churches. for World

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i 1

A MODEL

HEALTH

CENTRE

A Report of the Working Party appointed in 1972 by the Medical Committee of the Conference of Missionary Societies in Great Britain and Ireland

Conferenceof MissionarySocietiesin Great Britain and Irelhnd~,

Copyright 0 1975 The Chairmanof the MedicalCommitteeof the Conferenceof MissionarySocietiesin Great Britain and Ireland, Edinburgh House,2 Eaton Gate, London SW1 9BL. W

Permissionmust be soughtshould any of.the material be usedfor the purposeof financial or other gain.

The purposeof this copyright is particularly to protect the designof the Model Health Centre from copyrighting by others so that reasonablyopen access the to nutterialinay be maintained.

Rinted in the United Kingdom by R.K. Hudson, 53, ElmfIeld Road, London SWI 7 8AF

__ _A------CONTENTS

Page
Contents Foreword Members Medical Committee of Members SpecialCommittee of Introduction ChapterI. The background, the Model, important areasfor further study and the future ChapterII. A description of the Model plan ChapterIII. The drawings iii, iv Y vi vi vii 1 5 9 Appendix Socialareaand kitchens Under fives clinic Ante-natal clinics and family plannine Generaloutpatients Waitingareas PharmacyorW laboratory Centrd facilities Receptionand office Clerical work Admissions Wards Hostels Staff housing Sterilizersand sterile supplies Noteson an immunization area Disposal
Stores and store-keeping Equipment lists Extended room list and expansionoptions Treatment types Part-time workers Communications and responsibilities

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Duties of the doctor in relationship to the Health Centre (iii)

Appendix Teachingand staff training

Some teachingaids and their use

25 26 27 28 29 30 31 32 33 34 3s 36 37 38 39 40 41 42 43 44 4s .. 46 47 48 49 so 51 52

Homevisiting Schoolvisiting Eval~ting the work of the Health Centre and the useand designof records Someexamplesof patient retained records The useof school children for record making Community hygiene Nutrition and food TheOStlUCOfdbSSfJ Costsand materials Foundationsand roads Flexibility, expandability, massproduction and standardizationof buildings Latrines and sewage disposal Watersupply, purification and storage lktqy and plant

site rizer; thtlaIclinics Very small clinics Numbersof people served,the distribution and grouping of Centres and somewider planning problems The d&n of simple operatingtheatres Producing,handling and assessing statistics Setting up a Centre Orientation of buildings, their construction and environmentalconsiderations Reference readingin relation to a Model Health Centre Examplesof diagnostic and treatment routines serializedfor usein Health Centres A description of a small rural Health Centre Further drawings

..

FOREWORD At the International Hospital FederationsSeventeenth International Hospital Congress in Dublin in June,]97 1, one session held consideredthe value of standardizingbuildings and methodswhen planning for the provision of health care in developingcduntries. Thoseinvolved in the medicalwork of voluntary organizqtronsexpressed immediateinterest. Severalof the architects presentoffered their help in making a detailed study of this approachto health care. The idea of a Model Health Centrewaspresentedby Dr. D. A. Andersento the meetingof the Medical Committeeof the Conference Missionary Societiesin of Great Britain and Ireland,(CBMS)on 27th October, 1972 and found such favour that a specialcommitteewasappointed, under Dr. Andersenschairman& to bring in expert opinion. At the first meetingof this specialcommittee a working party wasse! zp to prepare a report describingthe buildings of a Model Health Centre,its staff, eqipment and the work which should be undertakenfrom and in it. The namesof membersof the MedicalCommittee,specialcommittee and working party are @venon pagevi. The working party met on twelve occasions and, in presentingits report, wouid lie to expressits appreciationfor the valuable!idviceand criticism receivedfrom many persons with specialknowledgeand experiencein the field of he&h carein developingareas. Acknowledgements The Medical Committee,in receivingthe report, gratefully acknowledges the specialcontribution of Mr. Mark Wellsin undertaking the major shareof the work its involved in the preparation of both text and diagrams. It also expresses thanks Mr. to Mrs. Phyllis Headwho served assecretaryto the working party, 1~) Jamrs (. McCilvray who produced the reading hst, to Mr. GrahamStone who madethe fair copiesoi the diagrams, the Witney Press to who printed the large dia ram at the end of the report, to Mrs. GladysHunt who readthe proofs, to Mrs. $,ouisaGrant, Lt. Cdr. Roland fiudson and Mr. GeorgeMoore who provided the ways and means for typing, printing and binding the final documentand to the many people, too numerousto mention individually, who havereaddrafts of manuscriptsand given the helpful adviceand criticism. It gratefully acknowledges financial assistance receivedfrom the Christian Medical Commission,the Medical Institute at Tiibingen and MISEREORat Aachen. The spezialcommittee recordswith deepregretthe suddendeath of Dr. D. A. Andersenon 4th December,1973. He had madea major contribution to the work involved in the preparation of this report and guidedthe committee with unfailing skill, toleranceand good humour.

Dr. D.A. Anderson&h&man to 2.12.73) Dr. Kathleen G. Wright (man from 3.12.73) Rev.C.B. Firth (Secretary) Dr. 15. Acres Mr. A.D. Askew Dr. H.H.W. Bennett k FEBzx$Mis 6. aeal MissD. Dykes

CanonAS. Neech Rev. T.C. Patterson MissR.E. Ranhin Dr. Nancye M. Ridley MissJ.M. Sharp Dr. Elizabeth G. Sloan Dr. Ii. Souster Miss B. Spanner Dr. J.L. Tester

MambemoftheBpfdalcommittee
In addition to the membersof the Medical Committeewho attended the Special Committeemeetiagr,the following consultantswereinvited: Dr. W.A.M. Cutting, London School of Hygieneand Tro ical Medicine Development Dr.~4~;o~~, Foreign and CommonwealthOfRce, Overseas . . Professor N.RE. Fendall and Dr. David Stevenson, Departmentof Tropical and CommusdtyHe&h, Uverpool School of Tropical Medicine Mr. G.H. Franklin, Departmentof the Environment, Building Research Establishment Mr. G. McRobie aad MissPamela l&e, Intermediate Technology Development J. Group Ltd. Mr. AE. North, AKhitectUre Department,Polytechnic of North London Dr. P.N. Swift, Childrens a)epartment,FamboroughHospital Mcmke!8ofthewerIdngParty Dr. David Morley and MissMargaretWoodland,Institute of Child Health Mr. Mark Wellsand Mr. Brian Brookes,architects Dr. Kathleen Wright and Dr. Daniel Andersen,MissionarySocieties MissM. Lethbridge, formerly Institute of Child Health Dr. William Cutting, London School of Hygieneand Tropical Medicine

INTRODUCTION This report is a contribution to the study of the problemsassociated with the provision of health careservices developinSareas. Suchservices in usually have their outreachinto the community by meansof small clinics, sometimes isolated in positions. Shortageof money and staff precludethe establishmentof any larger units, at least in the fmt inst;;nce. The small clinic is fully describedin the Appendices the report. to From suchsmall beSinning it may be that a siteon which a small clinic hasbeen established becomewell placedfor the careof a growing community. The will report showshow, with careful forethought in the siting of the first buildin@ and the allocation of land, sucha clinic may be developedinto a Health Centre. In the opinion of the working party the Health Centre,a Model of which is describedin detail, should be the most efficient unit upon which to plan the health careof a population of up to 20,000 peoplewithin a radiusof from 10 to 20 miles. Further growth of population or the improvomontof communicationsand tram ort facilities may show that ono of tho Health Centror is sowoll located that it shoup d be developedinto a District Hospital. This dovolopmon!is also describedin the rolovantAppendtcor. Every aspectencounteredin the courseof the BtUdieB (includfnB training of rtaff, staff duties, oquipmont, construction of build@s, provision of essentialservitor) has beenset out in tho A Bendices someof which are in dotail, others in a more curmry outlino, it being Roped that personswith grcatoroxporioncowill improvo upon tho report where detail is lacking. Whilst full usehasboonmadeof tho knowledgeand experience@nod from the ro arts of other oups, there are romo Bold8in which furthor BttIdieB essential. fh oseinclude t o training programmes arc for Btaffat all lovol8,with emphasis the value of the auxtliary health worker, and on the services the Hoalth Centro,asenvisaged, the hoalth education of the of in camunity. It is emphasized the Health Centreaspresentedin the report is a Model which that must be ads ted to meet the need8of eachindividual location. Only by translating the proposaf carefully into practice can their valuebe tested. All plans must be s subjectedto continuous revision in the light of experience. The Medical Committeewould welcomecontributions and criticisms which would improve the contents of this report, which ir now offorod a8a designprimor and reference book for thoseOngsgOd planning, dovolopingand operatinghealth in services whether at a national or local level.

Chairman,MedicalCommittoe . Conferenceof Missionary Societiesin Great Britain and Ireland 9th June, 1975

A MODEL HEALTH CENTRE Chapter I - The background, the Model, important areas for further study and tbe future. The Background Thcnecdfortkstudy Increasingly,the Health Centreis being seenasan instrument of forward-looking medicalpolicy. So now seems be a good time at which to clarify attitudes to to Health Centres,and to take a look at why they are needed,how they work, what they are supposed do and what they should look like. to l%emedi&needandhowitcanhemet Thoseconcernedwith health carein the developingworld recognizethat health delivery basedmainly on patients in needcoming to hospitals must fail to me& more than a small fraction of total health needs. The problem is vastand no expansionof traditional facilities can in practical termshope to meet the demand. A policy is neededwhich is capableof coping with this expandingproblem: this policy will haveto be radical and must take accountof economics,availablemanpower and medicalpossibilities. c Economics Costsmust be kept to the morally accept?h!e minimum. The setting of ti is threshold is a very major problem. Economically there is also the problem that peopleliving in rural areas practising subsistence agriculture are Jifficult to ma&, which puts up costs; and by deiinition contx3ute little to the national pursefrom which their health careis to be paid for. Moralsand economicsdictate the need for x reasonablyevenspreadof care-facilities. Manpower Thereis no possibility in the foreseeable future of a sufficient number of medical and nursing graduates beingavailableto deal directly with medical needs. It must be clear that planneddelegationof duties to auxiliary workers is inevitable and no one should be required continually to perform a task which someone qualified less can readily be taught to do competently. How this is to be done in the longer term is a massive problem, and many proposedsolutions offend established medical opinion. This report accepts needfor auxiliaries. It is particularly noted that the age-structure developingcountries, with a remarkablyhigh percentage young in of children, encourages st;ut on younger patients, and that this type of carecanbe a madeto ti0 in with maternity care!implying in turn a population increasin~y re;cted by immumzatron; auxrhary workers are particularly appropnatem these . Implement&on Weknow a greatdeal more about the causes, prevention and treatment of can diseases we put into practice. Severaldiseases be eradicated,preventedor than reasonable treatedcomparativelyeconomicallyand by lessskilled people. It seems to suggest suchdiseases their treatment should take high priority in the that and policy. A balancedapproach A balancedapproachis needed,a balancebetweenprevention and cure, a balance betweenunderuseof the highly quaiifiid in someareasand over useof the less qualified in others,betweensophisticatedcarebenefitting a limited number and much lesssophisticatedcarefor the majority, betweenapplying health to people wrth a hospital and teachingpoop10 the community to help themselves, in between a medicalprofessionrightly proud of its overall health carehistory and a systemof delivery that notes the importance of agriculture, nutrition and hygiene in the health of the community.

The value of the auxiliaq

The pressure on skilled manpower, the high cost of traditional facilities and delivery and the huge problems of delivery in a dispersed population may appear to drive practical solutions into the realm of second class medicine pedtied by auxiliaries, the retail outlets being cheap pseudo-hospitals. But in examining this problem the positive desirability of planned community-based preventive medicine, tied in with the essential basic needs of communities for adequate nutrition, hygiene, etc., suggest that in fact auxiliaries, supported by and communicating regularly with qutied staff, can do an immensely valuable job extremely well, and in doing so . may reduce the hard core medical problems to a scale where, with reasonable forecasts of availability of skilled staff, we can hope to deal with them. This report adopts this cheerful view cheerfully. The need for early action Ideally, fairly detailed evaluatiois of current medical facilities, current disease prevalence patterns and population spreads should be carried out by trained teams before programmes are put in hand. This requires the training of teams to carry out such evaluations in order that future programmes can be precisely aimed at specific problems. This report accepts that such surveys are not yet available and that thEre is a shortage of people who could carv them out. This is not seen as an adequate reason for delaying a&on, and it is noted that many Centres must be built before the problem has become so reduced and refined that precise aiming is necessary and practicable. It is also noted that training programmes must be instituted to train the people who will do the surveys.

The Model The aiq of the study

This study illustrates a Health Centre and describes it and its workings in some detail. The study is offered as a design primer and reference for people faced with planning problems in the field. In some cases,the plan may be suitable as it stands. In others, additions or omissions will be necessary. To assist in adapting the plan, much of the preliminary work behind the design is offered for examination in the Appei:dices. Using the Model The study was initially restricted to a single model plan. As work progressed, and as discussion widened, thz need for a range of facilities became increasingly dear, the range extending downwards to smaller units. The Model is therefore shown in the drawings both complete and broken up into smaller pieces. A specific layou: is proposed even in small buildings to allow for future expansion. Any arrangement or rearrangement can be made. Planners inspecting the Model may feel it does not suit them at all, but it is hoped that this consistent volume of information can still be a companion in the planning process. As most developing countries compared with the West have twice the number of under fives and half the working population, this report stressesa preference for the larger under fives clinic as the smallest desirable unit.

The generalplaceof Health Centresin the spectrumof health carebuildings

In most developing countries, five main categories of health care facilities exist: 1. 2. 3. 4. 5. The larger, often teaching, hospital (a Regional Hospital) The smaller hospital (a District Hospital) The Health Centre . The smallest reasonable clinic Mobile services

This study is primarily set in category 3, but areasof high or low density will need special consideration. It must never be forgotten that a Centre is part of a network of care facilities. *The references between Centres and the mutual responsibilities of more and less skilled staff, the links between rc,tltres and District Hospitals and sub-centres need careful thought, definition and firm implementation. It is not
2

intended to cover urban centres, although examination might show the fundamental theory to be the same in the town as in the countryside. The &a&g of the Model Centre The medical job to be done by the Centre can probably be best described by referring to what could be seen as a near ideal level of staffing as set out below: (a) Two principal staff: hospital trained nurses, midwives, medical assistants.

The principal staff will have a full nurses training or a full medical assistants training within the terms of the country in which they serve. It must be borne in mind that present-day trainiig may not be wholly appropriate. Three years is seen as a current minimum for formal training. (b) Four auxiliary staff: small hospital or Health Centre-trained nurses, midwives, medical assistants, dispensers, dressers, laboratory workers, etc. with a one to two year in-service training. locally recruited and trained.

(c)

Two local assistants:

These assistants can be expected to be useful workers in the Centre team within a year. (d) (e) One household assistant: locally recruited and trained for domestic duties. Clerk-storeman-driver-mechanic-handyman. *

Added to category (a) or within category (b) should be a health assistant trained in teaching and community medicine and familiar with the agricultural problems of the locality. One person in thi.r group must also have a minimum approved laboratory training. Additionally, teachers and farmers can be given part-time training and can be part-time health workers and may be unpaid. Whilst in different places different stresseswill be laid on the exact duty and meaning of each of these categories, it seemsessential to see all the staff as having interlocking responsibilities. Thus, for instance, the household assistant can be expected to draw the attentioli of the medical staff tu the arrival of B very sick child. Ideally all staff should a: : take part in community teaching and home visiting. The staff listed should be capable of dealing with up to 200 outpatients per day and ten beds, supported by hostel accommodation for inpatients not requiring bed care. Similar Centres to that illustrated work reasonably well with a considerably lower staffing level than that described here. Consistent with local customs, availability and suitability of accommodation, staff can be male or female, single or married. Two-way communication Regular visits by doctors and two-way communication between the Centre and the local hospital must be seen as absolutely crucial to the Centres being.

The Ckntrein the community

The Centre is to be embedded in the community it serves. Not only are the staff to go out into the community, but also the community is to have facilities within the Centre; these facilities being the main new idea generated by this study. Two-way commurdcafioTibetween the Centre and hospital is to tie the Centre into the nationwide health delivery network.

Expansionof the Model

Chance or policy may dictate that a particular Centre will grow. The Model is therefore proposed as an expandable unit with a specific layout judged against turning the Centre into a small hospital at some future date. Such expansion is illustrated in outline, but should not be seen as being in any way essential to the establishment of a Centre.

Important areasfor further study Evaluation of intention and effect in planning

The problem of evaluating buildings and organizations and services is one receiving much attention at the present time. The aims of these evaluations are threefold: fustly, to seewhether a facility is living up to expectations in use so that when the next run of facilities is planned the ideas behind the first run can be adapted to pive a better result; secondly, to measure the effect of the service in simple health improvement terms as opposed to testing the organization used; and thirdly, as a method of locating gaps in the service so that they can be filled in future.

Evaluation of resultsin the field

This problem particularly affects the worker in a Health Centre in relation to medical records. This is too wide a field for the workin? partv to hegin to cover in any detail. We note some problems and some proposed solutions in the Appendices.

Teaching.md communicating
This report lays emphasis on teaching, training and communication. People have to be taught to teach in addition to being taught the discipline in which they are going to work. This is another field which we have been unable to cover in any detail as insufficient is known about the techniques involved.

A framework for progress

The working party feels very strongly that a framework for progress should be drawn up in both these fields which might serve to co-ordinate all the work that is currently being done. We outline such a possible framework in relation to an ideal large scale organizational unit described in Appendix 44 as a macro-unit, the proposal being based partly on the proposition that centralized training runs against the precept of dispersed community-based medicine.

The future

Trying to locate the problems

The precise position that Health Centres should occupy in a particular countrys health delivery network, :he precise job the Centres are to do in that country, how they are to be staffed, run and financed, etc., will depend on factors too numerous and too varied for any specific comments on the wider organization of health units to be very useful. However, the working party, in considering staffmg and training, the distribution of Centres and hospitals, and the annotation of community health responsibilities, has found it necessary to build wider ideas against some sort of framework. This framework is discussed in Appendix 44 (Numbers of people served and the distribution of Centres).

The macro-unit
The macro-unit we have used is large, consistmg of one Keg~onal Hospital relatmg to ten District Hospitals, each District Hospital relating to ten main centres and a number of sub-centres. An organization proposed on this scale makes a useful analytical tool for breaking a national planning problem down into a limited number of parcels, each parcel being of a comprehensible size. Each parcel is big enough to cover such a wide variety of geographic and population conditions that it becomes reasonable, in setting the ideal into an actual situation, to propose a substantial but still acceptable loss of efficiency from the ideal pattern: if enough people are included in one macro-unit, then the precise proportional differences between town and country dwellers, reasonably accessibleand virtually inaccessible terrains, good and poor communications, and varying population densities, become less relevant, giving initial theoretical planning a better chance of being realistic.

The useof the macro-unit

The macro-unit attempts to give an overall organizational map on to which Health Centres of smaller and larger size, with their supporting network of hospitals, can be plotted with some confidence in the resulting requirements for staff of all sorts, for buildings, and Carthe organization of training.
4

. <

. .

,.

(This dkcriptioh is supported by a number of Appendices. Many of these overlap, but the. working party have preferred duplication within different subjects to complex cross-referencing. Each Appendix aims to cover a particular subject constituting in effect a check-list for that Isubject)

, -_ Principal hiter-relationships Fig. 1 showshow the main parts of the Centre relate to each other.
VILLAGE

Byic format

SOCIAL

AREAS

KITCHENS

Fig, i . The priictpal inter-reiatioirzhips in the Model Centre

OUTPATIENTS + ChXTRAL FACILITIES -h,LkDS

Thesocialarea~ The social area, kitchens and hostels a.replaced between the *%age and the Centre. This position demonstrates that the area is as mucl: viilage-terd:ory as Centre-territory. The buildings are to be improved local buildings, using materials and techniques available i.3 ;he community and within their Rnancial resources. The buildings will be silent teachers throughout their life, and will provide a place where two-way communication between staff and patients, between people and ..&.,.. Ireas are disctissed in Appendices 1 arid ! 3. people+?akesp!ace. Thpr* . Where problems of ,nalnutritici~ could be a!leviated by ,n-,rdencultivation on a small plot such a p!z shou!d form part ou^ social area. it should be worked by the a member of the Centk staff, using no more time or money than a member of the community could affc;rii.

Basic organimtion Fig. 2 expands the relationships between the main parts.

ALL STORES AND &WE

AGE

Fig. 2. Expanded inter-relationships in the Model Cm&e

.I :. i .,

WATER

STORAGE

&c

The Model plan Fig. 3 shows a simplifted outline plan of the Model Centre with the outline accommodation shown in Fig. 2 distributed round the buildings. Fig. 4 opposrte . shows a birds eye view of the plan looking from the direction of the black arrow. Village

-/
Stores and garage

op2z5j&~~gft~
20 metre.r

---I i
I Social area

Hostels : 1

Fig. 3. Outline plan with basic organization shown

Y--l=l

Und;;Gves ante-natal

r!

Gel

J-LA
31 facilities

1 f r
Kitchens Maternity beds

Additional governing factors Points about the Model Plan It is essential to remember that: 1. Only part of the Model may be appropriate for a small Centre. 2. More accommodation than shown may be required in large Centres. Some Centres may even turn into hospitals and this expansion has been planned for. 3. The buildings are laid out assuming that there is a best orientation for climatic reasons(see Ayl>endix 48) so they are set parallel to each other in the Model. 4. The buildings are designed so that they can be built with unsophisticated means and simple materials. The distance hetween walls or columns has therefore been kept as small as is practical. Where a bigger room is wanted or extra space is . gives a complicatcu outhue. needed the roof is pulled out a little. 11~s
6

Description of the plan Generaldescription of the layout Fig. 4 below showsa birds eye view of the plan with the accommodation numberedand the namesof the parts given underneath. The parts are numbered clockwise from the top. c

..

. 3,
. ., . .

Fii4.

AtypicalCentmontheModelplan.The mow Indicates the main approach. 10. Staff latrines 11. Central facilities 12. Outpatients including under fives etc 13. Pharmacy(dispensary)and laboratory 14. Latrines for social areaand outpatients IS. The social area,prominent in the middle of the plan 16. Reception (and information) set opposite the entrance 17. There ls an open areaat the ccntre of the plan. This should be well planted with treesfor shade 18. &alternative entranceposition is shown from the .

1. Stqresand garage placednfarthe entranceto simpllry early construction, to cut down trafilc and to achieve a public position renderingtheft more difficult $. &p dormitory
4: Hostel

Fig. 5. The main zones of interest in the Model Plan

There is no reason why the plan cannot be turned any way round or up. There are, however, fairly prease relationships which allow for growth and change. These tiould not be cpset if this can he avoided. Where sites slope. changes will have to be made, but should be restricted to the minimum. Covered ways are shown linking the main buildings, but not to the social area which is thereby given its own territory. The social area shown is smaller than the working party would like to see. If it is made any smaller it will not shelter sufficient people to make the building worthwhile. In some situations the social area could double as a sleeping shelter. (see Appendix 13 on Hostels). 8

chapter III - The +awings Drawingsand how to usethem Eolded into the back of the report is a scaleplan of the whole Centre. This canbe openedout to lie besidethe report. The plan showsdetailed dimensions which can for the moment be ignored. The plan showscolumnsasblack dots and walls asthick lines. Roof overhangs shown in a dash-dotdine,the ground floor are is outlined in a singleline, windowsare-shownastwo parallel lines. The lines away from the buildings with numbersby them locate the dimensionsand haveno other meaning. Enmediatelyin front of the plan at the back is Fig. 15 showingthe cross sectionof the building and a possiile roof structure. This may be ignored for the r moment. PrecedingFii. 15 at the back of the report is Fig. 14.which sho& details of latrines and possiblesewage lines. Earth latrines haveto be movedperiodically so a line of march must be allocated. Wherepiped sewerage installed the lines of the is pipesmust be laid to avoid possiblefuture extension. Theseare for later reference. Receding Fig. 14 is Fig. 13 which showsthe Model Centrewith its possible extensionto a substantialhospital outlined. Fig. 12 showsthe extension to a 25bed hospital. Theselast two drawingsmay alsobe ignored at this stage. Fig. 6 which follows the next section (How the buildings are to be built) shows the Centreasa roof plan with letters on. Theseletters refer to the main blocks of accommodation. They do not relate to the numberson Fig. 5. Below Fig. 6 is Fig. 7 which showsa plan of the rooms in the main buildings. The plan shows numbersand alsothe same letters asFig. 6. The numbersrefer to the key giving the room names. The namescan be found on the room list immediately apposite Fii. 7. This list. groupsthe roomsby letter, somerooms overlappingintqwo groups,and notesthe areaof eachroom. Circulation and coveredways are not noted on this list. A skeletonextendedlist for a smallhospital is given in Appendix 20. Following the room list is a seriesof drawingsin two parts much asFigs. 6 and 7 wherethe roof plan is shownat the top of the sheet,the detail plan below. E&h can be referred to the main fold out plan. Not all the possiblealternativesare shown. How the buildings are to be built and selectiugthe right size Appendix 48 showsthe basicthinking behind the plan and is written in nontechnical terms. A short spanhasbeenusedto keepthe structure simple,the spanbeing the distancebetweenwalls or columns. Details of windows and doors havenot beengiven asthey will vary so much from place to place. If there is a local solution that works (such assolid shuttersinsteadof glasswindows) it should be considered. Appendix 35 looks at materialsand costs. Again thesevary very widely. Selectingthe right sizefor a unit is a relatively simpiematter providing either availablestaff or availablemoney is known and providing an approximatecost per squarefoot or metre is known. The smallestunit recommended the working by party is unit C, the under fives clinic (seeAppendix 2). This will give enough spacefor a tolerable socialareawhere resources very slight. are Actually going about setting up a Centreis describedin Appendix 47. Whereonly a very small clinic is required following the overall layout and selectinga site (seeAppendix 41 on site sizes)may be totally irrelevant. It may alsobe wise to adopt a simpler structure that canbe.built by the local people without drawings. The approximate sizesneededcan,however,be taken from the Model plan.

Figs. 12 to 15 arein Appendix 52

Room list and somecommentson rearran@n# Model plan the This room list should be readin conjunction with Fig. 6 or 7 and/or the fold out plan at the end of the report. The numbersare not the sameasfor Fig. 4. The rooms aregroupedwith a letter referencewhich is usedto describesmallerunits than the Model, for instanceAtB is outpatients (A) plus laboratory, dispensaryand clean and dirty treatment (B): The letters do not show all the poqible groupings. @ combinations. It is convenient and practical to carvethe plan up on column lines. Onecould haveA + room 4 t a combined laboratory and dispensaryin the outpatients waiting areain front of 4. 4 would then combine the functions of 4 and 5. The same sort of thing could happen twg C but using it as the only clinic, and msking 10 into the office and reception. The social areamight bebuilt first where23 and 24 are on the Model. It could be movedlater, the old ma becomingthe office accommodation. F and C could be built fust, room 23 beingusedfor room 9, room 24 for rooms 10 and 415. Room 22 would be used ibr rooms 11 and 12. Room 15 is a suitableplacefor immunizations. Room 8 could double asa socialarea. An extended room list is given in Appendix 20. Possibleextensionsare illustrated in Appendix 52, Fig. 13.

Group

Room No

Room

Sire in ft.

Area in sq. rt

Total Room waain W.fi 784

Add or cotidors and overhangs 15%

Area for costin insq. ! t

Area for costing in sq. m.

A. outpatients

1 .3

store
EXMll,l~tiOSl

waiting Dirty; tre8tment ;I;~tJt~;trnent i%ii%ii waiting if requtmd

5x16 12x16 16x32 :~~:~ 8x16 8x16 16x32+

1:X 512 130 Et 128 5120

900

83.5

B. Treatment area

4 : 7

1106+

30%

d. Treatment ML D. UnJnNzand

As B, but room 4 mows to room 13 Under flva consulting room Examination/Ante-Notd Corridor and welghlng station Waiting Additional waiting for treatment 16x20 12x16 4%x40 12xso* 13x16. 16x16 10x13 12x26 8x15 trt 12x15 16x16 16x16 16x20 12x20
5X8

1: :: 13 :5 16 :78 19 f! F. Offica 22 23 G. Goodsarea 2: 27 38 30

ES 180 600. 208. 256 130 312 120 f f: 180 256 256 320 240 40 :zt Xt 88 490

1292

20% 20%
23.5

208

r&II8 beds store8 women and Childre~$ beds $gs centre of rctlvities Cleaners store grve store Staff/conference Reception/clerk Disposal Cl:Zl$r Liisn store Laundry Dirty linen Covered links Total including 13 sterilizing

1358

20%

1630

152

816

30%

1050

8x11. 8x11
8X11 8X11 8x11

480

25%

600

56

-.

490

10%

6534

Area shown has additional

apace available under overhangs or extended eavw.

Thesefigures do not include: Latrines, kitchens and laundry for;z;aen8e Hostels staff housing

SeeAppendix 13 for Hostel plans and Appendix 14 for Staff Housingplans.

0 0 40 10 80 ft. 20 me&es

Seealso fold out plan at end of Report and extendedroom list, Appendix 20.

Fig. 6. The Model Plan related to letter groups for reference to room list;

(roofs shownshadedasin fig. 4.)

North or South-

. . ----1
T Latrines .
l I

Ki tc.h ens .

1. I

r.-- f
10 i . 12

,Roof

overhang

Column

1;
I

Fig. 7. The Model Plan with room numbers referred to room list opposite.

(the sameplan asfig. 6 but drawn to larger scaleso that roomsmay 1 be identified)

L.l!Z!A r.1

--+ 0 0 A
5

c.-

-I
10 me&s 40 ft.

Staff latrines 11

:.: . _. .. ,. * _. . . , . *:,.

. .

:.:I.. . . . .. . . . . . .. .

0 A 0
.

80 ft. In 20 metres

, .. .

.. . .

. . I?. . -I. :
Ch-eiall outline of Model shown for

F&8. The smallestunit A ,- generalcliic

Overall outline of the Model shown for reference 1. Store 2. Examination 3. waiting

. __._ - ..--_

L-l D
\The smallest unit

IO metres

40

80 ft. 20 mclrc\

T. .-. -rIn

Ihe smalleat wornmended

unit

_ ._

D-

An under flvw bmd generalclinic

9.

if:
12.

Consultmg room Ex8mination~ante-natsI We&;g rtrtton

plus - social area stores hostels

he smallest ?commeuded unit

----.

i---1
--1
+--

13

I..
1

I. 0 .-. --- .. ... -1 . F-

.

. .

.::.

1040

20 ietresft. a0

. _-_ *. --.. : .

1..
. . . -.. f.. . . . . ::. :. a . . * .

.2xr -L . . ..<

__

.:.., . - ..

*.._ . . . . . -.: ,:: . . . .

,: . . . ; . .

l .

.. ..

. . . :. ./ (- . . : . . . .. . .. /
So.

<,

-. .

. .

Fig. 10. A wel! supported clinic unit.

24

I I l*I i I -1 i
]

~.ew-l~~

l .i G

.r . I .*

F
0 n

-.

0 l--7.

40 ft; 20 i -5 -2 --v-4 10 metrea

Additional

hostels

4dditiona wards

Additional outpatient
ClilliC-5

(gives 3 time: 5 area of Model).A, II I. ..

Ii

-4

X-ray and operating room yLi

Extended ward (+ 12 beds) _-

5 bed

5 bedr

Fig. 11. Possible extensions of the Model. See also Appendix 20 and Figs. 12 and 13 in Appendix 52 at the back of the report.

15

SUMMARY Thesenotes suggest a Health Centre might look and how it might &ork. It how could be built and run this way but the intention of this tepart is not to lay down hard uld fast rules,but to put forward only one solution to the problem of how to set up a Centrewhich would be a flexible vehicle for health delivery in the community and to statein broad outline the operational policy for a Centre of the sizeproposedin the basicModel. Only thosewith local knowledgeand experience can make the right decisionson distribution, operational policy and built form. A report which is so generalizedthat it w@not offend specialistopinion must inevitably suffer from many limitations and result in the exclusion of any reference to somespecialistareas. At least half of the Appendicescould be expandedto provide paperseachbeinglonger than the whole of this report. Wewould, however, like to feel that the report will provide a useful check list of important attitudes and ideasazd wil5help others to arrive at what may be quite different solutions.

16

Socialareaand kitchens Ihe social areais the point where the Centremeetsthe community and vice versa and is essentialasa health education facility. Displays,demonstrations,talks, film, slides,etc., should be allowed for and should cover: Personalhygiene Community hygiene Watertreatment, conservationand storage Nutritionand nutrition& rehabilitation Food gro - and preparation, and agricultud and gardeningpractice T The nature 0 diseases Baby and child careand family planning Theareashould be roofed and will alsobe usedasa waiting area. It should he prominently sited on the principal entranceroute and could be seenas a gate-house. It may contain an ideal home built in improved local construction asa permanentteaching display. It may be shut within the Centre compound by night. It should be built and maintainedby the community. Community development peopleshould be drawn into the life of the Centreand the socialarea,and should be approachedat the earliest planning stages advice,and later for assistance. for Wherepossible,it should havea drinking watei point. At least 10 kitchens in the local mannershould form part of the socialarea,for teachingand for ward and hostel use. Weare not planning to provide or prepare any food except for specialdiets preparedby the nurses: relativeswill feedpatients. The areashould havesomeaspects a market. A small number of local women of canbe offered the opportunity to sell bottles, para-medical local weaningfoods kit, and approvedfoods suchasHyderabadMix. This facility is to be absolutely under the Cimtrescontrol. The areashould be clean.dry and shaded,and supervised from a reasonable distanceby, for instance,reception. It must be clear to the vendor& that they are there under direction. A gardenis to be usedto demonstratehusbandry.including small animals,irrigation and the useof fertilizersan the household scale. The areashould haveassociated latrines under the control of the community. Other Centrelatrines could be used. Intentions regardingthe useof and access the are& what it is for and what it will to offer, when and by whom it may be used,and who will build, maintain and clean it must be madeclear in eachcasewith the local peoplebefore a project is started. Ideally Centre staff will be availablefor discussions matters of current intereat at of timeswhich cometo be recognized. This is preferableto a programmeof talks. Similarly, visiting doctors should be perguaded turn up andjoin in occasionally, to treating the eventliterally asa social event,but one to which a specialcontribution can be made. Local peoplewill alsoideally turn up snd discussthings of relevance, possibly askingquestionsetc. This kind of non-meetingwould be a good time to start new projectsby trying out the idea and testing enthusiasm. The social areashown on the plans is small. The biggerthe areathe better within reasonable limits. The problemsof the social areain cold countries needa separate study.

APPENDIX 1 SOCIAL AREA AND KITCHENS

Under Zii clinic The working party strongly recommends closeintegration of the Under FivesClinic with the Ante-Natal and Family PlanningClinic. (seeAppendix 3); The Under FivesClinic in the Model doubleswith the Ante-Natal and Family PlanningClinic. Wherethere is only one clinic in a small Centreit is reasonable to suggest should be the Under FivesClinic. Somelaboratory facility should be it provided in or very near to the clinic. The fuB theory of the workings of an Under FivesClinic can be found in Paediatric priorities in the DevelopingWorld, by Dr. David Morley (Butterworth, 1973). The essential principles can be simply summarized. Children from birth to five, accompanied their mothers,regularly attend the clinic whether the child is ill or by not. Weightis entered on a chart which givesearly visual warning of malnutrition or other maladiesresulting in weight loss. Staff trained in the recognition and treatment of the childhood diseases mothers and children in groups,so that see motherslearn about the pioblemswhich their own children may later present. Anie-riatal adviceformspart of this group system,generaldiscussionand comments being possible,experjences being sharedasdiscussiontopics rather than ascon. fidences. Nutrition, hygiene,etc., canalso form part of thesegroup sessions. Somedispensing, injections and treatment are normal during a session. Some clinics seegroups(of six to eight mothersand children) asa group and work through until everyoneis seen. Othershavesix to eight mothersin at a time, eachfamily leavingasit is seen,and a new family coming in. About 80 children is the maximum number a nursecan seein a day.

APPENDIX 2 UNDER FIVES CLINIC

The plan of the clinic hasthree main parts, a waiting area(seeAppendix S), a corridor behind a fence and the consultation room or rooms. Whenthe unit doublesasan ante-natalclinic an examination room is necessary. Built into the fence& the weighing counter, which should be at a convenientheight for standing mothersto be able to put babieson the scale. Height is alsomeasured some in clinics. Mothersgoing to consultation following weighing,etc. are let through a gatein the fence. Mothersleavingconsultation also passthrough the gate. This controls the flow of patients and ensures adequatedocumentation.

Patientsactivities The diagramopposite showspatients moving through the clinic taking full advantage of all its services. Every patient will not necessarily through the full routine. go This kind of diagramoccurselsewhere the report and attemptsto summarize in the activities involved with people USIII~ clinic and may alsoshow goods(e.g. the disposal meaning*goodsto disposal)and links to other roomsor departments (e.g. treatment meanspatient goesto treatment when on a side shoot, but means treatment is part of clinic routine whereit is in the main stream). Wordsin bracketsmeanthe activity will not alwayshappen. Thesesequences make useful checklists during planning - the plan muat satisfy them. The key featuresof this clinic are regularattendancewhether the child is ill or not, and continual two-way communicationbetweenpatients and staff. Teachingis a continuous process. Advantagemay be taken of waiting periods for formal teaching. Groupsof mothersand children are seentogether so that training in the recognition and treatment of the commonchildhood diseases forms part of eachvisit irrespective of the symptom for which a particular child is brought to the clinic.

ii)

Approafh Centre (mother brings childs card)

U,

visit or passth&gh social area A find and enter clinic

L (wait)
(Nurseor attendant* notes arrival) 1 (treatment) J (admission) . 1 settle down 4 (wait and learn from displays) \

(treatment) H I\

1 register/weighing/(payment)(measuring)~ (specimentaken), 4 (wait) 7 I seenurse,seniorhealth visitor or doctor asavailablefor: w drugsetc. examination/discussion/learning (treatment) (injection) (prescription) (receivemedicine), (documentation) (specimen, taken) K b wastesto

10%mother and

\ _. ?

(specimentaken)
\\ .&; I ,- leavenurse oisenior

(a&&&n)

i,, j <(injection) /

docum&tation \1 leaveclinic L

\ depart through social area away

(presentprescription) 6 (wait) -tY (collect medicine)

\L

* attendant could be a school child. Arrival can be noted in 30 seconds. This systemmeansqueuescan be avoided. Attendants should be trained to recognizechildren needingimmediateattention, hencethe introduction of (treatment) at this point.

Nwsesrthities The nursesactivities, following the patients registration, are describedbelow. The nursestartsher consultation by checkingthe correctnameon the we@t chart and usesthis name(unlessit is culturally unacceptable). Nurseenquiresabout the childs health, or if he is obviously well shecongratulates the mother on her childs health. Symptomsand their duration are recorded. Openschart and quickly notes: 1. Reasons specialcare for 2. Resent weight in relation to previousweight 3. Gainsa picture of childs progress past illnesses and 4. Notesparents attitude to birth interval 5. Sees any immunizations havenot beengiven,and whether they are due. if Asks about food given the previousday and frequency of meals. Raks mother on at least one point in the diet shehas givenbefore suggesting even minor alterations. Proceed with examination asfollows: Quid with symptoms Nurseobserves examinesrelevantpart of and child. If the condition is: Severe or not understood Accompanies child to seeseniorhealth worker or doctor if available. Mild Nursegivestreatment or Antimalarial tablets or Arrangesor gives immunization or Food supplementif required or Family planning adviceif required etc. Child symptom-free Nurseenquiresasto happiness of the child, and his development. Follows up any lead givenin conversationby the mother on family or other difficulties. Turns conversationto improving health. May draw other waiting mothers into this conversationand, for example,get their opinion on the most suitable birth interval. Aims to be a sympatheticand patient listener. Makesentries on card.

Appendix 2 (ctd.)

Mother and child leave

(iii)

APPENDIX 3 Integration of the under fives clinic, ante-natalclinic and family planning clinic is stiongly recommended. Recordscan be constructedin a way which showsthat the health of both mother and children deterioratesasfamilies get larger, and that the ahorter the birth interval, the quicker the deterioration. Conception,pregnancyand childbirth are surroundedby many folk-traditions and taboos,and an understand@ of theseis essentialbefore phu1&8 a teaching of for campaign. An understandingis also necessary the reasons frequent pregnancieain any given community. Thesemayinclude a high infant mortality rate with the consequentneedto havex number of babiesto ensureone son living to adulthood; the needfor a succession herd-boys,water-carrier&etc; asproof of of virility in the male or fertility in the female; or simply that the woman doesnot feel right without a baby. With this backgroundknowledge,the optimum bii interval may be worked out; this will vary in different cultures, but will probably be in the region of two to two and a half years. A family planning campaigncanthen be introduced aathe way to ensureoptimum spacingof children and not asa mew of lhniting family size. Family planning will not bring to an end misery. ill-health and starvation,but it shcndd lead to a noticeableimprovementin the well-beingof a noticeablenumber of families. It is very much the job of Health Centrestaff to annotateand point out the improvements. Ideally, motivation for family planning is best discussed with both parentstogether. Next bei is to haveseparate sessions men and women and the least successful with method is to have only the women attending. The contraceptivemethod of choice wiU dependon many factors, and it is essential that both parentsunderstandand acce t the method recommended. Specific instruction on contraceptivesmay weIf be combinedwith the work of the ante-natal clinic. Attendanceat the ante-natalclinic should be monthly up to 28 weeks,then fortnightly up to 32 weeks,then weekly. Only rarely will this ideal be achieved; most patients will attend only three or four times and at irregular intervals. The first visit will include history-taking, physical examination, weighing,pathological investigation(Hb, urine, testsfor parasites),and theseinvestigationsmay be se aratedat future visits. All visits will include prescriptionsfor vitamins, iron is P , anti-malariah and appropriateimmunization asindicated. Any visit may revealcomplicationsrequiring more frequent attendance,comingon a specialday to be seenby the doctor, referral to the basehospital, or admission to the Centre. The Centremust havea clear policy on admitting for delivery, which will depend housing conditions on local circumstances. In the village situation with reasonable and a reliable co-opetitive folk midwife, a high proportion of home deliveriesmay be possible. With a scatteredpopulation, very poor housing, or bad communications, delivery at the Centreshould be encouraged. This may meanthat the mother must movenearerto the Centrewell in advanceof the expecteddate of delivery and use could be madeof the hostel areafor this purpose. Mothers will probably bring their other children with them, and it must be remembered this isan excellent that opportunity for teaching,especiallyon food values,cooking and home budgeting. It must alwaysbe remembered an apparently straightforward delivery can that becomecomplicated a very short time, and this is often given asa reasonfor in adridtting every mother for delivery. Health Centrestaff should not attempt full coverwith insufficient funds and facilities available,but adhereto the agreedpolicy over admissions acceptthe fact that unpredictablelast-minute complications and are not their fault. The compositelabour graphdevisedby Professor R.H. Philpott (1) for useat Horari Hospital, Salisburyis easyto useboth for home deliveriesor at the Centreand is a good early warning systemof impending complications. Post-natalcare can be limited to one visit six weeksafter delivery and the importance of attending for this examination should be stressed. It is also hoped that mothers will bring the new baby to the under fives clinic at regularintervals. ANTE-NATAL CLINICS ANDFAb!ILYPLANNlNG

(I

Ob~tetda, Family Planning and Paediatriu pmbl&hed by the FemR- . .--.g , m-r-*Amo&:lon

by R.H. Philpott, o? Rhhodesia.

K.E. Sapire and J.H.M. Axton.

APPENDIX 4
A separate of room8for generaloutpatient8 is best, but where the clinic is very set small and only one room is poadble,it is better to plan thi8 for UI e! a UFC and useit for generaloutpat@ntsalso, rather than the other way round.

GENERAL

OUTPATIENTS

Categories patient8attending clinics will be: of a. b. c. d. e. Adult male Adult female- non-maternity Adult female- maternity (where clinic8 are combined) Children ftom fne to 8ixteen Under five8(where clinics are combined)

In countries wheremen and women may wait together, a, b, and c, can usethe sameclinic. Wherestrict 8egregation necessary, generalout atient areawill is the be usedfor men, and all women and children will be seenin the UP; clinic area. C It is also recommended rchool-children be treated during vi8its of Health that Centrestaff to schools(seeAppendix 28). Immediate attention and treatment for all patients is abvloualy the ideal, but will rarely be achieved. Waiting time should be kept to a minimum, and a simple method of preventingqueuejumping is advisable. This could be doneby issuing numbereddiscson arrival, or by collecting patient-retainedrecord card8and call@ them in rotation. it is not a good method to havepatients doing a bench shuffle every thne one of them is called. Wherelargenumber8of patient8attend a clinic, patients for treatment may have to be pooled and treated in batches. Ideally there should be one senior staff memberseeingpatients, and another superviling the treatment area. The pharmacy should be near the clinic, but preferably with a separate waiting area. Routine medicines(e.g. iron tablets, anti-mahuials,vitamins) should be hold and issuedin the clinic room, particularly for the under fives. The best record documentsare those carriedby the patient8 themselves a strong in plastic bag(seeAppendix 30). Local or national governmentmay also require the keepingof other and separaterecords. In someareas, specialclinics might be run on different dayr, e.g.ulcer clinic8, TB, leproty etc. It may also be convenient to seepatient8 for repeattreatmentsat ti different time of day, provided this is acceptable locally a8well a8to the clinic organization. Nevertheless, patient coming from a distanceshould alwaysbe any Seen treated irrespectiveof whether he ha8comeon the right day. Aho, ail and clinic staff should be constantly alert to spot the arrival of very ill patient8and ensurethat theseare not kept waiting. Statisticsoffered to us from varioussources indicate that the breakdownof attendances be about 10-15 per cent adult male, 30-40 er cent adult female; will 40-60 per cent children. Daily attendance8 vary from P may O-250. An average of not more than two visits per year per adult may be expected,and a high proportion of visits will be connectedwith maternity care. It is an open uertion whether this pattern of attendanceis a reflection of the care offered or of ill e potential demand. An urban hospital outpatient department,excluding UFC and ANC wffl see2! per cent adult male, 30 per cent adult femaleand 45 per cent childreii. & the face of it the statisticsjgivenabove. therefore realistic, sincethe imbalyce are gn;; reflectsthe concen!ration on under fives and maternity careat theJ%alth / . t j, . *fl/

APPENDIX Facilities are requiredfor: standing Sitting Drinking - clean,obvious, well-drainedtap in view of the staff Disposalof rubbish Latrines High shelves belongingswherethey can be easily seen for Low seatingis to be preferred wherethere are mothers with small children The social areacanact asa waiting reservoir,and proximity to the social areais important for childrens and ante-natalclinics, for teaching and demonstrations purposes. Plenty of space required, well shaded. is Children may haveto be dressed undressed the waiting area. Male and and in femaleareasshould be separate a waiting room is to be madea part of the clinic if for interviews or examinations. Teachingdisplaysin a locally digestiblemanner areimportant throughout all waiting areas. The position of the clinic and its waiting areas must be obvious and once patients are involved with the clinic it should be clear wherethey must go to receivetreatment. In the Model plan patients passthrough to the back of the clinic for treatment wherea smallwaiting areais provided.

WAlTING AREAS

,i

PhamacyorDispensary The object of the pharmacyis to get the right drug to the right patient conveniently and efficiently and to makesurethat the patient knows how to useit. The drugsthemselves mUSt a. Effectively treat the relevantdisease b. Be reasonablyeconomical c. Be stablein availablestorageconditions Humidity and temperaturecan ruin drugsvery quickly in store: the best drug, even the cheapest, may be useless this reason. There is a particular problem of cool for storage,particularly of vaccines,which needsstudy. Requirements haveto be predicted, drugsordered, checkedand stored, the bulkpackagingbroken down for use,the prescribeddoses issuedin a suitable manner for the patient to hold and usethem, and stocksreplenished. The key-notesup to is issueare tidinessand forethought. Counting out pills during a session irritating and and a wasteof time. Batchingshould be done before the session, if possible about twice a week. A suitableset of open pigeon-holesof varying sizescan then be filled, and the required drug8taken out and issuedquickly, re-stockingneeds beinn obviousto the eve. It must be noted that pigeon-holes should not be re-filled un&ll the packetsark used,or caremust be takento ensurethat new packetsare placedbehind or below the old ones. Batchesmust be preparedin packagingwhich is reliable. Plasticsachets madeup with heat-sealing machinesfrom plastic sheetingappearto work well in many cases, interactions betweenplastic and drugsneedchecking. If patients bring but their own bottles or jars, theseshould be rejectedunlessscrupulouslyclean. The phauuacistshould sit in public view - patients wig be more tolerant if they can seehim working - and a counter at a good height is more human than a hatch. The higher counter will alsogive more storagespaceto hand. Patientsshould not be able to reachin and grab drugs. Instructions on useand instructive labelling are essential. It hasbeensuggested that picturesbedrawn to describeuse. Two examplesare givenbelow from the Dabou Hospital in the Ivory Coast. Clearly thesepictures are ambiguous,but are better then-merewriting or verbal instructions.
HOPITAL PROTESTANT DABOU 2 GOUTTES DANS r YEUX

APPENDIX 6 PHARMACY OR DISPENSARY

BP 115

1VERBEDEAUCBA

Two examples of explanatory labelling for drugs

Wherea folk-medicine parallelsthe Health Centre systemit is advisibleto check that the drugsuseddo not resemble folk-medicine in appearance. A brownish syrupy liquid may havevery different actions and method of usein the two circumstances, evenif a patient may not misusethe drug, a relative might. and A consistentprescribingpolicy is necessary. It is better to give one patient one pack for a short courseand another patient two packsfor a longer courseof the samedrug rather than making up different sizedpacks. This saves time and reducesthe possibility of mistakes.. Details like half spoonfulsshould be obviated by making up weakersolutions.

(9

Wheredrugsare madeup on a fairly large scaleat a National or RegionalService Centre,packscan (with advantage) madeup for usebefore issuing to the Health be Centres. This saves time in the Centre and meansthat machinery may be used economically,xv<+& better hygieneand fe+er mistakes. ihiiirg wiil also be more economicalif carried out centrally. Whereoutstations are suppliedfrom the Health Centre,staff must realizethe total dependence the outstation on their services. Stocksshould be ready well inof advance delivery time, documentingmust be clear, packagingand labelling clear of and simple,and dated. For liquids it is better to return a partly full container and issuea new full one, washingthe old one at the Centre,rather than to go in for messytopping-up, which canlead to the progressive dilution of ineffective old stock. Theft canbe controlled by keepingwell-locked and supervised storeslaid out so that the progressive diminution from the back of a pile which can occur is stopped. Thievesshould be instantly dismissed. Accessible stocksmust be kept to the useful minmrium.

Appendix 6 (ctd.)

(ii)

Laboratory
Laboratory for Developing Countries (t) by Maurice King with the assistance of UNICEF. We reproduce opposite one of his illustrations showing a laboratory. The main feature of the laboratory is a work bench about 10 feet long at a good workmg height (in this case30 inches) and 30 inches deep. Some people will prefer a higher bench to work at, with a small lowered area for writing, as 30 inches may be too low for working standing up when the worker wants to move around, whilst being somewhat too highfor writing sitting in a chair. The work that wiil be done in the laboratory will depend on the skill of the assistantconcerned, available equipment and the prevalent disorders in tue community. A microscope in a good caseis a must, the instrument to be well maintamed and admired and inspected regularly by senior staff. Teaching of the existence of microscopic organisms is greatly easedif people can and are encouraged and allowed actually to see them under a microscope. The laboratory has a major role in the working of the Health Centre. Training and encouragement are essential for recruitment and the improvement of the service. With the staff described for the Model Centre the range of work that can be undertaken will include but will not much exceed the following: Testing urine for albumen, sugar and acetone Identifying mala:~;~ .III~~II~.III~ parabttesin blood Simple test f01 sizkle cells Identification of more common parasites in stool specimens Haemoglobin estimation. In some areasOther investigations, ds for instance fiaria or leprosy tests will be essential. An outline equipment list is given in Appendix 19.

APFENDIX 7 LABORATORY

Laboratoriesfor Health Centres are covered in detail in tbook, A Medical

(1)A

MEDICAL LABORATORY FOR DEVELOPING MA Cantab., MRCP Lond. Edition assisted hy t!NICEF (Oxford I niwrsity Illustration reproduced by permission

COUNTRIES. Press)

Maurice

King,

A health centre laboratory

CelltmI fhciIities The Model is basedon the principle of avoiding duplication to achievemaximum efficiency and ecr nomy. The Model hasno X-ray facilities and no operating theatre. A better description of Central facilities might be sharedfacilities, shared, betweeninpatients and outpatients. There are three main groupsof rooms:1. A treatment/injection sequence 2. Laboratory and pharmacy 3. Staff accommodation The treatment, injections etc., roomsare designed with an eye to staff economy. The inter-relationshipsmay be seenbelow:-

APPENDIX 8 CENTRAL FACILITIES

CLEANCASES

CLEANUP ANti STERILIZE

App. 8. Fig. 1. ~er;reetiotrhips facilities

SOMEBEDREST FACILITY

DISPOSAL

\1

Wherea dirty treatment room is provided, sunlight should be allowed to enter the room asit hasa beneficial sterilizing effect. A high seatfor patients with leg. dressings saves staff much bending. The treatment centre will alsobe usedby inpatients and may in somecases asa follow-up dressings act clinic. Injections facihties will receivehighest call from the under fives clinic. The cleanroom is alsoto be usedfor re-hydration, injections and possibly also for bed rest. The principal call on laboratory and pharmacywill be from outpatients, but inpatients will alsoneedtheir services. Additionally, the pharmacymay in somecases needdirect access from outside the compoundwhere the compoundis shut at night. Money may alsobe taken at the pharmacy. All thesefacilities and staff accommodationare discussed their separate 1q Appendices.

Receptionmd office The reception areaand office should be clearly visible from the entrance,should be both an enquiriesand a direction post, and thoseworking in it should be able to see the main darts of the Centrefor giving directions. It will alsobe the clerical and documentation centn, and may well needa safefor cashpayments. In the Model plan receptionis shownbetween outpatients and Inpatients rather than aspart of outpatients assuggested severalauthorities. The position shown by is preferred by the working party asit allows a space within the Centrewhere ticord &king, collating, and the preparation of progresschar&&. can take place. Seealso clerical work (Appendix 10).

APPENDIX

RECEFTION AND OFFICE

Clerical-work A clerk may be necessaty someCentres. in The following types of documentation are noted asprobable: Requisitionsfor suppEes, probably on a monthly or quarterly basis. A requisition book wiIl be normal (geeAppendix 18 - Storesand Storekeeping) Simpleaccountsfor petty cash Accounts of incoming sums,i.e. fees,and outgoing sums,i.e. local payments. Feesshould be standardizedasmuch.aspossible,to avoid complications and to makecheckseasier. Governmentmonies,if applicable,to be accountedseparately, probably involving receipts. Correspondence Referralnotes from satellite clinics and areahospital Registerof notifmble diseases Ante-natal registerand births Centredeaths Records Somelocal statistics,e.g.censusinformation, should not be part of the Centres duties. Whena patient is being documented,staff should be set at a high counter so that their eyelevel is similar to that of the patients. The staff should alsobe trained and encouraged be welcomingand friendly. to The outpatient aspectof the Centrewill makethe greatestcall on recordsand offers the major load of paperwork. Wherever cardscan be held by the patient, this should be encouraged. Recordsof all sortsshould be asfew and simple as possible. Seealso Appendices29 and 30 on record-makingand patient-retainedrecords.

APPENDIX 10 CLERICAL WORK

-/.

AddSBiOIIS

APPENDIX 11
I

The documentation required for an admissionmay be largely dictated by government., Whetherthe acceptance a patient asa temporary hostel resident of constitutes an admissionat law will needclarification in eachcountry. The basic rules for documentationmust be that they are: As simpleaspossible Designed do the job in hand to Useful asa guide to the progress the Health Centre of Useful for national statistics Useful for forward planning Oncedecisionshavebeenmadeasto what kind of treatment a Centreis to carry out on admitted patients it becomes possibleto decideon routines. In general terms and taking very bald figuresprovided from working party experienceadmissionsare currently divided up asfollows: 5 per cent adult male 25 per cent children 70 per cent adult female Thesefiguresrevealagainthe bias of current Centresto maternity and child care. A most important decisionis whether this tendency is to continue or whether the Centreis to take on more work in fields other than maternity. The majority of admissions most situations are nonelective, that is to say that in there is an elementof emergency. This will apply evenfor deliveriesif a policy of dealingonly with abnormaldeliveriesis adopted. Whilst it may be acceptedthat motherswill accompanychildren through most of the routines in the Centre the following attemptsto summarizethe activities that must be satisfiedin the Centre by its plan, staff and policy.

ADMISSIONS

EMERGENCY

ARRIVAL

EXAM/TREAT

IN

OUTPATIENTS

CLINIC

DECISION

TO ADMIT

REFERRAL SUB-CENTRE

FROM

-I.(EXAM/REGISTER)<-

\ / TREATMENT \ h

RETURN FROM HOSPITAL BUT NOT TO BE DlSCHARGbD

INFORM ARRANGE ETC

RELATIVES, ACCOMMODATION

BED LEST (EXAM/REGISTER) ETC

In the Model plan we seeinitial examination and treatment being madein the back of the outpatients block, in the treatment roomsasappropriate. Documentation can then be completedin the Central Facilities block before the patient goesto the ward. Patientsfrom the outpatient clinic may need no further examination, but admissions documentationwill only disrupt the clinic. Somepatients should be got into bed immediately and documentedetc. at their, rather than the staffs, convenience. The secureand proper storageof belongings,the informing of relativesor village, the accommodationof relativesin hostel or local village lodgings- all theseare jobs which if they are well done by the Centre,will easeeveryonesburden.

(0

Oncea patient is admitted it is best if time can be found for someone explain to what is involved in terms of daily routine, facilities, whether different food can be ordered,whether relativescan stay etc. This is a job which can be done well by any interestedperson. If it is Centrepolicy to allot somekind of housekeeping jobs to patients this should be explained early to makeit clearwhat goeson, although the patient may be in no sort of stateto take up duties immediately. Admissionspolicy will dependon ,staffand facilities. The technique of being humaneis a matter of attitude. Thereis a sense which staff can relax once the in patient is admitted. The staff can then control virtually everything that happens. Staff must alwaystry to rememberthat the more familiar and routine somethingis to them, the strangerit probably is to a patient. Somemutual understandingon admissionhelps the patient and the patients family enormously.
.

Appendix 11 (ctd.)

It hasbeensuggested patients should be admitted in order that they can be that held until a doctors visit. This seems mappropriateuseof facilities. If an accommodation availablein the hostelsthis would seemto be a better place is for patients to stay pending a doctors visit.

(ii)

warda This Appendix relates to the Model plan which showswhat is probably an absolute minimum bed accommodation. In somecultures men and women will haveto be kept entirely separate. This Canbe done most simply by having a link coveredway split down the middle with a wall. The women then haveaccess the hostel area to 0 and kitchens, the menswxds being approachedfrom the clerical block. This ,.simpleidea canbe carriedthrough into the outpatient area. ; The wardsshould haveeasyaccess their surroundings,must relate closely to to kitchens and hostels,and canwith advantage relateto the social area. The ward must also relate to central fa$lities for laboratory treatment, cleri&l and staff _ latrine purposes. Animals must bekept out. Plenty of good bench seatingis desirable. 4Washbasinsshould be of generoussize,although depth is not important: one in eachbay. The labour room is to be b& enoughfor two beds,must havea sink, and should be a room more or lessseparated from childrens bedsbut under good observationby the nurse. An instrument cupboardis required. A cooking facility is included in the nursescentre for cooking by nurses. In some Centrespatients may be allowed to usethesefacilities. Storagefor patients belongings,and asmuch generalstorageaspossibleshould be included: the Model plan showsa minimum. A ventilated cleanerscupboardis an advantage. At least one relative should be anticipated asaccompanyingeachmother or child. Relativesmay haveto be accommodated the hostels. in Clotheswashingand drying facilities are provided in relation to the femalepart of the ward. Theseshould accordwith local customs,must be well drained, should not be too closeto latrines and drying area,and should be reasonablysecureagainst theft. The diagtambelow showsthe proposedlayout of the bed area:
TO AND FROM TREATMENT, FACILITIES, STAFF LATRINE CENTRAL ETC

APPENDIX 12 WARDS

_. --DELIVERY ROOM I TO LATRINE FUTURE EXTENSION

3 BEDS MATERNITY

App. 12. Fig. 1. rwr

of

TO LATRINES AND CLOTHES WASHING AND KITCHENS

Hostels Two categories accommodationmay be provided: of 1. A sleepingshelter only for relativesof inpatients and outstation patients not requiring bed care. 2. Hostelsin the form of local houses(madein the local mannerincorporating : suggestions improvement) for rehabilitritional patients and waiting for mothers. At least two hostelswill be required, one for men and one for women and children. _, The improved housesand the sleepingshelter should be built and maintained by the community and are to be a community responsibility, including sweepingand cleaninglatrines, but under the direction of the Centre, and aresited near the social areaand compoundentrance. Hostelresidentsusethe Improvedlocal kitchens in the social areaand should have access clotheswashingfacilities. Womencoulduse the maternity ward kitchens to andlatrines. but someCentresmay wish to keepward kitchens and latrines entirely for the useof inpatients. In somevillagesresidentswho might otherwise usethe sleepingshelter may be able to find accommodationin the village. The furnishing of the hostelsshould reasonablyaccordwith local customs. Some staff should havethe duty of visiting the hostelsevery day, howeverbrwII> I L1 checkthey are being kept cleanand free of, particularly. insect pests. Storage spacefor belongings,food, fuel for fires and lamps,and possiblyalsowater will be required. The hostelsshould be big enoughto accommodate to twelve peopleeachin up reasonable conditions, probably five partitioned or partly partitioned areasbeing acceptable. The local housestyle may not be big enough,so a simpleplan is shown below for a dormitory:

APPENDIX HOSTELS

13

. . - - ---.r I

. -. -. -. .J---y
washing area

A dormitory

App. 13. Fig. 1. A simple dormitory

iockable

cupboard

Detail of a cubicle in the dormitory

fixed platform

Hingedsleepingplatforms attachedto the walls will allow for day-time useof the spaces. Thesesleepingcubicleswould eachallow spacefor two adults and two children, and should be sufficiently flexible for most centres. This type of dormitory should be usedto supplementhostelsbuilt in the style of local houses, the buildings of which in an improved manneris part of the Centresteaching function and should not supplant improved local househostelsentirely.

Stiff housing The Model Cen:!i- requirestwo housesfor principal staff who may havefamilies: thesehousesshould be within the compound. Ideally, housesfor the auxiliaries should also be built within the compound. Staff housing should be of good quality in local termsand should ideally be improved local construction. li is currently easierto raisecapital finance than running finance for externally sponsoredschemes, which suggests it is advantageous build initially and save that to rental later. Staff may be male, female,married or single,with or without children, and possibly, wheremarried, %othhusbandand wife will work in the Centre. The samebuihlhtg criteria apply to housesasto any other kind of building.. An extremely simplepian is givenbelow for a small two-bedroomhousebasedon the samestructural bay sizeasthe other buildings.

APPENDIX

14

STAFF HOUSING

Latrine

App. 14. Fig. 1. A small-two-bedroom house

This basicplan can be madehuger by putting on a higher roof and pulling the eaves well out. In hot countries the demands privacy are frequently much lessstringent than in for colder countries asthe needfor ventilation makesfor little noise.privacy. High !evelventilation slots are an excellent idea.
An extremely simple house plan. and one which can be extended easily is shown below. Kitchen and latrine asin fig. 1.

App. 14. Fig. 2. A simple house plan

Sterilizersend sterile supplies

IlltdUStiOll

APPENDIX

15

STERILIZERS AND STERILE SUPPLIES

In ste&xi.ng it is not better to travel hopefully than to arrive. A practical routine for the treatment of goodsin any given situation is a routine which can be followed without mistakeand with confident knowledgeof the result in all foreseeable circumstances. Much is misunderstoodabout sterilizing, sterility, sterilizersand sterile areas. One can readthe whole unit is sterile, but someparts havea different degreeof sterility. What doesthis mean? It means,presumably,that the whole unit is a great deal less likely to causeinfection asan environment than somewhere (in the hospital), else and that extra carehasbeen taken in particular laceswithin the unit. The chances are that continuing total sterilItyin clinical wor&-m hospitals or Health Centresis impossllle. It is all a matter of degree. neaimofsterilizing The aim of sterilizing is to kill off asmany organisms possiblein the circumas stances, reduceinfection risks asmuch aspossible. If a cloth dampenedwith to antiseptic and usedto wipe things over is all that is availablein a particular place, then that is the practical sterilizing routine there. Sterilization doesnot therefore relate to sterility, but only to a degreeof cleanliness. There arefurther subdivisionsof practicality. A smooth surfacedsimple metal object with no cavities can be dealt with with confidence. Hollow or complexjointed instruments, syringes,etc. areharder to deal with. Also, somegoodssuchasgloves have to be handledwith specialcareasthe sterilizing routine, whateverit is, leadsto deterioration. Finally, the best sterilized article in the world stopsbeing sterile when it is exposedto non-sterile air. Gradingsterilily This sloppiness the useof termshidesthe real problems. Three gradingsare in needed: 1. Highly sterile 2. Hospital sterile 3. Kitchen clean Thesegrades be defined asfollows: can Hlgbly sterile. Specialproceduresat all stages the production and/or presentfor ation of goodsto environmentswith specialprovisionsfor maximum practical sterility in areas wherepersonsare requiredto usespecialroutines when entering, etc., etc. Hospital sterile. Based the useof properly wrappedor packedand properly on handledinstrumentsetc. passed through pressure-steam similar sterilizers. or Kitchen clean. Basedon the useof routines and equipment other than pressuresteamor similar sterilizers. The needfor understandingsterile routines There ls theoretically no upper practical limit to High sterility until total sterility is achieved,but standardsneedto be set in the other two grades. Thesenotes are particularly concernedwith Kitchen cleanbut somereferenceis necessary to sterilizers of the pressure-steam similar sorts. The notesobviously cannot be and comprehensive, will hopefully serveto establisha basicunderstandingof the but problems. If all concernedhavea reasonable of what they are supposedto be idea doing the chances success much better. of are Resswesteamand similar sterilizers Equipment usingdry steamat high pressures with pumpsfor drawingvacuums should be called pressure-steam autoclaves can produce highly sterile goods. and Pressure-steam autoclavesare discussed more detail at the end of this Appendix. in (0

Ethylene Oxide Sterilizersand Formalin cabinetscan alsoproducehighly sterile goodsbut can be more safely consideredasproducing hospital sterile goods. I&a-red ovenscanproducehighly sterile goods providing the goodsare packed properly. Their useis usually restrictedto syringes. For hospital use,hot air ovensshould not be consideredasproducinghospital sterile goods. Ultra-violet radiation hasgood sterilizing propertiesbut no practical application in hospital goodssterilizing. No other equipmentcanbe consideredasproducing highly sterile or hospital sterile goods.
Kitchen clean

Appendix 15 (ctd.)

Hospitalsare notoriously reservoirsof infection and breedinggroundsfor inventive new organisms which have an apparent passIon tor drteatmg nlanoeuvres made againstthem. Health Centres,being smallerand lesscomplex and attempting fewer procedures exposingpatients to a high riskSactually need less complex defences againstorganisms can reasonablyacceptlesscomplex sterilizing and routines.
Defences against infection

Cleanbuildings, minimum dust, nothing to attract insects,protection against animals,cleanwater, good crossventilation with sun-washed well spaced air, buildings, cleanstaff and clean patients, well maintainedlatrines, well washed and sun-driedlien and uniforms are all first line defences againstinfection and must be seento all the time. Early recognition of infections in patients, staff and visitors and their prompt treatment in a suitablemanneris the secondline of defence. The third line is the actual processing handling of goods. The goodscan be and broken down into two types: 1. Goodsexposedto known infection 2. Goodswhich may havebeenexposedto infection Both must be treated the samein the end, but goodsin category 1 should be dealt with immediately and handled carefully.
Kitchen clean &Wig

The essence sterilizing is the exposureof harmful organisms an environment of to which kills them. Suchan environment can be found inside a sterilizer (even a boiling water sterilizer, providing the organisms exposedto enoughheat for are long enough.and providing the:e are no sophisticated organisms present J Tl~r basickiller of organisms heat. As goodscan be sterilized in boiling water it follows is that sterilizing them in a pressurevessel (such asa pressurecooker) is a better method, asthe temperatureinside is higher. Sterilizing by exposureto high temperatureis known aspasteurizdtionand this report recommends minute pasteurizationof ten goodsin a pressure cooker asthe minimum acceptablestandard. Box jointed instrument: will needfifteen minutes;dismountablebox jointed instruments are preferableand needonly the shorter time.
Cleaning goods before sterilizing

Goodsmust be cleanedbefore sterilizing. A good scrub with a scrubbingbrush, perhapsa preliminary boil to loosenany adheringmaterial, flue brushing of syringebarrelsand the cieaningof needlelumens with a wire areessential. This will allow maxbum heat to get to all the surfaces the goods. Needlesin of particular needcareful rinsing in cleanwater before sterilizing.
Linen, bowls, etc.

Scrupulouslywashedand sun-driedlinen is adequatelycleanfor Health Centre (ii)

purposes. But the storagearea(and preferably the drying area)must be fly free. Bowls may be washedin cleanwater with a good dismfectant(seebelow) but must if be dried with cleanlinen and stored coveredin a fly free area. Dressings. it is essentialto re-usethem, must be pressure cooked,then rinsedand sun-dried. Someform of linen drying cabinet may be essentialin areas with prolonged monsoons.

Appendix 15 (ctd.)

A sterilized item startslosing its comparativecleanliness soonasit is removed as from the sterilizing container. Goodsleft in more or lessopen containersin the water in which they havebeenboiled are particularly at risk. Wetgoodswill pick up airborne infection more quickly than dry goods. Unwrappedbut coveredgoods will pick up more infection than wrappedgoods. Gleangoodsplacedon trays with uncleanedtongs, or placed on uncleanedtrays or in uncleanedcontainers,or coveredwith a previously usedcloth are soiled goods. Goodslaid on a cleantray and coveredwith a clean cloth which is then lifted periodically are soiled goods. The ideal aim is to cook and usefresh, handling aslittle aspossible. A practical routk for a Health Centre Returned usedgoodsshould be washedand then sterilized by the best available method. Keepthe washingareawell away from the sterilizing area. Goods should be taken from washingto sterilizing on clean trays by cleanstaff to avoid undue contamination of the sterilizing area. This careis not so important in modern sterilizing units wherepackingprotects goods but is most important in lesssophisticatedpractice. Do not store unsterilized goodsin the sterilizing area. At the end of the day it is better to washand hold goodsin the washingareathan to put them ln the sterilizing areauntil morning asthey can carry and then spreadinfection. Goodscan be sterilized, then stored,then sterilized againbefore usebut this double handling is wasteful. Goodssterilized but not usedmust be re-sterilizedbefore re-issue unlesswell wrapped. Sterihzlngcontainers,following whateversterilizing routine is employed, should be emptied with tongs included in the container on to a double thicknessof sound linen, on a smooth tray well wiped with a strong antiseptic agent. The linen should then be carefully folded over the top of the goodsand the bundle turned over on the tray. Do not touch the faceof the linen that will he in contact with the instruments; do not let the linen lie on uncleantables. Turning the pack over secures wrap wlth minimum fuss,makesit difficult to raid the pack, and will the meanthat the goodsare adequatelycoveredand protected. Smallersetsare better than larger ones. A local method of identifying contents may be necessary;do not stick pins through the wrappers. Goodspreparedand wrappedln this way wlll maintain a reasonable degreeof cleanliness somehours, but the wrapsmust be kept dry. Heafgunswith for magneticheadswhich can be sterilized should be purchasedand usedin preference to syringeswherepossible. wrappingsand trays Wrapscan be madefrom old bed sheets. Trays can be any kind of metal tray, but smooth. If no wrappingsand no trays are available,carry the goodsto the site of usein the sterilizing container, open the container when the goodsare needed,use small loads for quicker use. The site for useis the principle sourceof contamination.

Much faith and many instrumentshavetraditionally beenplacedin drums. In the early daysof steamsterilizersdrumswith open ports in their sideswere placedin what amountedto sealedsteamchambers. Steamfilled the chamberand the drum, settling and condensingon the instruments,creatinghigh temperatures which were then more or lessmaintained by pressure more heat. At the end of the cycle and the chamberwasopenedand assoonaspractical the ports weresnappedshut. As the drum and its contents and the air inside it cooled so uncleanair wassuckedin unfiltered. Linen is better, drums are dangerous, Linen or paperwrappedgoods placedinside a drum which hashad the ports pulled off and drainageholes cut through the bottom can be safely sterilized in a modem autoclave(seenotes at end (iii)

of this Appendix), the drum then making a good container for the wrapping, the wrappingprotecting the instruments. Drumsmay be convenientcontainersbut they are not in any sense sterihxing apparatus. Antisepticfhxidsanddiainfecting Inadequatelymixed antiseptic solutions which aretoo weak and havenot been allowed to stand (so that the agentcan disinfect the water into which it is poured) and which havebeenmixed in unclean bucketswhich havebeenleft around empty without coverson may smell comforting but do not do an other usefuljob. Using antiseptic solutions which are too weak is a totally ralseeconomy,being in fact a dangerous wasteof a valuableresource. Goodsto be placedin antiseptic solutions should be cleanedand rinsed fmt, and the solution should not be usedfor longer or more often than recommended the by manufacturer. Wheredisinfectant is being usedon a cloth to wipe surfaces goods,do not rinse or the cloth in the disinfe&nt betweenwipes. This makesfor an infection reservoir in the solution, the infection in the end beinglaboriously spread. A secondcontainer for rinsing and evena third for wrhtging makesmore sense howevertiresome. This method prolongsthe supply of active agentand is wasteful only of water.

Appendix 15 (ctd.)

Airborne organisms frequently travel on dust particles from bed linen and clothes. Brisk, efficient peoplerustling round wardsexpertly twitching bed linen are people stirring an unnecessary aerial soup of harmful organisms. Bed making should be quietly carried outwithout linen touching the floor. The counting of linen on the ward is an unforgivablehealth hazard. Frequent floor sweeping accompanied by much whisking of dust is harmful. Slow sweeping with a soft paddy brush into a container is perfectly acceptableproviding the brush is not then shakenout of the window and the container dumpedjust round the comer. Dust and organisms stirred in thesewayswill travel into the sterilizing area,on to the goodsand into the patients. sunshineandventilation Sunshineand sky glarecontain radiation that is an effective sterilizing agent. Sun should be let into latrines and dirty areas. Well spacedbuildings without enclosed links allow the sun to keep infection down. A balancebetweenshadetreesand sterilizing sunshinemust be kept. Air that hasbeenblown acrossa field will be virtually sterile, Clearcrossventilation will allow this air to flush out buildings. Modem sterilizing practice larger Health Centresmay well have sophisticatedsterilizers. This last section of this Appendix is long but is only attempting to clarify what sterilizersare and what they are supposed do. to Modem sterilizing practiceis basedon the useof goodswrappedin steampermeable wrappings; linen, cardboardor specialpaperand specialcelluloid. Theseare placedin a fairly complicatedautoclaveand sterilized with heat from steam. The autoclavemust be in good working order, and new onesshould not be bought without fool-proof guarantees maintenancecontracts. Malfunctioning autoand clavesare a dangerous wasteof money and effort. Wrappingis essentialasin any normal circumstances unwrappedgoodscease be to sterile assoon asth; ; ?:YP the sterilizing chamber,being then exposedto nonsterile air. Further, ; ,.I+ 4y wrappedor packedgoodscan be stored for quite long periods (up to 2~ .*.YS a good double linen wrap) and can be carried round in andhandled in safet) .-tidingthey arekept dry. Adequatepackingbefore sterilization is the rc JLof modem sterilizing practice. Modern sterilizers;javecomplicatedcycles. First a partial vacuumis drawn, then steamis let in, thc;i the partial vacuumre-drawna few times. This is known as pulsing and replacesair in the chamberand in the packswith water vapour. After (iv)

is the this flushing; stearrr pushedinto the chamberunder pressure, temperatureof ring raisedby the,pressure. This pressurethen hasto be held, asdoes and , for the right length of time. The pressureis then released an which dries the load. Filtered air is then let in to bring the chamberto atmosphericpressure. The sterilizer can then be opened. Without pulsing the first steamentering may rush towardsinstrumentsin a pack (training) trapping air inside the pack, which ah may insulate the goodsfrom the sterlhzing action of the live steamand from the very high temperatures reached when steamcondens&on the goodsreleasing latent heat, The*alritself may remain unsterilized; (This hasln the past beencalled the smallload effect). A post-vacuumis necessarytodry the goods,otherwlsemoisture in the wrapping or coming out through it will open a path for the ingressof harmful organisms through the inevitable movementsof the moisture ln the process the pack drying of out. It will be seenfrom the foregoingthat unwrappedgoodsin traditional drums with ventilating ports are dangerous, that openingthe sterilizer door assoon aspossible to assistin cooling and drying is dangerous, that saferoutine modem sterilizing and requirescomparativelycomplex apparatuswhich needsattention and maintenance if it is to do its job properly. In sterilizing it is necessary establisha practical standard,acknowledge to its effectiveness, work out practical routines related to the degreeof sterility obtainable and stick rigorously to theseroutines. Autoclavescomein large,medhun and smallsizes. ModemWesternpractice has favoured the largeautoclaveasit is more amenable factory line type processto ing of goodsand, when filled efficiently and usedwith a rapid turnover, it shows Seems irrelevant (usually because the good results. Wherea factory line process unit throughput is small) smallersterilizersaremuch more appropriate,having shorter cycles(the cycle may haveto be varied for different goods)and therefore allowing for a sporadicpresentationof goodsfor sterilization. Well organized,a somewhatlarger number of very much smallersterilizers can fulfi the demandsof very large units extremely well, and there is the additional advantage breakthat downs arelessdisruptive. Units havebeenbuilt with one largesterilizer capable of doing all the necessary work ina few cycles. The fallacy in this economy is revealedat the fust malfunction. Robust pumps,a suitable and limited rangeof cycles,accurateand unfussy instruments,simpleeasily repeatable replaceable and door sealinggaskets suitable water pre-processing and units are essential. Demand pulsedpre-vacuum,and a drying after-vacuum. Demandrealistic cycle times and capacities,and resistloading, racking and stackinggadgets until it is found that they are needed. Much can be achievedby building wood and cardboardmock-ups of autoclaveson offer. Thesecan then be trial packedand compared. Senior staff resistingthis idea maintain their dignity at the risk of their patients health. An essentialof any well run unit is a seniorstaff memberwith direct and known responsibility for performance. Small. so called flash sterilizers are available. Thesework for unwrappedmetal or glassor polypropylene goodsset on a meshtray. Bowlsetc. must be placed u#de down (this is not entirely satisfactory). Steamis admitted which rushesto the goods,condensingand producing a high temperature. The chamberis then pressurized a short time, the pressure for released, door openedand the hot the instrument taken out. Flash sterilizershavea deftite placein hospital sterilization. Placedimmediately adjacentto an operatingor treatment room in a cleanand well ventilated lobby, the ventilation sourcecleanableand as.faraspossiblefrom any infection source,thesesterilizersare extremely useful for droppedor unrepeatable to instruments. Somewhere washthe instrumentsis essential. Most sizesof sterilizerscomewith doors at both endsfor pass-through work. This meanstwice the number of gaskets, hingesand locks to go wrong. Double-ended sterilizershavetheir uses,but big double-enders trouble sources. are Downward displacementautoclaveswheresteamsoaksdown through a load driving the air out at the bottom, the air cock then being closedand the pressure built up havebeensuperseded high pre-vacuumautoclaves. They should be seen by asbig pressure cookers. Syringes,glovesand rubber goodsare alwaysa problem. Glovescan be carefully wrapped(well powdered)and sterilized on a suitable cycle in most good autoclaves. (4

Appendix 15 (ctd.)

..)

_.-

,=I, S~~J~canbe-dealt,~~ on a stand&d cycle. kubbe; goodsand anaesthktic i :, &&iment neid@ueful andparticular consideration. Ethylene oxide sterilizers .: ..,wh.ich~c+n usedf&these go,ods be needcareful maintenanceand exceptionally .. careful handl@g,4reing liable to explode. It seems reasonable site them away to :;, f&unwork areasand-othermachinery;. Forma&i is both the sterilizing agent-and % main drawbackoffonnalincabinct sterilization. -.the :, Hoi air cabinetsmaybe useful for drying goods,but their effectiveness sterilizers as -i ti ieg doubtful / - _ -T ~3 :I .~Sy.$rgescan wt$l be sterilized,mh&red conveyorovens,packedin metal capsules. i I These,.~$sul~are convenieqtto handle, pro@rly sealedhave.a very long sterile life, I a$ robust:easily identified and are near.ideal. It seemsverydoubtful whether is tnily effective in h pm-vacuumautoclave. With-the growth of the use :: fy$% and i o drsposables j&spray gunsovensare no longer madeasstandardequipment. Sterile fluids and lotions can be sterilized in standardautoclaveson appropriate cycles. There.$snoideal cappingsystem. Rapid cooling systemsare available. In thesethe vessels the chamberare sprayedto cool the,fluids which would otherin wiseboiloff violently asthe chamberpressure reduced. An alternative. to was is prograinmefluids for the end of the day and allow them to cook quietly. through the night. Ointments and linen can alsobe put through suitablecycles. i Bowlsof all sizescanbe wrappedor stackedsingleor in pairs (pairs being separated by a small folded towel, otherwisethey sealtogether) and usedasoccasiondemands. Big outer wrapson bowls canbe usedto drapestands. Bowls with Bpsturned out over and down should be avoidedasmoisture can be trapped in the rims when the bowls are sterilized inverted. They are best sterilized laid on their sidesand should not be sterilized right way up. Opera&g theatre instrumentscan be madeup in standardizedkparotomy kits laid or,extras up in linen on cafeteriatrays. Specialsfor individual doctors preferences to extend the rangeof the possibleproceduresare addedasa separate bundle. Eye surgerycalls for delicateandvery specialinstrumentsand it is recommended that the specialistbe aBowedcompletefreedomof decisionon the handling of these l3-. Sterihzingtechniquesand routines and steriIizing arealayouts do not appear,by andlarge, to be assimpleand uniform asthe basicroutines involved would seemto indicate. Commonsense doesnot seemto be the keynote of design. The basic activity sequence a largeor small, complex or simple unit is as shownon pagevii. for The demandsof this sequence activities can be met with a very simpleplan. of Complex partitioning is unnecessary the goodsareto be wrapped. Some as authorities prefer to seeseparate stripping areas, washingareas,severalpacking areas a sterilizing area,all linked by doors which are usually propped open as and soonasthe designerleaves. The partitions cut down air circulation in hot countriesand hinder the passage goodsand people. If the goodsarewrappedit of doesnot matter wherethe.air goes. Wheremechanicalventilation is practrcal, heavyextract at the stripping areawili draw air away from the cleanerparts. So often one sees extract at the sterilizersto cut down heat. ,This, of course,setsup the wrong direction of air flow. In a simplebuilding the stripping and washing areacould be separated from the main work room by a completely open lobby. The goodsthemselves still havesomecontamination on them, but sterilizing will beforewrapping is not necessary. Complicatedwork stations are often designedfor packinggoods. They are totally unnecessary;ordinary table tops with a formica or similar surfaceare practical and adaptable. Cardboardboxesdo well for carrying goodsround in the unit. Sprayracksare neededfor testing needles,foam blocks for carrying them round if (they are stuck into the block). A capsulingmachineis necessary syringesare beingsterilized in metal tubesin an infra-red conveyoroven. Otherwisethey can be wrappedin linen in tin boxes(or beercanswith the top removedand sharp edges blunted, theseto be sterilized upsidedown). Tapswith suitable nozzlesare neededto flush out tubing. Big low level sinksare neededfor washingbowls, galleysetc.

Appendix 15 (ctd.)

of Washing machinesare a problem. Good agitation, hot water and a good squeeze lemon juice producebright and apparently clean instruments. A converted domesticor commercialwashingmachinemay do the trick and will be at least as effective asand more easily servicedthan an ultrasonic cleaner. Goodsshould be packedin a wire box packedwith rubber netting so they do not rattle and break. Wire boxes are good for issuinggoods. They can be locked againsttheft between issueand arrival at the usepoint. There is much to be saidfor wrapping lots of smallersetsand making up bigger cari packsafter sterilizing. This meansthat someone sit down and wrap fifty galleyswith swabsin, then do spatulas,thendo somethingelserather than having to collect all the items first, then wrap them in a thoroughly complicatedmanner. Glove powderingcan well be done in a separate cubicle to stop the spreadof dust. Thesenoteshavetried to strike a note of homely common sense. There is no substitute for this commpdity in designingand running sterilizing units. Two days spent in a largeroom or a car park with tablesand packing cases represent to equipment, with an experiencedstaff membergetting a completemock-up day worked through, will solvevery many designproblems very satisfactorily.

Appendix 15 (ctd.)

issuepoint goodsreceivedand possibly held (somemay require pre-sterilization if grosslycontaminated) to disposal\ 4 packs,setsand instrumentsstripped to laundry e if goodssorted into: / (a) bowls, (b) syringes,(c) ru+bber goods,(d) instruments washand dry if necessary 4 inspect f---------

to disposal 5-----------

replacements from store if necessary draw from store necessary materjals (including disposables, whete,theseare included in packs) wrapping materials and cleanlinen

<E

sterilizer trolley

wrap and label -

dressings

4 sterilized items

trays, trolleys or boxesfor carrying goods

APPENDIX 16
i-c ,y : F.; 6. i

:c (. . .-. -..: : :-^ .. in -. a;::, 8...: IC!, pi,I $T.. v ,!. i;.

a This Appendixilhrstrates an imrnunlzation room layout. Such~ room is not included in the Model. If a separateroom.wererequired it could be placed betweenthe laboratory and the dispensary. This would meanan increasein the sizeof the treatmentroomswaiting area,but this would probably be a good idea as only a fairly largeCentrewould have the needor the staff for a separate room. The aim is to hnmunlze all children who attend the Centre. The room is in use eveiy day from 7.00 am. to 3BO p.m., exceptsunday, and hasthe following,main . features: ., 1. Vaccinesarekept cold and away from light. Vaccinesmust be protected from stronglight during a working session. A cold box is advisedfor holding during a session. 2. Two setsof syringesand needlesare in use.one set sufficient for a days work (one set in useand one being sterilized). 3. -4 sterile needle(or multiple puncture blade) is usedfor eachimmunization given. Syringesareusedeight times. A bifurcated needleis availablefree from the WHOfor SPvaccine. The needlecontrols puncture depth. 4. MagneticheadHeaf type multiple puncture.gunsare usedfor smallpox vaccination(freezedried), BCGand HT. The Pan-Jet(previously named Dermo-Jet)availablefrom SchucoInternational London Ltd., Halliwick Court Place,Woodhouse Road, London N. 12, England,ls recommended for administration of soluble drugsby intradermal infiltration. The instrument rinsing and test ftiing with can be sterilized by boiling. Partial disassembly, distilled water is recommended once a weekor every 500 shots. 5. A helper receives patients card, recordsit and stampsthe card, asthe the vaccinationis given. Patientscardsarekept on side trolley away from the . actual work bench,but near by. l$emindercharts Chartson the wall at the back of the work benchshow Heaf test reaction numbers, sitesand methodsfor the various inununizations and dosages. Suggested arrangement for the work bench (seediagramfollowing) 1. Refrigerator 2. Cold box with openedvaccinesactually in use; one vial only of eachtype of vaccine 3. Coveredtray with magneticheadedmultiple punctureguns(two) (Heaf model). 4. Folded sterile towel with dry sterile gun bladesready for use 5. Polythenetray with syringe for Triple Vaccine 6. Polythenetray with syringe for TetanusToxoid 7. Polythenetray with syringefor ATS 8. Polythenetray with disposable syringesfor measles vaccine 9. Tray with sparesyringes,tins of sterile needlesand scissors 10. Coveredtray with syringefor rabiesvaccine 11. Smalljar with dissectingforceps(sterile) i 2. Squeeze type poiythene bottle of spirit 13. Cotton wool swabs 14. Tin of sterile needles use in 15) &) Small bowls of water to receiveusedneedlesand blades
16)

NOTESONAN Ih-lMUNIZATION AREA

1 ft.6 in. ( Ym.1

APPENDIX 17 All dressings which cannot be washedand reused must be burned under supervision. Heavily soiled linen should be soakedin a bucket and rinsedasthoroughly aspossible,then boiled for at least ten minutes before being processed through the usualwash. Syringes,needles, etc., must be thoroughly broken up under supervision. No drugs of any sort should be disposedof in any form in which they could be taken. Paperboxes, cardboard,etc;, should be collected and burned periodically. A large bin is suitable for this, but it should havea perforated bottom, a lid with a chhnney with a hood, and the bin should stand on a plinth. Rubbishwhich can&t be burned, suchastins, should be collected in closeablebins, the contentsbeing periodically compressed much aspossibleand buried. Bins smelllessif shaded. as It is a mistaketo put them out of sight and out of mind. If there is a security enclosurein the central facilities area,the bins should be within it to discourage scavenging. Wastewhich can be usedasgardenwasteshould be properly composted,and should not be left around asit will becomea fly nuisancesource. Composts should be coveredwith fresh earth every two days. Food wastecan often be usedby a local farmer, who should be under a direct obligation to removeit frequently and to keep the collection point clean. Excreta, vomit, blood, pus, etc., can be emptied into a latrine or pit or flusheddown a WC where running water is available. A disposalroom is shown on the Model plan. The intention is that supervised treatment of rubbish can be madeperiodically from the disposalroom, which should havea door opening to the outsideand a hosepoint (where there is adequate water). The floor and walls should be imperviousand cleanedregularly. Fly screening,sun and ventilation are advantages. Following disposalroutines, handsmust be washed. DISPOSAL

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APPENDIX 18 STORESAND STORE-KEEPING

:Thedrgge buildii in the,Model is sited at,the entranceto the site for easeof Thestorage ar&ssifor easeof supervision,and for initial useasthe storageshedduring ar&ss;.for Construction. Additionally, in this position, there is mom for considerable expansionwithout markedexpansionof site size. The building must be rat-proof. . A building on stoneor concretemushrooms .->;: with this problem very well, but the mushrooms deals must be high enoughfor effective clearingof undergrowth and rubbish from underneaththe building, as this spacemight otherwiseattract snakes, mosquitoes,rats; etc. The sizeof the store will dependon frequency of delivery of goodsand the store for inilammable goods possibility of irregularbulk donations. A separate suchaspetrol and kerosene essential; it should be placed sufficiently far enough is . away from the main storagebuilding for fire spreadto be unlikely in the eventof accident. Closedbins, metal or concreteshelves,and possibly a separate for linen etc., area are advisable. Avoiding storageon the floor makescleaningeasier. The store must be adequatelyventilated, but a ceiling is unnecessary. Doors must be big enoughto allow huge packingcases be carried in easily. The to storemay be usedasa garage, which casesomefire precautionsarenecessary. in A simple form of store-keeping book will be essentialin order to maintain a reasonable ordering system. The minimum information to be shownin the book ! wiII be: 1. Date of receipt (entry to be madeon day of receipt) 2. Nature and quantity of goods 3. Condition of goodson receipt 4. Price of goods(can be ffied in later from invoicesseat by post) 5. Any specialstoragerequirements A systemis alsoneededwhich showswhen remainingstockswill shortly be reduced to the point where they will be finished before a new batch can be orderedand delivered. This meansthat normal order and delivery times and consumption ratesshould be known and recorded. In its simplestform the amount of any given storeditem which will last through the order and delivery delay period should be clearly shown at the storageareaso that any staff membercan check. The issueof goodsmust alsobe carefully recordedon the day of issue. The record should show amount issued,date issuedand to whom issued. Notesrequisitioning storesshould be checkedperiodically and matchedwith the issuebook. Periodic stock-takingis necessary. This involvestotting up the total of goods received,adding in amount h-rstock at last check,checkingthe amount issued, checkingthat the differenceis still in store and checkingthe stateof the goods. Wheregoodsdeteriorateor get broken they should not be thrown away before inspection. Drugs,syringes etc., must be thoroughly broken up and rendered unusablebefore disposal. The placing of goodsin the store should be clear and systematicasthe storeman may be ill or away and someone may haveto take over. It is best not to stack else goodsagainsta wall and PO havean aisleon both sidesof stacks. In this way systematicpilfering from the backsof piles can be avoided. Anyone caught pilfering should be instantly dismissed. It is unlikely that a storemanwill be kept busy enoughby a Health Centreto work in the store full-time.

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APPENDIX 19 EQUIPMENT LISTS

i..

The Appendix notes items of furniture, equipment, drugsetc; It is not comprehensive, particularly in the matter of drugs. It doesnot show quantities, nor are all theitems listed required to run a Centre, aad there is someduplication, i.e. in sterilizing equipment where a sophisticatedautoclavewill makemore primitive equipmentunnecessary. The list is offered asa check list. Dependingon many varying factors the lists may be greatly reducedor widely extended.
Cookiag quipawat, plates etc.

Not listed
Domestic aad cleaning quipment

Soap,includingbabies soap Toilet rolls Matches Uniforms, footwear, headgear Bucketsand bowls Childrenspotties Beakers Razors

Detergent Brooms,brushes,mops,cloths, scrubbingbrushes Baby bath and stand Jugsand measuring jugs Hot water bottles Funnels Razor blades

Scouringpowder Nail brushes Aprons Washingbowls Latrine buckets Bedpans,urine bottles Insect sprays Stretchers

Luger equipment which needs consideration in building

Autoclave (sterilizer) Refrigerator- kerosene,gas or electric Generator

Steriking quipment Wire boxes Tongs String, labels Needlesharpener magnifying leas and Steamresistantsticky tape

Incinerator Drying cabinet Washingmachine Steamplant

Gasbottles and boiling rings for sterilizing Cansof kerosene Heat sealerfor packing drugs

Pressure cookers Wraps Photographsof standardpacks Bripac cardboardboxes Autoclave test phials

Boiling water and sterilizers Trays for set-ups Instrument cleaningequipment Steampermeablepaper Autoclave cycle recordingpaper

Somesuggested sterilizing packs (theseare offered for thought only. The rangeof possiblepacksis enormous,the secret is to work out the fairly complicatedonesthat are neededin emergency,or packsneededfor outstation visits or sets frequently usedasa matter of routine. Examplesaregiven below).
1. Maternity (glovesnot included)

a. Delivery pack: 2 Towels(absorbentpaper or J cloths or material) Swabs 4 Maternity pads d. Maternity additional: Partsof vacuumextractor and/or forceps Towels

b. Cord dressing: Swabs Cord dressing Cord ties e. P.P.Repair: (comparewith 1.c. There may be unnecessary duplication here) Speculum Needlesand sutures Pads Swabs(gauzeand cotton wool)

c. Maternity emergency pack: Swabs 2 Rolls of packing(i.e. cotton wool: 2 Towels

2: Bums and Wounds etc. .a. Burns: Selecteddressing plus 2 auto&wed plastic bags. The old dressing removedby putting the hand inside a bag,graspingthe is dressingand turning the bag inside out over it. The new dressing applied by the hand inside the secondand cleanbag. is The dressingcan be sterilized inside the secondbag if a pressure steam autoclave(seeAppendix 15) is usedand provided the steam dressingis left protruding from the bag so that steamcan get in and out. The protruding dressingwill be protected by the pack wra,)ping.

b. Wounds Ribbon gauze Sinusforceps c. Stitch up sets Selectionof needlesstuck in a lint pad Swabs d. Incision sets Bard Parkerscalpel,handle and blades Curvedscissors e. Soredressings Folded gauze Spencer Wellsartery forceps, 2 large,2 small Swabs Swabs Sutures Gauzedressings . Swabs

Appendix 19 (ctd.) Gauzeand cotton wool dressing

Stitch scissors

Sinusforceps Cotton wool and gauzedressings

From the foregoingit may be seenthat a pack containing swabs, gauzedressings, packing and towels might suit all soft goods requirements,so that only instrumentshad to be added; unusedsoft goodsto be returned for repacking. Careful thought and strong decisionsare neededon thesesubjects.
Iiaea and bed requirements

Adult mattresses washable and covers Pillows and washable covers Blankets(antibac or cotton cellulose), cot blankets Towels(mothers and babies) Towels(hand)
Stationery etc.

Cot mattresses washable and covers Sheets, sheets cot Polythenesheets6ft. x 2 ft. (cut from rolls) or rubber sheets Plasticaprons Mosquito nets

Crib mattresses washablecovers and Draw sheets Mothers gowns Babiesgowns,nappies Polythenebags Containersfor bed linen

Account books Store-keeping ledgers Exercisebooks for: ward reports daily registration of outpatients registerof deliveries Adult cardsin polytheae envelope Requiredreport forms and statistical return forms Envelopes Ink pads Ball-point pens,pencils Largesheetsof graphpaper,etc for mapsand charts Typewriter Screen Visitors book Map of district to largescalemounted on soft board (for putting in pins) aad coveredin spray-onor stick-down plastic (for visiting rosters,community projects etc. to be kept on display)
Drups list (i)

Receiptbooks Temperaturecharts Under fives weight chartsin polythene envelope daily consultation cardsto go with same Notepaper Carbons bferral forms for patients transferred to hos ital India rub&er Files Containersfor paperetc. Film projector Cardindex boxesand refills (for recording community projectsetc.) Mappins or pegs

Requisition books Labour ward charts Maternity cardsin polythene envel&e (this piekancy only) (disoosable) %mary 01 obstetric hislory to be retainedand addedto (permanent) Date stamps Staplerand staples Felt tip pens File boxes Bill spikes Slide projector Lar e stiff cardboardfolder t home made)for mapsand charts.(Seealso Appendix 26, TeachingAids.)

(During the preparationof this report a list of drugshasgraduai)ybeenbuilt up and commentedon by different authorities. The working party put forward the resultsfor thought. Someof the entrieswill causeraisedeyebrows,others annoyance and/or worry. Wehavechosento put forward the list for discussionrather than suppress from fear of causingargument.) it Tableg aad powden Vitamin capsules Yeasttablets or B complex Sulphadimidine Aspirin Welldorm Thiacetone+ INH Iron tablets Chloroquine Tetracycline or chorampheaicol Codeine Bepheniumor tetrachlorethylene Other specific anthelmintics (ii) Folic acid tablets Daraprimor substitute Penicillin v Phenobarbitone Piperazine

LDcd applicationsimd antiseptic solutions surgical spirit

KilOlill

Appendix 19 (cd)
Gentian violet Arachis oil or local equivalent Tinct. benz. co. Eusol powder (for making lotion) Eye ointments Benzyl benzoate Vaseline Hibitane cream Ear drops Copper sulphate crystals

Sterzac powder Hibitaae lotion Eye drops Triple dye others Disinfectant

Insecticide fluid

Cough mixture Iroa mixture (infants) Simple mixture

Syrup of chloral (infants) Vitamin preparation (infants) Purgative

Elixir piperazine (Antepar elixir)

Streptomycin Syntometrine amps I ml. Sterile giving sets (disposable) Bi&er lactate urhletestiagstrips Albustix

Procaine penicillin Intravenous saline (disposable packs) Half strength Darrows solution

Crystallhre pencillin Intravenous dextrose (disposable packs)

Clinitest tablets or acidify, boil and use Benedicts solution

As available and can be stored

Oxygen
hked cupdrugs Anaesthetic ether Pethidine Nikethamide Pentothal Family planning supplies(if relevant)

Trilene or penthrane

Ethyl chloride spray Morphia Let&drone

Atropine Lignocaine 1 per cent Vit. K. injection

Pill DrugsIist (ii)

I.U.D.3

(The drugs list below was prepared for a group of Ceatres in 1965. We reproduce it to show the kind of list that can be prepared at a specific time for specific circumstances. It is the availability and cost of drugs and their ability to withstand storage conditions that will dictate choice as much as anything else.) Benzyl Benzoate Emulsion Chloramphenicol Ear drops Sulphur ointment Magnesuim Trisilicate Flavine Solution 0.1 per cent Aspirin Tablets gr. 5 CascaraTablets gr. 5 Sulphanilamide Powder Chloramphenicol Eye ointment Gentian Violet Jelly Cetavlon. Solution 10 per cent (to be diluted to 1 percent before use) Ferrous Sulphate Tablets gr. 5 Chloroquine Tablets (150 mg. base) Lint Bandages open wove Dermicel or micropore Towels Maternity pads (which may also be sold to mothers) (iii) Dusting Powder Turpentine Liniment Kaolin Light Powder Iodine Solution Methylated Spirit Yeast Tablets Bradosol Lozenges Cellulose Bandagescrepe Triangular bandages Linen

Drwhgs etc
Cotton wool Gauze Elastoplast Splints Sutures

Append;;cZ (ctd.) Cold boxes for vaccines Height measurement scale Boiling water sterilizers Polytheae sheetingaad bags Adults weighing scales Pedalbias for soiled articles Drip stands Trolleys
Childrens weighing scales Prisms stove for local boiling Angle-poise type lights

arm Beds: cots, cribs, beds,delivery, -,1ocll type Chart and map racks
Shehiag: solid, slatted, washable

chidrs: mothers) :ozif low (for

Stools: high for e.g. lab normal

Smau children) (for Exaat couch Cupboards: lockers for staff general lockable (e.g. drugs) bedsidelockers

Benches Tables Work benches:

working height writing height Towel rails ori walls Blackboards Curtains and blinds Bowl stands

!Janitaryfittings (where m z2baJins(bk) Loag bath Bucket sinks(low level) xedicalquipment Heaf gun UNICEF kit Forhome delivery

water is available) Surgeons bas@s(deep with wrist

or elbow taps) Baby baths W.C.s: as appropriate and including urinals

Driakiag fountains ( with unsuckable delivery pipes)

BCGintradermal vaccinator Sphygmomaaometers stands on Fatal stethoscopes Metal hypodermic needlesNo. 1, No. 12 Palsometers Thermometersfor refrigeratorsaad cold boxesfor vaccines

Bifurcated needles Binaural stethoscopes Tape measures Thermometers, clinical and low reading, oral and rectal

Artery forceps 8 iach bowl with lid (polypropylene) Iriamab for outpatiaht drcsinp

Scissors inch) (7 GaUipot

Receiver with lid (polypropylene)

Dressingforceps Sinusforceps Container for sterilized instruments . Gauipots Suture scissors 5-6 inch toothed forceps

Dissectingforceps
RObiS

8 inch dressingbowls with lids Receivers with lids Scalpelhandles 5-6 inch nontoothed forceps

Scissors Cheatles forceps Cheatles container Needle holder Scalpel blades

For are of unconsciousor anaesthefized patients Mouthgag Sponge-holdingforceps

Tongue forceps Rubber wedge Metal spatula Adult sucker (pedal variety or home made model with Higginsons syringe to provide suction)

Other aaadsyitems Ear syringe Au&cope Assortedpolythene connectors

Pipettes, supply Polythene tubing or rubber tubing Polythene catheters: urethral size 8 baby feeding (can be resterilized two or three times) Enemas: equipment as selected Bottles and containers for: medicines, mixtures, ointments, specimens, used goods, sterile goods, syririges, instruments, thermometers

Syringes: 20 mi for doctors use

(disposable) ;;;pcz 8ame (disposable)

Wooden spatulas

Test tubes, rack and spirit 1pmp, urine test reagents

Mucusextractors (disposable, be caa sterilized two or three times) Disposable polytheae gloves Resterilizablegloves(seeAppendix 15) Orangesticks

(ii)

Additiod equipment

Appendix 19 (ctd.)

The Health Centremay hold equipment for anaesthesia useduring doctors visits. Similarly vacuum extractors, for destructiveinstrumentsetc. may be held for or brought by the doctor.
IaboratoIy

(With the equipmentglveabelow a laboratory assistantcould undertakethe jobs noted in Appendix 7 and could collect, prepareand pack specimens be sent elsewhere inspection.) to for Springloadedmicroscope Pipettes Hagedomneedleor substitute ~~3issecting forceps Urine collecting glasses Measuring jug Haemoglobinmeasuring device e.g. Lovibond Comparator (:omplete L&&mans stain and buffer Methylated @rit Litmus paper Chinagraphpencils Microscopeslidesand cover slips Drop bottles Scissors Wireloop Containers,various Polythene washbottle spirit lamp Vaseline Benedictssolution (alternatively Clhristix range) Sodium chloride Filter paper Recordbook Blood pipette with rubber tubing Bladesor substitute for finger pricking PIasticrods Test tubes, 125 x 16mmand stand Funnel Primusstove, gasring, electric heater Sulphosalisylicacid Acetic acidMethyl alcohol Sodium acetate Report forms Labels .

,,

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ar$ apdba a$I expaasiba optioas

(SeeModel room list on page10)

APPENDIX 20 EXTENDED ROOM LIST EXPA%ON OPTIONS

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This Appendix suggests.tiuther suggests.Euther roomsthat could be addedto the various groups and showstypical possiile extensions. Fig. 12 at the back of the report in Appendix 52 , Additional Drawings,showsthe Ceatreexpandedto a 25-bed hospital. If the extension wasfor surgicalwork, option H would be taken, if for-maternity option I. Any Xray or&erating room facilities would be placedin extensionJ. Thesewould againbe accessible from option K, extension of the geaeralclinic. J will alsobe accessible from group D (uader fives and ante-natal) down the back of A, B and C and acrossa aew link. Fig. 13 (Appendix 52) showsthe Centre expandedto 125 beds. Womens, childrens and maternity bedswill tend to be in options L, meassurgicaland medicalbedsin M. Ante- and post-natal and childrens clinics will be in option N and measand surgically basedclinics in 0. A will then be well positioned for allocation to orthopaedicwork, being also accessible from the beddedareas. Option Jwill displacethe incinerator. Option N will meanthe removalof the latrines from the social area. ReferrGgto the numberedplan at the back and to the room list on page. extra 10, offi accommodationcanbe madein option P and by changingroom 22 (store) into an office. Room 26 will be conveniently placedfor theatre goods,rooms28 and 29 (mea) will go elsewhere will becomesterilizing, storageand work space. and Option Q, extension of the under fives, will probably be sufficient to dealwith any likely work load asthe roomsthen available(9,10, Q and possibly 5) would cope with over 200 children a day. Combination of rooms6 and 7 will give an adequatelaboratory for a largeunit, a new dispensarybeingmadein N or 0. Either could be extended into room 8, (additional waiting space). The latrines by the socialarea,earlier noted for removal, could be madeinto specimen-taking latrines, under which usethey would havea long life. Additional hostelswould be built in the hostelsarea,new kitchens being madehere, and new latrines if necessary. Outline room lists for theseoptions are given below, commentson simple theatres and commentson sterilizersand sterilizing areasaregiven in Appendices45 and 15 respectiveIy. related ward: Cleanstore with sink and lockable cupboard ;;gtdrGm Bed sp:ces(12) Additional latrines and washingplaces Coveredlink to E Generalstore Nursesdesk Bed spaces (12) One or two small roomsfor children with mothers Coveredlink to E X-ray room Dark room and store Rearrange sterilizing suite Small operatingroom Room with half prrtition for scrubbing, anaesthesia recovery and Additional staff latrines and showerand associated changing Coveredlink to H (if applies) Coveredlink to K (if applies) Increaseroom 1 to biggerstore, make clerks deskbetween 1 and 3 New exam room asroom 2 Additional waiting Coveredlink to 0 (if applies) Area for costing purposes 1,345sq. ft 125 sq. m
(t 224 sq. ft, 21 sq. m)

.I,

1,345sq. ft 125sq.m

(+ 224 sq. ft, 21 sq. m)

1,920sq. ft 178.5 sq. m

(+ 224 sq. ft, 21 sq. (t 224 sq. ft, 21 sq.

640 sq. ft (t 25294s:?fF21 m) sq.

6)

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L. M. N.

RoomsasHorI RoomsasH Two examrooms Store and clerks room asK Possible re-iocation of dispensaryand associated extension of laboratory Waitingspace New latrines As N, but include room for changingdressings accessible from N, much asrooms4 and 5 are accessible from A and D in the Model

Appendix 20 (ctd.)

1,920 sq. ft 178.5 sq. m 1,920 sq. ft 178.5 sq. m

0.

Eachadditional 1Zbed ward will call for accommodationasH. The wards are calculatedashavinga 16 feet (5m) width betweencolumns,one wall being flush with the columnsand having three bedsper bay, the other wall being 4 feet outside the columnswith two bedsper bay. This will givevery closebed spacing. A 25bed ward would needdouble the areagiven for H and I, although a 30 to 32-bed ward would needa clear one bay lessthan three times the H and I area. Eachadditional clinic asN. Clinics with only one exam room arevery inflexible. If one room clinics are planned within the Centre, then makeit possibleto open through waiting areasso that wider usecan be madeof the space. Except in respectof two exam roomsper clinic thesesuggestions minimal. A are generallyaccessible treatment room in the ward areawould be a great advantage. Centrally placedadditional storagemay be thought necessary, which casea new in sterilizing suite should be madeoutside room 26, the operatingroom being displaced further out, rooms25 to 30 then being availablefor storage. Wherean operating room is included, considerationshould be given to a space with two to four beds, centrally located,where post-operativecases, particularly children, can be given specialcare. A room for mothers should be located closeby or mothers given a divan in the room. If a nursery is required E or L are well located. The areafgures given for costing purposesare only approximate. They do not include latrines or additional washingspaces, do they include additional staff nor housing,hostelsor any extension of the social areaor main stores. All the groupsare summarized Appendix 20, fig. I which showsthe.Model extended in to a 125bed hospital.

(ii)

Appendix 20, Fig. 1. Extension options (Seealso room list iwe 10)

/
Addition

I tons

PI 0 0
I
I L

0 P
Q D F

1 rP T
E

Additiinal

hostels

0 A 0

80 ft. 10

20 mem?s

(iii)

Treatment types

The working party hasspent much time attempting to establishthe outlines of treatment programmes. Only very generalconclusionshavebeenreached. The table immediately following showsthe kind of actions that medicaland paramedical staff can take and where. It is not comprehensive.
meIytreatmenta-gladedlntothreegroups

APPENDIX 21 TREATMENT TYPES

Giving of tablets and medicines. Taking temperature. Small cleaning iE* external ear, small blister, application of GV - mouth Showing*motherhow to cleanand drop ears/eyes child. of Showingmother how to spoonfeed. Removalof easyforeign bodies from nose/ear. Showingoral giving of fluids. Minor dressingchanges. Prescribing. Issueof safemedicines.

Cool spongingfor convulsionsand/or hyperpyrexia. Dressingof most soresand wounds. Cleaningand dropping ears/eyes. Urine testing. * Injections -therapeutic and immunization. Simplelaboratory procedures (either collection of specimenor simple tests). Small burns. Easy fractures. Taking blood pressure. AN exam. Rehydrating children - oral, sub.-cut,intra-peritoneal,and scalpvein. Helping mother with engorged breastsand reestablishingbreast feeding. Preparingand demonstratingfoods for malnourishment. Day or emergency care of sick child or adult. (Decisionlater to sendfor hospital careor home). Smallincisions and repair of lacerations. Removalof jiggers,tumba. Delivery. Issueof medicines.

Severe illness. Severe burns. Largebleedinglacerations. More difficult and adult fracturesand injuries. Testsand investigationsthat cannot be done in Health Centre. Difficult removalof foreign bodies. Largeincisions. ComplicatedAN - labour - PN cases.

Someauthorities suggest many existing Centresdemonstratethat many treatand mentsnormally consideredto be within the sole capability of doctors and hospitals can be carried out by auxiliaries in Health Centres. Given an unlimited supply of staff, time and money there is virtually no end to the rangeof treatmentsthat can be undertakenand the rangeof rare diseases that canbe looked for with sophisticatedapparatus; there is virtually no end to the possibilitiesof prophylactic and preventivemedicine. As staff, money and time areall limited goalsmust be set. The generalsystemfollowed in most countries at the presenttime is esotericmedicinepractisedin a limited number of sophisticated institutions, the sophisticationin facilities and treatment trailing off to, in too many cases, treatment at all. Health Centresaim to spreadcare,and are no intended to be staffedby auxiliaries. The rangeof treatmentsthat can and should be carried out in Health Centresby auxiliaries will needseparate considerationand decisionin eachcountry and often in eachlocality. Wherethere are fewestdoctors auxiliaries will haveto carry the biggestresponsibility. The selectionof treatmentssuitable for auxiliary based Health Centremanagement a crucial factor in planning, surveying,training, is recording etc., etc. Health Centretreatmeht must deal with commonlocal ailmentssuccessfullyif the Health Centreand its staff are to gain local respectand confidence. Treatment and educationmust alwaysgo hand in hand; ante-natal,maternity and child careaspects the Centreswork are crucial and excellent pathwaysinto of community co-operation.
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.Treatmentsundertakenshould alwaysinclude two or three diseases which can be expectedto ahowpositive response availabletreatment. This is asmuch for the to benefit of the staff asof the community. Selectingmain areasfor efforts in staff training, treatment and closedocumentation will dependon: 1. Treatability 2, Ability to show results 3. National decision 4. Local necessity 5. Available staff 6. Available drugs 7. Available equipment 8. Available facilities 9. Available money 10. Available transport In Appendix 29, Evahtatingthe work of the Centreand the useand designof records,it is suggested the work programmeof the Centre should be organized that to somedegreewith the main intention of making record making and evaluation feasiblewith simplemeans. The key to the whole record making problem lies in defining medicalgoals. Onethen knows what is to be recorded. Goal selecting will also define staff@ levels,necessary equipment, building, transport and training; the placing of units etc., etc. This problem of selectionlies on the battle lines drawn betweenHealth Centresand hospitals, betweendoctors and auxiliaries, betweenhigh cost carefor the few and too little carefor the many, between ;zrntry basedmedicineand institutional medicine. Firm and very difficult decisionsare needed. The working party hasnot managed to reachany sort of agreement.

Appendix 21 (ctd.)

Fart-time workers There aremany aspects a Health Centreswork which can be copedwith by of part-time workers. The workers can be of almost any gradeand canwork in the Centre or in a sub-Centreor evenwherethere are no formal facilities or organization at all. They may be radio telephone operatorswith someability, to recognizediseases or farmerswho havegraspedthe ideasbeing offered and are willing to help their neighbours. It could be that a memberof the community understands well digging or somesimilar craft and will help others on request. They can all becomepart of may be requestedto get word the Health Centrearmoury. Alternatively someone round that a doctor is visiting, that an immunization team will be through the district on a particular day etc. It is helpful if the Health Centrecan call on some one to get word round. Similarly, if bullock carts or somesimilar vehiclesare to be usedasambulances someone haveto be willing to lend his or to produce one from his friends or will village. In selectingpart-time workers the Centreacceptsquite a responsibility. Character judgment is obviously important. Wherevillage health committees(seeAppendix 23) exist they could be approachedfor advice. In generaltermsit doesnot seemUNeasonable suggest it may nat evenbe to that necessary pay part-time workers. Providing the tasksare not onerousand to providing the worker receivesrecognition for what he is doing there may be no need of payment. It is proposedin Appendix 31 that schoolchildren can be usedaspart-time record makers. Similarly there is evidencethat in many countries schoolleaversare willing to do community work of one sort or another. The essence this problem is the motivation of those who might help and defining of areasin which help will be useful. Surveyingand the preparation of information, such ascropsbeinggrown,areareas which inexperiencedbut intelligent workers in offering themselves a voluntary basiscanbe used. The information coming in on map must be dealt with. This is another areain which a large scalecomprehensive of the Health CentresareaCouldbe extremely useful for both defining problems and storing information. It is againa matter of finding needand proposinga solution which is statedin terms of possiblestaff. Part-timeworkersmay be able to do very well someof the jobs which might otherwise far1to over-qualifiedstaff.

APPENDIX 22 PART-TIMEWORKERS

-~o&mtj@cj~@na responsiiilities and ;. -IThe,importance of two-way communicationsthroughout the structure of a health delivery servicecannot be overstressed. The-Centrecommunicates with the people of the villagesand district, with the sih.ool.s, with public health and agricultural services, with the governmentand s sponsors, .a; with viSitingdoctors and the District Hospital and with other Centres. ,, I_. $@ing isgainedby isolation. . -,_, P&hapsthe most important streamof communicat& is betweenDistrict Hospital doi-tors and the Centre. Much of the confidenceof the Centrestaff and the.quality -ofcare offered dependsonthesedoctors visits, and,from this cotidence should ~,%pp a meanir@l network of carecentres,which centresshould inter-communi. Repetition of the words and the links cannot adequatelystressthe importance of j this central notion. It is easyto saythat every Centre of any sizeshould have a vehiclewith a high clearance, four-wheel drive and a robust frame and body; capableof carrying stretchersand goods; able to travel in very wet or very dusty conditions; supported -by a maintenancesystem- and it must be said. Mobile clinics, home visiting, the support of small peripheralunits, hospital referrals,the carrying of suppliesand the generalmobility of staff are the jobs the vehicle is to be usedfor. The extra expenseof this transport and the extra problemsof mainten;lnceare far outweighed by the enormousadvantages. Isolation can alsobe effectively combattedby radio telephone. An isolatedsemiskilled auxiliary, living perhapswithin his family group in terrain inaccessible real in terms,can ring up for advice,support and if necessary, transport. Similarly. Centrescan ring up eachother and can ring their District Hospitals. Smallperipheralclinics cankeep in touch with huger organizations. Isolation will be greatly reduced. Diagnostic,or rather &ease recognition skills can, in this way, spreadcare. Eachunit in an areawill be responsibleto the District Hospital. The doctorswill carry a people and health management responsibility aswell asa strictly clinical responsibility. As teamleadersthey will needto understandthe cultural background of the peoplesin their area.They will needtraining and practice in dealingwith local social hierarchiesand must havesomeinstruction in management disciplines. This Appendix hasdrawn the working party closeto a discussionof how this extra burden of training can reasonablybe imposedon doctors, who is to plan it and do it, etc. Part of the answermust be in someof a doctors training period being in a District Hospital, and this period must include Centrevisiting. Traditionally, young doctors, at the end of a sophisticatedtraining period, quite possibly in a foreign country, are thrown into an isolated rural situation where the facilities they havebeentrained to use,and the staff they havebeentrained to rely on arenot immediately available. Simple contemplation of this apparentabsurdity may result in suggestions alleviating the problem ot clverhurdcamg alreadypacked for UI 1 course. The doctors duties are further expandedin Appendii 24. As well ascommunication with other medicalorganizations,schools,agricultutal advisers, etc., the Centremust communicatewith the population it serves. One method of doing this is through the village health committee. Typically sucha committee would havethe village chief or other influential personaschairman,the local teacherassecretaryand a memberof the Centrestaff asinitiator or organizer. The principal object is the improvement of sanitary and water facilities in the village. Thereafterimprovedhusbandry, tree planting if relevant,goat control and similar projectscan be taken on. Improvementsin animal slaughter,the condition / ,of any market, improved housing can all be implementedthrough the committee. Starting fifty village committeesin all the villagesin a Health Centresorbit all at .oncewould put an intolerable burden on the Centrestaff. It is probably best to startin two or three villagesnear the Centreand to wait for requeststo comein from other villages. The organizeror initiator will have the job of #... ....Din .V... . nllttino ..r irlplp .

APPENDIX 23 COMMUNICATIONS RESPON%ILITIES

(9

i.

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.,

._,-, __I( ;:

_-

.-

_I

about what canbe done, includii someidea of costs,controlling wilder and over ambitious schemes keepingup a map or other form of record of activities so he and or shecanmakeintroductions betweencommitteeswhereself help can be useful. This should not be seenas a full-time job for the health worker concerned. Either the committeewill get on with +bejob with a reasonable minimum of help and adviceor the health worker concernedwill needa large secretariatto do the job for them. As the secondoption is out of the question the committeesmust be supplied with basicinformation, their specificquestionsshould be answered much and encouragement given; but they must do the job and must seethat astheir aim. A successful villagehealth committee will include women and representatives of every type of household. Membersof the Centre staff must makea point of visiting the committees,the visiting doctor must be persuaded showlively to interest and annual or more frequent gatheringsof representativesheld whether in a village or at the Centre- evenat the District Hospital if it is well placed. In someareasthere may be a taxation systemfor the support of rural improvement programmes. Thereis somethingto be saidfor giving to the haves. As a village improvesitself so it is given more money for further improvement. In the village in which the Centreis located different problemsmay appear. If the villagehasbeenmost helpful in building the Centrethey may feel quite proprietorial towardsit. They may feel that all their villagesdeliveriesshould havepriority over other villages complicateddeliveries,etc. It must be madeclearearly that it is not only theirs but everyoneelsesaswell. ThIh;oo-py communication systemmust be started asit is intended it should be .

iqpendix 23 @d.)

(ii)

Duties of the doctor in r&onship

to the @e&h @We (seealsoAppendix 23) I

APPENDIX 24 DUTIES OF THE DOCTOR IN RELATIONSFIIPTO THE HEALTH CENTRE

The doctors duties are asfollows: .. 1. To seepatients referred for his opinion 2. To educateand encouragestaff and patients 3. Trouble shooting at all levels 4. Responsible maintaining standardsand reviewingprogress for 5. Responsib!e instigat&g and main*&ung changes Improvements for and 6. Responsible introducing any,younger doctors or studentsin his sphereof for influence to the theory and practice of HealthCentre work. 7. Responsible maintaining the major links betweenCentresand District for Hospitals,, other disciplinesand the local Health Centrecommittees. *en visiting the Health Centre the doctor should have aimssimilar to those of the Centre staff when visiting a local home, i.e. to adviseand encourage, support and -teach, to note progress suggest and improvements,etc. These duties imposean extra burden on the doctor beyond thosehe carriesby virtue of his medical qualifications, and they call for a flexibility of teachingapproachwhich one could reasonablyexpect to find only in a limited number of suitably gifted people. This problem could be lessened the doctor could learn to think of all the staff of the if Centreastiusted colleagues who wiIl inevitably benefit from any advicehe can give: evenif the adviceis not understoodby the personto whom it is given, at least a feeling of confidencein their job may result. A curriculum of lecturetteswith very simplecontent would offer a good basisfor this essentialinter-communication betweenthe doctor and the Centrestaff. A three to five minute talk, preferably supportedby slidesor other visualpresentation, should be sufficient to promote immediatediscussionand questions. There is no reasonwhy thesediscussions should not be developedin further meetings. A set of twenty lecturettes taken in rotation, someof the subjectsbeing followed up in two or three discussionmeetings,would provide an adequatecycle for the average Centre without wasteful repetition. The Centrestaff should be encouraged to continue readingon and discussionof thesesubjects. Thesenoteshavecontinually suggested the local community must be brought that into the power structure of the Health Centre. It is suggested the local that committee, which should of courseinclude Health Centrerepresentation,should be in chargeof the Centre excepting specifically any medical power and with only a limited involvement. From the earlieststages should be clearwithin the it committee that they will be askedto acceptadviceon all medicalmatters and on financial mattersover which they havecontrol where theseare involved with medical problems,but it is essentialthat all thesematters be fully discussed the in local committee. It is suggested the visiting doctor should havethe right of that fina decisionand direction in thesematters,it being assumed any decision will that haveinvolved full discussionwith representatives the community and the Health of Centre staff.

Teaching and staff traiuiq

APPENDIX 25

Doctors will teach nurses nurseswill teach auxiliaries and other nurses,all three will teach patients and vi&tors. The teachingfunction of the Centrecannot be overstressed.Seminars the local hospital are also essentialfor the maintenance at of standardsand morale. The basisof good teachingis two-way communication. which is often helped by good teachingaidswhich are discussed Appendix 26. Simpleanswers in to questionsfrom an interestedaudiencewill go a long way to establishingconfidence in both staff and visitors in the teachingsequence. Most teacherswill not havethe opportunity of a spell of specializedtraining in teaching. Further study of this probiem is neededand proposedsolutions must be phrasedin locally understandableterms. Further, it seems essentialto stressthat any proposedteachingtraining should aim at the possibleand practical and should not assume all the students aregifted teachers,or evenquite good ones. that Simple rules are neededlike If youve talked for ten minutes youve talked for too long. Regularvisits from the areahospital staff are the principal foundation of staff instruction. Visiting doctors must explain any new techniquesand acceptthe help of auxiliaries. Week-end refreshercoursesfor staff are recommended leastoncea year. at Gatheringsof staff with similar problemsshould be encouraged. As a primlyle, It should be stated that gatheringsand seminars should take placein Health Centres and District Hospitalsin rotation. Onceevery two yearsa fortnights refreshercourseand in-servicetraining in a hospital is very greatly appreciatedby Health Centre staff. Auxiliary staff training for higher grades needsspecific study and recommendations for Health Centrework. Appropriately tailored tramlng programmes could, it is believed,reducethe formal training period to two years. This can be partly inservicetraining. i raining centresmust not be centralized in a capital city, should if possiblemove round the country periodically, and should be closelylied with the Health Centrenet-work aswell asthe District Hospitals. Training programmes needearly establishmentand careful design. They are perhapsthe most essentialfeature of the whole Health Centreidea. Intense and early effort is neededin this area.Further notes on this subjectcanbe found in Appendix 44.

TEACHING AND STAFF TRAINING

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APPENDIX 26 The problemsof communicatinginformation are describedin Appendix 25, teachingand staff training. This Appendix puts forward ideasfor teachingaids wheretheseare appropriate. Staff should be able to understandcharts and pictures so teachingaids,well prepared,canbe usedin staff training sessions. Teachingaidshavethe folIowing aims: 1. Clearpresentation Memory aids for the teacher - 3.: Visual material is alwaysbetter than just taiking I- 4. They give confidenceto a teacherwho is perhapsnot very experienced.
2.

SOME TEACHING AIDS AND THEIR USE

A military lecturer askedthe secretof his evident success replied that his technique was,Fti itell them whatIm going to tell them, then I tell them, then I tell them what Ive told them. This technique is very useful and no amount of teaching aidswill makeup for a lack of clear,firm,simplepresentation.Visual aidswill either help in explaining somethingvery complicatedor will punch home a simple point. If possiblea complicatedpicture should be preceded a related simple one and by followed by another relatedsimple one (possibly the first one back again)so that the idea is remembered evenif the detail is forgotten. Aids fall essentiallyinto the following categories: 1. Ready-made (commercially produced or home-made) 2. Kits that canbe put together and taken apart and usedagain 3. Picturesor displaysarrangedduring the talk or just before and probably not usedagain 4. Things usedin demonstrationswhich go back to their original uselater Ready-nmdeaids Commerciallyproducedor home-made charts,books, pamphlets,pictures. posters etc., fdms. fdm strips, tapes,slides,transparencies projectors, overhead etc., projecting drawing tablesetc., notice boards,pm boards etc., kitchens and buildings in the local manner; all theseare teachingaids. They are all fairly expensive exceptfor home-made work on paper. They all havestorageproblemsin hot, dampcountries and the more elaborateequipmentis subjectto theft. Drawing pins and felt tip pens,slide containers,film spool tins and paper are also needed. The essence theseaids is that talks arebuilt around them, and must of follow their demands. The material cannot be changedduring a talk. Very experiencedteacherscan stop half way through a set of slidesand still makesense. Most people,if delayedbefore or during a talk, find it very hard to shortenit or changeemphasis. Ready-made should therefore be preparedfor presentation aids in short batches. Two or three batchescan be strung together with questionsin betweenwherea longer session appropriate. If a film is being showntry to run is it through first and seethat it is in one piece,makessenseand sayswhat you think it says. Makesureequipment is there and working before you start. make sure slidesare in order and that the projectionist knows which way up they are. If you want a slide repeatingask for it to be taken out while it is still on the screen so the projectionist doesnot get lost. Try not to talk to the picturesor to the apparatus. Facethe audience,try to look at individuals and moveyour eyesaround the whole group. If you want to pick somethingout on a picture stand to one side of it and nearly behind the screenor board, and usea pointer. In the dark usea torch with most of the beamblacked out asa pointer. The audienceshould be arrangedfor the presentationin mind. A smahgroup looking at chartsor pictures could squat or sit in a half circle, or could possibly sit on bedsor on a tree trunk. Try to involve the audienceby askingquestions, but makesurethey havea reasonable chanceof answeringthem. In small groups members the audiencecan be askedto pick out things on a,picture. Children of can sometimes encouraged shout out the answers questions. be to to Wherecharts or pictures are pinned up on a board on long term display, for instancein a waiting area,it is helpful if a routine can be established. A member of staff can go into the waiting room and talk briefly about an item and answer

_I T 7:I. -. i . ,

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questions: ques@oml TheahnwiIl be to put one or two points over only, the points closely and related to the picture or chart. Done regularly this will he acceptable expected. This implies a planned rota of material with programmedchanges pictures. A of limited number usedin rotation is more valuablethan having a permanentdisplay which quickly losesinterest. The sametechnique can be usedin staff teaching. Flip standsare very useful. An easelblackboardcan be convertedto a flip stand with drawingpins. Using this technique one startswith the chartsin reverse order pinned by their tops to the top of the blackboardwith the pictures facing j the back of the blackboard. The first picture is then flipped (pulled gently!) over the top of the board and then facesthe audience. Practiceis needed,particularly in pinning the pictures together. Big rolled up chartsand mapscan be stored on pegsset into strips af timber. The pegs should be about 3 inchesapart and stuck into the backingtimber at a slight upward angle. The backingtimbers plus pegsare then fmed to the wall and the charts laid and acrossthe pegs. This makesthem lesssusceptibleto mildew, cockroaches termites. Chartsto be usedon the tlip stand should not be rolled up as they will not lie flat on the board when flipped.
Kitsth8tanbebkenapart

Appendix 26 (ctd.)

Flannelgraphs a good exampleof this kind of aid. The baseis flannel (felt) and are bits are madeof felt. The bits are madeto any required shape. Setsare commerckrllyavailablebut canbe home-made. Any felt or lint-like material which will stick to itself will do. The baseboard is set up at an angleso adhesion doesnot haveto be too strong. The advantage the flannelgraphls that the of piecesmadehel@he teacherto organizematerial but the piecescanbe usedin any order, members the audiencecan help put the pictures on and many different of usescan be madeof the pieces. Flannelgraphs particularly suit story telling for children (with a suitable teachingpoint). PIasticmodelsare availablefor teachinganatomy, the way babiesgrow etc. These are useful because, again,the student can do the disassembly assembly and which greatIy aIdsmemory. Wheremodelsof this sort are usedthat are not at the right story of the community scalecaremust be taken to explain this. There is the classic which, when showna big scaleand beautiful model of a tsetsefly, expressed relief that their tsetseflies were very small, so they did not really havea problem. Blackboardsfall into the categoryof re-useable asthe pictures and diagrams aids drawn can be rubbed off and the board usedagain. Colouredchalksc&nbe used, and if not availablewhite chalk can be coloured with ink. This is not totally satisfactoryasthe chalk goessoft if thoroughly soaked. The chalk can howeverbe tinted so there is a visible colour difference. Blackboardscan of coursebe other colours; greenboardswith yellow chalk area commonalternative. Blackboards on easels havetwo sides,so complicatedpictures can be drawn on the back before a talk, and not producedtill the appropriatemoment. Studentsshould be encouraged to help in preparingpictures during a talk. Overheadlight table projectorsare very useful. Transparentsheets a continuous or roll of transparentmaterialare laid over a light. Drawingsmadein felt pen on the sheetare then projectedby a lens on to a wall or screen. The drawingscan be done during the session whilst talking, studentscanhave a try, a pointer is not necessary asthe pen showson the screenand can be usedasa pointer, and successful pictures or rolls can be kept and usedagain. Sheetscan be preparedbeforehandand used much like slides. This aid can be usedfor largegatheringsand is perhapsthe most useful availablefor generalteachingpurposes. It wiIl be found particularly useful for semhrars more advancedstudentsaspart of their training must be to learn for how to put over information.
Fiied displays for single talks

Staff may wish on occasionto set up exhibition displays. This may be aspart of a seminar,aaa featur,: for a particular effort in propagandaor aspart of the Health Centreaco-operationwith schoolsetc. Displaysof this sort are best set up-in a sequence, start at one end and work to along to the other. Charts,pictures, objectsand modelscan alI be linked, literally with coloured tape or string or with someother more complex referencesystem can such aswriting or symbols. Horizontal and vertical surfaces be used,thus a

&&&na table could havespicture of the school, and a picture of the Centre FT..:, could @,on the table. Aribb$from eachmight then go to a third panel showing 3,.b:, together. If a cookery display is being setup, take careto~be G&:;;.em>:, zthe Wo;Working y; -T realistic~~Attachbig raw~ food stuffs to an empty pan on a table with,ribbon, and g _ .-thenatiaching a picture of a healthy and satisfiedbaby to the pan from the other ,.- , , .I.-. -. sIdecould interpreted in many hilarious ways, none of them asintended. If a ,be >.,. .x:--:-- pqr&Ion in food preparationis to be shown then eachstagemust be shown. A .._ ;, simnle disnlav on theselines changedreasonably often will attract interest wherea will rapidly be&me part of-the wallpaper.
+

Appendix 26 (ctd.)

kitchen in the local the local meansand usedfor demonstrationpurposesthe ,unless changeis being a <,.. gkih~ in which casethis-mustbe madeclear. J&ring in is important here. _ ,f...,. i- r. *_ If the careof a babys mug and spoonis being demonstratedaaksomeone who does it properly tobrhig .theirs rather than using a spanking, demonstrationset. Get new L--L-- >-1--II . _. . . . motnersto aemonsuatespoonreeamgassoonasyou can rarner man aouig II yourself. A demonstrationin which everyonecanjoin in is worth many words.
, i, ,-i-

Stikks, stones,leavesand marksin the sandcan be usedfor teaching. Here is a houseon this hill (a atone),here is the latrine (a pieceof stick) and here is the well (a hole in the aand). And here is the water going from the latrine to the well and I here Is tha owner after using the well (drop a leaf); The latrine must be away from the @l (move the stick). It must be at least 60 pacesaway and more if it is uphill. Anyone can learn thiskind of routine ,andrepeatit time and again,anywhere,and without teachingaids.

ThereIs no usepretending that all Centresaregoing to be staffedby peoplewho handle pens,ghre,string, paperetc., and are expertsin presentation. In the same way no ahrgleset of answers do asdifferent communitieswill understand will different presentations. Co-operationwith any local schoolwill help. There they must know what is understood. Highestgradesof staff will learn from the more sophisticatedmethodsand wilI take in more complex information. Junior staff will havelesssophisticatedlearning methods. Villagers may needsomethingvery simple. Peoplewho aregoing to * haveto teach with no aids or facilities must be taught to usemud and sticks because that is all they will have. Peopletaking on lots of teachingmay needa journal or card index box in which they note what they havedone with eachcollection of people, and will needprogrammes organizetheir subjects. to Staff will needto makenotes,for which purposep&is of talks, but not fuIl notes, can be issued. Thesehelp studentsto remember what wassaidwithout makingit unnecessary them to makethe effort of remembering. for A typewriter, or simplesignwriting set or big rubber stampswith coloured ink padsand someform of dupllcatingmachine,or periodic access one, will complete to a useful set of aids. Fig. 1 over illustrates a useful kit which canbe carried round and usedfor several purposes. . Fig. 2 illustrates the construction of the kit. This drawing is cut down to show the details. The box should be madeto the overahsizesshown in Fig. 1, or somewhatlarger than any chartswhich may be used.A very much simpler version canbe ma& with stiff cardboardand linen hinges.

(iii)

A Tmdling

Teach-box

Appendii 26 (ctd.)

To useasblackboard,open out box and stand up. For flannelgraph,reverselid and stand up. For flip charts,take off lid, lay out charts,put back lid.

Appendix 26, Fig. 1. The, Tmelling Teach-box A - closedfor carrying B - open for teaching
e Lid
iI i

Put on hmtdls 8t point of balance when carrier in completed

Ii .I

- catch

Width of box inside to be at least width of c&rts plus 1% inches Do th of box clear in&de to 1 l tnickness of charts plus thicknw o flat box, like cigar box. s uch boxer 8re u&d for chalks and for flannel piecer etc. . Kee board duster in Y beg as cRalk dust will spoil flannel

When box is opsnod for tanding up charts will hang down, 80 make box 4 inches longer than charts at bottom and 3 inches longer at to to give rprce for hinge, c Rart hanger, etc. Make P pointor, to lie diagonally in box.

KCY to Appendix 26, Fig. 2.

Hingemadefrom long strong screwset deep in lid Flannel surface Blackboardsurface Tab for lifting lid Bottom of lid angled Metal plate suchasa hinge cut in half This dimensionto bc half the thicknerrsof the lid Line of lid hinge (A) Lid thickness Lid closes this ledge on Split paperclip goesthrough hble in wooden batten to hold on flip charts Catch Rail ledgeangledto push lid back into socket at other end when lid is closed Strong rail at bottom The box will be much longer than this. The drawinghasbeenpushed together so that it will fit on the page Plywood or thin timber back Tacks Strong cloth for hanging flip charts over back (lid to be taken off whilst this is done)

Appendix 26, Fig. 2. Lktails of the construction of the Teach-box Key on page iv.

Homevisithlg Homevisiting is an important feature of two-way communicationin health delivery. &Fh memberof the staff will be responsiblefor the overall home visiting proKmll dependon qualifications, availability and programmingof the work of Whereschoolchildren assistin the collation of recordsby visiting homes(as proposed in Appendix 31), home visits should be related to this record making programme. In an areaof dispersed population, home visiting may in fact meanvisiting a small Population sub-group. in someareas home visiting may becomeindistinguishable from a mobile clinic situation. The idea is, however,not the offer of curative medicine but the cementii of co-operativerelationships. The object of the home visit ia to check on the health of the family visited, to encourage them to usethe facilities of the Centreand to try to ensurethat they are following adviceand instructions given to them during visits to the Centre. The visit should be asiaformal aspossible. Suggestions improvementof diet and for improvementof the home, hygiene, childcare,etc., arepart of the.duty of the home visitor but suchadvicemust clearly be given slowly and carefully, and the needfor changeshould preferably be brought out in discussionon a basisof friendship. Local customsof greeting,methodsof enteringhouses,the politeness of sitting and standingetc., should be studied in the area,ascultural clumsiness doesnot assistin the transfer of information. A map of the areato be coveredshould be preparedwith the housevisiting schedule on it. 8 this way the schedules more likely to be met. Local committee In are centresshould be marked on to this map, alsozonesof interest of government advisers on cuItm~, amitation, etc., and schools. Homevisiting is the clearest expressiono the tweway health dehveryprocess. All the more seniormembers Y of the Centrestaff should havehome visiting duties. The keynote of home visiting must be the avoidanceof criticism.

APPENDIX 27 HOME VISITING

1&

-1

havea teaching and caringrole towards the school or ndly and co-operativecontactswith teachersare important. , pri%givings etc. whilst time consumingwill assistin Anne&ix 31 discusses role school children am play in record making. Thla the ., ii&fbrman integral part of the curricuhrm having avahtableteachingc&tent in m&s,-iriaphs, presentationmethodsand co-operativeteamwork. .,. TJ$schwl should havesanitaryfacilities of a good standardwhoseproper use shotrIdbetaught. Personal hygiene,-agriculturaland gardencareshould alsobe tauaht in coniunctlon with the staff usina the Centre-as local base. Theseefforts a i areisseti~6,the preventiveprogrammi. The Centre may alsobe responsiblefor schoolhealth. Height and welightcanbe recordedby children before the medical team arrives. Sight and heating can be checkedby children under proper supervision. Glands,generalphysique, feet, skin and any deflnlte defectsor abnormalitiesare medicalteamproblems. The teachers adviceshould be soughton any children having apparentmedical problems. All chIhlren seenshould be checkedfor immunization. Local immunization drives canbe run with the schoolshelp. The children havefree access their own to homesand can be usedto disseminate Information. It will be seenthat, when a new CentreIs being establlshed,early co-operationwith schoolsis of great importance,and the teachershould be drawn into and should understandthe programme. An older pupil canbe madea dispensaryassistantbeing given someresponsiblllty ln the weighing,measuringand record-makingfield. Similarly sanitary prefects* appointedin rotation could carry responsibility for maintaining standardsof hygiene. The visiting doctor should visit the school occasionallyto back up the Centre stafls efforts. Community teachingprogrammes be started in the schools,the can children preparing displaysetc. As much as five days a year may be spent in inspectionsand immunization sessions at eachschool. Probablythree eveningsa year should be set asidefor discussions with teacherseither at the school or the Centre,andthree or four eveningsa year spentin someform of school-orientatedsocialgathering. Any specialprogrammes wlll needfurther involvement.

APPENDIX28 SCHOOLVISITING

Evaluatingthe work of tire He&b Centreaud the useand designof records Evaluation of the provision of health carein the more developedcountries of the world hasdependedon data suchas the lowering of death ratesand the diminution of diseases astuberculosis. such In developingcountries communicat:onsarepoor. Systems registration of births of and deathsusually do not exist, and if they do are frequently not sufficiently accurate to be a satisfactoryguide. For this reason,the Health Centremust and doesattempt to keep recordsof the work undertaken. Recordsmay be eriher quantitative, suchasthe number of patients and their agegrouping, or qualitative, in terms of the actual health of those seen. Whatever kind of record is kep- i.t needsto be very simple,and it is generally not considerednecessary record a patients name,or evenhis number. Wedo, to however,needto know whether he has Ittended before, and clear recordsof the most common diseases needto be kept. However,recordsorganizedon the basis of a detailed breakdownof diseases rarely satisfactory. are The type of recor? developedin Malawi and Zambia is describedin the chapter on Under FivesClinics, in PaediatricPriorities i3 the DevelopingWorld, by David Morley, publishedby Butterworth. Such simple recordshaveproved effective and useful. in assessing nutritional statusof the children, the proportion who fall the below a certain line on a chart which is usedthroughout the country can be noted and this givesa useful indicator of progress both qualitatively and quantitatively. In assessing success a clinic in its preventivepolicy, the proportion of the of children who havecompletedall their immunizations - the so-calledprotected children - is probably the best guide. Somesimilar systemfor adults is needed. r-cords at length and hasfound no answers. We Ihe working party hasdiscussed distinguishthree different aimsand find them in conflict. 1. Patientsrecordskept to assistin trea.tment. 2. Centre recordskept to: 4. ask: in setting target3 b. ched . the progress the Centrefox the satisfactionad information of the of staff (.4&h we considerto be very important and readily show the visiting doctor how +beCenlre is do;ng c. a;sistin changingdirections in treatment etc. if necessary d. include - ommmmity hygiene projectsetc. 3. District, regionalor national recordskept to: a. b. c. d. e. assistin planning givea basisfor comparativeevaluation of different Centresand programmes demonstratethe progressof, for instance,national immunization programmes provide national statisticson birth ratesetc. Providea basisfor annual accountingand budgeting.

APPENDIX 29 EVALUATING THE WORKOF THE HEALTH CENTRE ANDTHEUSEAND DESIGNOF RECORDS

At somestagethe recordsmust also beginto indicate the kind of things that must be looked for in an initial surveybefore establishinga new Centreand its programme. Patient retainedrecords(seeAppendix 30 for examples)are strongly recommended by the working party. Field experiencesuggests losses recordsare low once that of the patient understandstheir importance. The loss rate is saidto be very much lower than the loss rate in a hospital system. The under fivescard is a classic exampleof this kind of record. The card showsprecisely the information needed, demonstrates when somethingis going wrong evenbefore it is otherwise obvious, givesa running checklist of supporting treatments,carriesadditional information on the family and can be understoodby the family. The problem is that someone sitting in the Centrecannot seethe records. Someauthorities therefore keep the recordsin duplicate, one in the Centre,one for the patient. This doesnot seem economical. The alternative is the useof someother agencyfor generalstatistical analysis. Onesuchmethod is describedin Appendix 3 1, The useof school children for record making. Designis a major stumbling block in record keeping. The under fives card is designedto show progress,70illustrate developingproblemsand to be readily

The undemtandable~~ designof adult cardsfor the samepurposesis more diffidult. This problem is discussed further in Appendix 21 on Treatment types. -Whena Centre patient is referred to a hospital he may be X-rayed. Who is to keep the plate? If it is kept at the Centre,who will ensureit is brought back to the hospital if the patient appears there again?,Qn the other hand, will not a visiting doctor want to seethe plate ifhesees the patient during a Centrevisit? Stomkeepingand requisitioning problemsalsoaffect the run@& of the Centreand recordkeeping. Thus if, say, lOOtIunits of a particular drug are requisitioned then the booksmust show: 1. balanceremainingat any givenmoment 2, batchesdrawn from store and dates 3. useof the batchesto checkproper issueetc. 4. whether the requisition wascorrect for the time spanconsidered 5. whether the book balanceremain@ haabeencheckedin the store to check theft, deterioration etc. to Item 3 is on a patients record. Is tbat record designed help in following up drug issueinformation? If not, then work is being duplicated and the chancesof error are increased. In this connection a standardizedprescribingpolicy and central prepackingof drugs(seeAppendix 6, Pharmacyor Dispensary)help as 1000 units can appearas,say, 10 packs. This reducesaccountingand the checkingof remainingsupplies. If a patient retained record hasa &al number and if the dispenser notes that mrmberon his batch slip for a particular drug when it is issued by him then: 1. the recipient can be checked 2. the marking in of the serialnumber denotesissue 3. the completedslip can, by referenceto the serialnumber register,give information on the age,sexand geographical distribution of that drug use 4. if ti drug is usedonly for one condition the incidenceof that condition can be plotted and followed and 5. home vlaiting will help to find out if the drug hasbeenproperly used,if usedat all. Fairly preciserecord keepingon drugsis essentialanyway, so the burden of marking inaserialmrmberisnotsogreat. Similarnuukinginofwrialnumbersinaclinic could becomeburdensome. Thus, quite commonly, the total number of people seenis noted by putting on to .apiece of papera vertical stroke for eachof the first four attendances, crossingthem through for the fifth and so on. Thus each crossed batch is five attendances totting up is fairly simple. Splitting and attendances down into conditions requiresseveralsheetsof paper. Unlessforms are provided that are specifically designedto give,in effect, a proportional forecast of conditions, the resultsmust be a daily pile of largely blank paperwhich wastes time, money and storagespace. Splitting down into conditions and marking in serialnumberscould take ten to fifteen seconds time, sortingout and counting up a and recording the resultsfrom eachsourcein the Centrecould take half an hour a day, storing so that a particular condition could be statistically traced over a period of time without having to go through the lot would take another half hour, and getting the information into a form that will be useful in showingthe progress of the Centrewill take another half hour. This represents man ho.ursa day two spent,essentially,in puabingpaperaround. This problem is discussed further in Appendix 21. This report burdensthe doctor visiting a Centrewith duties of advice,checkingof progress, medical work and supervision,encouragement staff, somehome visiting, of teaching,checkingon the progress latrine building in the district etc., etc. It of seems reasonable suggest someform of aide memoirecum report sheetcum to that progress record cum major problem annotation will be essentialfor him. The staff can preparesuch a form before the doctors arrival, and, if the sameformat is used eachtime, the doctor can, with a little practice, bring himself fully up to date in a matter of a few minutes. The doctor can spot check the information given to him by making a few well chosenhome visits, possibly on his way to or from the Centre. The implication is that daily recording of attendance0 should be made etc. in sucha way that the information required for the doctors check list is instantly available. It also follows that this check list should be usableasa periodic return from the Centres,and that it would well include goodsrequisition information. If the Centrehasa vehicle then the form should also show if it is due for servicingand

hther maintenancehasbeencarried out. Clearly, such a visit form cannot be compreh&isi~e. The institution of community hygiene and food improvementprogrammes also needsrecording and progress needschecking. If possiblesuch recordsshould he ~derstandable tid readily checked. One answerwould be a large wall map ot the areaserved. Colouredbamboopegscould be stuck in to show where unp~ove~~~c~~~ schemes havebeenstarted,one colour ewh for gardens,field culture, latrines, rubbish disposal,water supply and a$mal management. Publicly displayedsuch a mapwill showhow different villagesaregetting on and could be a powerful propaganda agent. Eachcommunity could haveits own display showingproportionai progress usingthe samecolours. If school children are taught how this works they can both explain the systemto their eldersand do the surveying,reporting and marking up. Sucha systemwill: 1. show need- no pegs 2. indicate progress- not enoughpegs 3. record results - how many pegs? 4. encourage action - why havent we got any pegs? A simple refinement would be lo punbesidethe map a spacefor eachvillage with. for instance,a latrine peg for eachhousehold. A pegis movedon to the mup when a iatrineis built. This systemwould alsoserveto indicate the needfor lilrther survey. Medic11 mapscould be preparedon the samesystem. Periodic records can be madephotographically. Well preparedrecordsof this sort will encourage, plan, show progress, show needand give simple and accurateresults,the photographsgiving a full and understandable permanent record. Oncethe generalidea hasbeenunderstoodprogress be demunstratedm the community by showing can slidesbesidethe map. The bonesof a programme clear. Eachpatient needsa medicalrecord. The are Centreneedsrecordsmadein such a way that information can be simply extracted in a form which will show progress. The doctor needsa time savingcheck. Requisitioning of goodsetc. should be tied in ii possibleam! regionaland national statisticsshould be reasonablyaccessible. Fully comprehensive recordsare an intolerable time burden. If you know what you want to do with what you have recordeddesigningthe record form becomes possible. Otherwiseit is paperfor paperssakeand a terrible wasteof time.

&tadix

29 (ctd.)

_.

a~%, _I

s&y&mip@

o&dient

rained

records .

APPENDIX 30 SOMEEXAMPLESOF PATIENT RETAINED RECORDS

Recordshavetraditionally beenheld in the Hospital, and this systemis logically transferredto Health Centrework. However,experienceshowsthat where patients-keeptheir own recordsthe loss rate is lessthan 10 per cent. This is an excellent performance,andconsidering the savings time, staff and spaceresulting in from holding only a minimum of recordsin the Centre, a performanceworth investigating. Wherean entirely new kind of record, suchasan under fives road-to-healthweight chart,is.introducedthere is no backlog of tradition to be overcome.If adults records for the patients retention are to be introduced it may be necessary prove that the to new schemeworks better than the old. A competition betweenthe old and new eystemsmustproducefalseresults asthe Centrerecord staff will be put on its mettle and will makea specialeffort. The fast steptherefore is to note the generalrecord lossrate over a.period of time and before introducing the new scheme.Patient retained recordsshould then be introduced for a specificdisease, preferably one requiring reattendances.After a period of usethe lossrate can be compareddirectly to indicate preference;but additionally the reattendancepatterns can alsobe examined to seewhether the patient, holding his own record, is persuaded reattend to to programme. Wherepatient retainedrecordsare usedstatistical analysisis a problem. Visits to as homesare necessary. This can haveadvantages the statisticscan be set into a social background,disease incidence being relatedto socioeconomic position, statusof housing etc. School children can be usedfor someaspects assessment of (seeAppendix 3 1). The cardsaregiven out in strong plastic bags. The patient should be told to keep all the familys recordsand to keep them together. The record must be explained to the patient. Three examplesfollow: Fig. 1 Fig. 2 Fig. 3 Fig. 4 page(ii) page(iii) page(iv) page(iv) Chestclinic card The reverseof chestclinic card (Fig. 1) A childrens card (the reverse lined across the is like lower part of the front) A childrens tuberculosiscard (the reverse blank) is

This subjectis discussed length in Patient RetainedHealth Records, at Co-ordinatingAgencyfor Health Planning,(C/45 South Extension, Part II, New Delhi 110049),printed by Pamassus Publishersand PrintersPr. Ltd., (H.S., 30 KailashColony Market, New Delhi 110048). 1973.

1; g 1 +I y ! ! ii 1 Visit to Doctor T&lets. 1st. Two w&r. Medicine . Dly. injection 1 2 3 4 5 6 7 8 9 10 11 !2 ,, !j I ___._- ___-_.__1 c __ ---T ._ ..-..-.. ^__ _ - ___.________.,..._..__.....- -.--. --..-. .. . -...--- .__ _ .k 2nd. Two wks Visit to Docor Medicine Tablets. j I Dly. Injection 13 14 I5 16 17 18 19 20 21 22 23 24 ;j i j/ W Streptomycin ... . . . Gm/dy. P.A.S .. . ... Cm/dy. I&H. ..- . Tabs&. --t----:i ii iii;. I: :: i: i 4th. c Dly. $ --11 :! ii 5th. :I 2 .--. _ -..f-. -_-. $ .i 6th. it i: P i !I t 7th. F d :;fcti:58 sputa ?n Test Medicine 25 26 27 28 29 30 31 3L 33l,ae;5 36 I( r

~~~Sf-fA'WESEY GUILD HOSPITAL 1 -.i 2 .~ -CH@k CL[hlC CkRD OF -..... 0. P. No ___. ...._- i

._._. ._._ . _

..---.

-..--------.-. .--.../ ---

- ----.

__. 1-- ..- .- .;

, Visit to Doctcr Tablets ;: Two wks Medicine Injeitioo 37 38 39 40 , 41 42 43 44 45 46 47 48 1 --:i ii Tablets. : Two wks. Sputum Test Medicine (X- Ray Chest) _ __.._,_ ___. ._-._.. ..__......__...........,.................,.. ..-.....-- ....-.. ...._..._.._....._.._ _ t -............ .. ..___...._ -...... - ----.- - -. - __.. r ----Two wks. Visit to Doctor Medicine Tablets. 1 ______--_--._.-_-___ ---ii :: Tablets. /I Two aks; Sputum Test Med$iae :. ..-- -_ ! 8th. Two wks. Visit to Doator Tablets. i/ Medicine _-.- -----. 1/ ---..- --.----. ..:--..-- -_-__ __L _I.. - ........- .....- . .. .. . ........~..____.__..__.__.._...__.._ ._ Sputum Test ii ..--.-.-........_....._^ - _.._.......__. _ !i - _ . ..-.-....... -........I! visit to Doctor Medicine Tabltta. /I Medicine ...... Mcdidae .__...__. Tabkts .
Viait

: 9th. Two wks. ____.__._._._. ---.10th. Two wb. Tableta. -- _--__ . .._ _ -------_. _._ _-.. . _ _ ---.. _-__ ___ .._ _._._.___

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to Do@or

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Sputum Test i3tb. Two wb. Rqy ._--l_-l ...._ -.---..-.-(X ....-.-. Chest) -14th. Two wks. 15tb, Two wks. 16tb. Two wks. ------_I_18th Two wks. 19tb. Two wks. 20th. Two wks. mm21st. Two wks. -22nd. Two wkr .-_-23rd. Two wkr. 21th. Two wks. 25th. -lwo wks. Visit to Docior -Sputum Test (X Wry Chest) Visit to Doctor SpWum Test ---- Visit to Doctor ..._... .I........,_ .. -. .. ...-.-..-.. ........- -,...... - .-...__ -___ __...... . ..-...-.-._.I.._.._._...._._.___....~.....~...~....- .....................-......-I...-..-.-.-.....- ..---.- ... -I_ Visit to Doctor - _--_ -.--.-.Sputum -Test Visit to Doctor ....e_.__P -.... ---_.----.--.. .-.-...-...-- -.____

.- .... --......I....___. - ....^.___...I.._..___ Visit to Doctor -_.-- - ---

--

-...

Visit to Doctor 26th. Two w&s. ...... -..........-.........--.....-.. ....-...... ...I..-..............^.. .... .._......_.__, ......._............_.._.. ..__-..-_YOU HAVE TURERCULOSJS 0 NI B-QKQ Egb@Q le aan ti rba tQju re dede. J&b#Q ma bps rw~n ti 0 ba ni ahan na hi tQju q. Ewe ni k&bo Ikp Bgbq yi jo fun awQn Clomirnn. JkQ pg@qjc cwu ala fun awon QmOde. J&i Onivgun ri awQn QmQ WCWQ Yh 0 k dab&o ik WQII ~QYQ IkQ &be. MA!$E J&?GARl TABI QGFD@ AGBAGBA.
MA

Tuberculeals can be cured if treated regularly, Peopk with tuberculosis usually dre from it if thy pm not tmk, Your Sputum is dangerous 13 others. fobcrcuJosis is dangerous to small children. Let the doctor see smrli children from your bow. He can protect them against tuberculosis. DO NOT EAT CASS4VA OR ___L---EAT BEANS v-m EVERY DAY. PLGNTAJN

JB

EWA

ERB LOJOJUMQ &hi Pm, --Phorb 2&W &ha

ILESHA
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ILEsHA WESLEY ?3JILD HOSPITAL CHILDRBNY TUBERCLJLOSLS naammm cam

SCHOOL CHILDS CLINIC (up IO 14 yeatr) Name ------.---L---w-

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Date 1 Uoctor

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Yoqr child cot 4ayraus and strong if l ud feed him

has a form of Tubsrculoris It is to otMs. Tha child will g:t well you grve the tablets regularly good food.

^-

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Good Food: Any food made from beans: Ewa Ere, Ok, Gbcgiri, Ekuru.
-.----

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Feed one of these at least once P day. Also: Rict, Yam, I&q. tabi
( Ipckere ).

Do not Fee& Gari. Eb?, Qka-Qg@;

Qgdc.-Agbtwha Fii3 A-scad

Fig. 4 A childrens tuberculosiscard

The

of schd childrrn for mcord making

i
I

APPENDIX

31

Wherepatient retained recordsare usedinformation which may be neededfor statistical researchor future planning surveysmay be in the homesin the villages and not on the Health Centreshelves. It is important that this information should he available. Rather than sendingout members the Health Centrestaff it is of proposedthat this collection of information can usefully and interestingly be madehy school chlldrcn. In addition to the merecollection of information this systemwill Serve introduce to the children to community service,to the rangeof facilities availablein the Centre and to the methodsand progress community development. of This systemwill not work unlessrecordsare designed with this kind of data reasonable suggest a fairly to that collection and collation in mind. It seems limited number of diseases be widespreadin a particular community and that will thesecould be givena code number and a simple treatment reference. Thus for instancean appropriatemark in a box numbered 15 and an associated C could box indicate an upper respiratory infection treated with a palliative mixture. .4t the end of that line could be a seriesof date boxes to showyearsof incidence. Sucha record would be very limited in scopeand application but would be extremely useful. Rarer diseases would needmore complex annotation which the Centre could easily handle. A systemfor collecting information from under fives weight charts is describedin outline below. It is obviously important that informiul~~llwhich might be consideredconfidential or embarrassing should be kept off recordsthat are to be used in this way. The senior school children start with someinstruction using typical chartsin the classroom. Whenthey understandthe chart and what they are to do they visit all the housesin the community or a sampleof them. After introducing themselves discoveringwhether there are children under five and in the household,they askif they may seethe growth charts: from thesethey would extract information on to a sparechart, or a papercopy of one. On the aparechart they would useone line acrossfor eachchild and thus be able to use one chart to extract recordsfrom ten charts in the housesvisited. It is most important that the information to be extracted is simple. An examplels given on the chartswhich follow of how simple this information canbe. Chart A. (Fig. 1): This is an exampleof a chart they might find. Chart B. (Fig. 2): This is the chart on which they will extract the information. Line 1 refersto Chart A 1 refersto a weight being recordedin that month refersto the month in which they are carrying out their study JI On the accompanyingChart B the following hasbeenrecorded: 1. Attended 4,5,7,8,9, 14, 15, 16 months and was 18 months old child 2. Neverattendedand was 11 months old Child 3. Attended 1,2,3,4 months; 4 months old Child 4. Lost card; 5 months old Child 5. One month old, not attended Child 6. Attended 1,2,3,6,7.8 months; 29 months old The school children, probably working in pairs, wlll collect information on ten children. On return to me school they can work out tables gning:
Child

THE USE OF SQIOOL &L&EN FOR RECORDMAKING

1. Proportion of children agedO-l -2-3 registeredat a clinic at any time 2. Proportion of children aged0- 1-2-3 attending a clinic in the last three months More complex information canbe extracted if other symbolsare used: - Weightbelow lower line

wea

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B = BCGgiven S = Smallpox T = Triple Antigen M = Measles Child 7. Attended 2,3,4,5,6,7,8,9,10, 11,12 months. 13 months old. His weight wasshown below the lower line in 6,7 and 9 months. Child 8. BCCand Smallpox in fust month, Triple Antigen 2,3 and 5 months. Measles vaccinein 10 month. Working with this information tablescan be preparedgiving proportion aboveand below the lower line and at what agethey crossthe line (that is, havea reduced velocity of growth). Detailed tables can alsobe preparedon the ageof immunization and proportion of chiidren immunized. Preparingthesemay seemcomplex but will not be so once a routine hasbeenestablished. Problemsthat would ariseover calculating the ages of children are largely removedby setting them out on a chart. More detailed information on the under fives systemcan be found in Appendix 2. Examplesof other patient retained recordsare given in Appendix 30.

Appendix 31 (ctd.)

comlllunity

hygiene

APPFsNDlX32 COMMUNITY HYGIENE

Programmes encourage to smaller,healthier familieswill not work if infant mortality ratesrermin at the horritlc levelsthat obtain in somedevelopingcountries. Gastm-enteritis,worm infestations and diseases carried by flies areproblemsthat can be literally buried. Adequatelatrines, soakaways fluid wastes, for the rotting down of manure for pits (coveredwith earth every two days), a pit for the burial of refuse,or an incinerator, soakaways associated with animal pens(particularly in areas with non-poroussoils), and the reasonable management water resources be expectedto have of can dramaticresultsin the reduction of disease. The Health Centrehastwo roles to play in this connection: 1. The method by which it controls its own sanitation problemsmust serveas an examplefor the community at large. Evenwhererunning water is availableat least one earth latrine must be built, usedand maintained. The provision of a wheelbarrowand a spadefor a village sweeper, sweeper the to haveclearly defined duties and a possibly nominal reimbursementin cashor kind, preferably drawn from the community, should also assistvery materially in the reduction of disease. The implementation and successful continuing useof community hygiene facilities will dependon a changein the understandingof disease. Improved hygiene should be part of the resI ponsibility of the local health committee. 2. The staff at all levelsmust know the necessary method of construction, size, time taken and cost of making latrines relevantto the local terrain; must know how to keep them in reasonable order; and must include the familys management its latrine in the home visiting programme. The advice of given,mustrelate directly to local conditions. Similar details must be known for soakpits for fluid wastes. It may be possibleto position soakaways so that adequatelyfalteredrun-off will water kitchen gardens. The Centre staff must alsoknow the rudiments and cost of well digging although the siting of wells is bestleft to a visiting expert. Someknowledgeof local geologyis essentialin selectingsitesfor latrines. Run off from latrines must not be allowed to contaminatewater sources. Schoolsin the zone of influence of the Centremust havelatrines and soakaways and the children must be taught why they are there andhow they are to be used, not asa matter of somethingspecialbut asa matter of course. It doesnot seemunreasonable suggest money spent on village sanitation to that might show at least asgood a return in terms of community health aswould the samemoney spent on a Health Centre. It is proposedthat the community by communaleffort can maketbis contribution without direct cost to anybody else. Ideally, governmentmight offer a cashawardfor the improvement of a communal water supply to everyvillage achievinga givenpercentage private sanitation. of Tied in with this sanitation programmethere should be a parallel programmefor the teachingand encouragement personalhygiene,this programmebeing of judged againstthe practical possibilitieswithin the community concerned. The memberof the Health Centrestaff primarily responsiblefor home visiting should co-ordinate community hygiene projects at least to the extent of knowing wherethey are going on. The visiting doctor should be kept informed of progress and encouraged visit sites. to Homevisiting staff will havethe opportunity of first contact at a personallevel, and should attempt to find out about sanitary facilities, if any, in a particular houseor compound, and could makea note on fly problems,generalcleanliness, etc. This should obviously be a confidential note, and should be expressed in termsof &a useful place to start rather than fdthy house. Community action is besttaken through the local village committee. There is little to be gamedfrom attempting to by-passthe local socialpower structure. The health committee should be visited by someonefrom the Centre, and should periodically be represented at least one of its members a meeting of comby at mitteesat the Health Centre. Hereideascan be exchangedand progressnoted and, possibly,joint action betweenvillagestaken.

(9

Whilst thesenotes suggest all the Centre staff membersshould havea working that knowledgeof solutions to local problems,there is obviously a practical and useful limit to the spreadof this knowledge. One staff membershould be the local expert if there is no governmentofIkial available. Alternatively, schoolteachers could well be brought into this arena. There may be culture-based objections to people showingan active interest in sanitation. This is most likely to happenin a castedivided society. At least initially more may be achievedby using the castesystemthan attempting to changeit.

Appendix 32 (ctd.)

Nutrition and food Properfeedingis very important to health in developingcountries. In particular it is important in the weaningor transition phase(which can be long-lasting)and in early childhood. In India many of the problemsof malnutrition could be overcomesimply by more food. In other countriesthe bare food supply may be sufficient to fill the stomach but may not be well-balanced. Investigation of locally grown food-stuffs may lead to the discoveryof all that is neededfor a balanceddiet contained quite literally m the (unfortunately) despised weeds. In most cases crop strainswill haveto be improved or new food cropsintroduced altogether. Four things are neededfor growing crops: Topsoil Water Care Plants

APPENDIX 33 NUTRITION AND FOOD

Without topsoil there is not much to be done. Wherethere is topsoil three years rains can washaway40,OlMyearsof the accumulatedmatter which forms topsoil, so conservancyis essential. The basicweaponsin conservancyare contour ploughing so that water and rain-washed are trapped,leavingwind-breaksin the soil form of trees,and nourishing the soil by any availablemeans. In a sense, one usesfertilizer in year 1 to ensurethe existenceof the soil in year 3. Year 2 crops may well grow without it. In primitive jungle-clearingcultures the felled treesare left to rot, the cropsbeingplanted betwe,en them and shadedby them. This is good sense: the more efficient clearingand burning is highly destructive. This yearsefficiency may be next years erosion. Re-afforestationis an excellent conservancymethod but is very expensive. On the other hand if everyoneplanted a tree a week the eventualeffect would be dramatrc. Topsoil without water is useless. Wherewater is very limited conservancyis essential. Ground water can often be reachedby diggingwells. If the ground water hasaccumulatedover generationsof ramsthere is a fair chancethat it will be exhaustedin two generationsof irrigation. Modem irrigation throws tons of water in the form of spraysover the crops. The sprayis partly subjectto evaporationbefore it hits the ground, much of it sits quite uselessly the leaves on and evaporates. Often the water is deliveredin cuts or canals,theseagainbeing from canalsmay well reestablish ground water, subjectto evaporation. Seepage on the other hand wherecanalsare available,wells probably are not used. Or, wells may not havebeenusedbecause ground wig not hold water, so seepage the water is lost. Wholeriven can be lost by wasteful irrigation, depriving others, living down river and away from its rain-source,of this essentialresource. The cashcost of this squanderingcannot be equalledby the apparentincreasein the valueof the irrigated crops. Carein planting, watering and shadingof plants may be the best tool available. A smallquantity of water deliveredfrom a can to the shadedroot areaof the plant may be all that is required. Why usemore? Additionally, a well-tendedsmall patch may be labour intensiveand may not yield a cashcrop but may be it will feedthe family well. Mixed planting of shadeplants with food plants may also be a good answer. The selection of plants is of paramount importance. The only answeris to find the best authority availableand ask,bearingin mind that the growersconcerned must be willing to eat the recommended crop. Demonstrationis the main propaganda weapon. Grow your own garden. If a memberof the Centrestaff or a villager is employedto work the garden,then it must not be biggerin sizeor labour requirementsthan everyoneelsecan manage. Rip out flower-bedsand put in food, and tend it and useit. If the proposition is that one canlive off a small patch - then prove it, and cut food bills. Livestock, usually cattle and goats,are desperate a menacein many communities. Goatspromote deserts. It is arguedthat only goatscan usethe desperatelypoor vegetation,but in fact they are often kept ascultural or cash,rather than culinary, assets. They do not convert plants to animal proteins efficiently and usually do noi evengive milk. They do destroy the only remainingvegetationand shade. The alternative to a total goat massacre (which is the best answer)is the introduction of a strain of goat that will give meat and milk when kept in a pen. Whereinsufficient plant material or water is availableto feed a pennedgoat, the O& practical solution is to shoot the existing goat population. This is not a job (9

for Health Centresat a practical level, but it is a propaganda for the Centre job staff. National agricultural authorities are usually not gearedto small gardenagronomy, which is what is needed. An offk5a.lally in gardenculture is valuable. Govemment for its own good reasons look after cash-cropland owners. Peoplewith will tiny bits of land needhelp, adviceand encouragement, the Centrestaff must and do all they can in this effort. Establishingfood values,improvementprogrammes is a subjectwell coveredin etc. variousbooks. Alternatively someone know the answers will be keen to will and help. Four problemsremain in the Cent&s responsibility: Establishinga well-balancedand locally practical diet Cooking the food while preservingits value Transitional foods for weaning Food storage Any proposednew foods will needto be popularized,and existing inadequate methodsof cooking improved. The only starting point is an understandingof local taboos,preferences availabletime for cooking. Taboosand preferences and canbe altered in the courseof time with patience,understandingand example. Do not attempt to introduce methodsof cooking and food preparation which are not possiblein the time available,or which useunfamiliar utensils. If the cook cannot do the new method in the sametime and with the sameeffort as the old, then it will not get done. Careful observationand planning are required. Transitional or weaningfoods are important. If possibleinfants should havethe samediet asadults; this will probably give them the widest rangeof foods. Experiment may show that, for instance,maniac (or cassava) leavesproperly preparedand then choppedvery small will give a child the food it needs. Unchoppedthey areindigestible. Similarly, curry is fme for a child, but desperately hot curry is destructive. The key is to examinethe local diet and attempt to adapt it so that it serves child well without additional cost to the family, the without extra expenditure of time (the cook is a very busy personand cannot lose time in he daily round) and without being basedon an imported ingredient which may cease be available. The Centremust havea demonstrationkitchen in the to local marmer,stockedin the local manner,and usedin the local manner,and the food should be eatenby the Centre staff. If it seems be possibleto improve the to local kitchen designwithout additional cost, then the demonstrationkitchen should show such improvements. Food storageis an important factor in the householdeconomy. Study what jd done locally, makeclear notes and askadvice. It may be that certain food is not stored because rots or is eatenby insects,and there may be simpleways of it overcomingtheseproblems. The answers should againbe demonstrated,but ail in the local mannerand within local pockets. Recent&dies haveshownthat in Mozambiqueliver cancerMlls one man in every 40 households; about 50 tunes asmany deathsasin Britain. This is now known to be related to a liver poison, atlatoxin, producedby the mould Aspergillus. This funguscan attack staplefoods such asgroundnuts or maizeif they are stored in warmhumid conditions. (South African MedicalJournal 2,508,48 : 1974.) Vitamins B and C arefrequently lacking or in short supply. C can be madeup with fruit and a suitablevariety must be soughtand grown if none is available. B can be madeup with, for instance,unpolished rice. Advice on the best sourceof thesevitamins in the areaconcernedshould be sought. The best laid schemes food improvementcan founder on drought, insect or for disease attack. This is obviously a pity but the local farmerswill be familiar with tbis problem. Schemes founder because crop will not grow well in the that a locality arenot well laid and will be counter-productive. The best-fednational animalsare probably intestinal parasites,and the . worst-usedfood that which passes through intestinesthat cannot absorbit because of diarrhoea. Both theseproblemsare very much in the Health Centresorbit. In a very wide sense efficient modem agriculture is destructive. With machinery it is possibleto reducelandownerscats; the peoplewho then worked the land iii)

Appendix 33 (ctd.)

and alsosupported themselves a certain extent with livestock and gardensare to driven away to the towns wherethey cannot produce anything for themselves, but consumethe bulk of the increasein the crops resulting from irrigation etc. in other words, the assessable effect of modem methodsmay be an increasein human misery. Should suppliesof the fuels neededto work the machinery fa& disaster will be total. The samematerialsthat go to make the fuels also makethe fertilizers necessary modem methods. for Nutritional education hasthree aims, first to break down harmful local beliefs, secondlyto encourage better diet and thirdly to show how the improved fooda stuffs can be produced and existing food-stuffs improved. It is important to rememberthat the food customarily eatenis eatenbecause growsreasonably it well and is reasonablyresistantto fungi etc;. that there may not be a practical or economicalalternative; that talk of irrigation etc. must be linked to the practical possibility of irrigating; that the best run progmmmes founder on yroltzged can drought, etc. Additionally, the important people in the areamay be healthy, strong,energetic,vital and intelligent, and are children from very many generations of peoplebuilt on the samediet. It is peoplelike this who do the convincing in the community, and nutritional education hasto convincethem first. My wife wasa weak womanand had weak children but I now havea new strong wife is a statementsolidly basedon observationand evolutionary probability, and Why should I wasteextra food on someonewho wasweak anyway? may not be a romantic reply to suggestions about increaseddiet, but it is a reply packedwith logic in a community with a subsistence agriculture. Nutritional rehabilitation can be a very useful weaponin food propaganda. A malnourishedchild respondingto a changeddiet is a great teacher. It is vital that the family knows what is going on. It is no good doctor waving bowls and pills and medicine at the child which miraculously recovers. The family must be taught to do it all themselves with locally availablefoodstuffs. Pills that aregiven should be the sameasthosegiven to others anyway and everyoneshould know it. Nutritional rehabilitation closely associated with the Health Centreis an excellent teachingpoint and moralebooster. But the impossibleshould not be attempted or the end result witI be a lossof confidence. mothersgiven additional iron, folic acid or protein during the last trimester of pregnancyproducebabieswith significantly increasedbirth weights. This is encouragingin view of the relationship betweenlow birth weight and perinatal mortality. fn somecultures heavy feedingduring pregnancyis associated with big babiesand consequentdifficult births. This coldly logical proposition must be overcomein discussions about feeding.
Regnmt

Appendix 33 (ctd.)

Lactating mothers needasmuch if not more food than pregnantmothers. This is often overlooked and sometimes contradicted by cultural custom. This problem is substantially hidden by the wonderful ability of the mothers body to provide highly nutritious milk from poor materials,but this miracle is wrought at the mothersexpense. Infants in the first months and throughout the fust year needgood food to support growth. Skull and brain developmentis prodigious; inadequatefeedingccn lead to brain deficiency. Encouragement. exhortation, psychological pressure, a,ly meansof encouragingmothers to breastfeed for a year should be used. Advert&ements for artificial substitutesshould be quietly removedfrom the district, and televisionor other advertisements ridiculed. But breastfeedingmust be supplementedwith solids from six months, and the aim must be for balancedsolids,until by one year the infant should be able to eat most of the normal family foods. Highly spicedand coarsefoods may be rejectedby infants. This doesnot necessarily mean they are not ready for solids. Toddlersand infants up to the ageof five makeup the most obviously malnourishedgroupsin many countries. In transition from mother dependence to independence problem is particularly noticeable. Toddlers benefit twice from this contirmed breastfeeding,first from high quality protein, secondfrom the decreased chanceof competition from a further pregnancyand birth. Underfed children respondwell to just more food than they havebeengetting. Caloriesare often the main deficiency.
oil

Staples pulses,leafy and coloured vegetables, and animal and vegetableprotein and should all be viewedasessentialadditions to basicdiets. (iii)

Peoplein rural communitieshavewhat is often called natural dignity. Thus, when encouragedto eat more of an unti and possibly flavourlessfood they may not reply Well, why dont you eat it insteadof tinned.tomato soup?but they may well think it. Exampleis very important in teaching. Food preservationand storageand cooking areimportant items. Most will be learnt asa result of demonstmtion. Demonstrateimprovement in a child, demonstratea good-diet, demonstratecooking. Talks and pictures are indispensable talks should be but very short and havea simple theme like Well fed mothers of healthy children. Questionsand answers needto be kept simple. Picturesneedto be explained and then usedasmemory aids. Protein, vitamin and similar words are only tagsfor convenient conceptsand are meaningless themselves. Perhaps in analogywould be most potent. A bullock cart is the protein, the bullock is the calories,the driver iron and other salts,the prodding stick the vitamins. It is nearenoughto be accurateand wholly understandable. The idea here is to tag the message some to thing which is readily understood and sufficiently complicatedto hang the whole idea onto. With inadequatenutrition we have unhealthy and deadchildren and mothers, so family planning teachingwill be difficult until nutrition is improved. Food is understandable,so it is a good pathway into understanding. Agriculture is important and a good basisfor co-operation,and can show quite positive resultsin a fairly short time. An understandingamongstthe Centre staff of local nutritional problemsand answers practical termsseems be very important. It also seems be in to to important that schoolteachersbe taught nutrition exactly asthey will haveto teach it. Biochemistryis obviously lessrelevantthan the communication of basic facts.

Appendix 33 (ctd.)

(iv)

nelmtultoft!iK!me Rople in a rural community may fmd it asdifficult to understandthe nature of disease most well educatedpeople do. Virus, bacteria, germ, infection are as words which areusedto describeme&anismsand organisms barely understand. we The idea that the air, the water, the Health Centre,the hospital, the lungs etc. are full of germswhich can strike a strong man down is not very sensibleto a strong man who is not being struck down, neverhasbeenand quite probably will not be. It is probably abviousto him that weakerpeopleget sick more often because they areweak,not because anythhrg else,and it is an arguableidea. Attempting to of explain the lowering of defencemechanisms not clarify the discussion. will A medical training may blind its recipient to the simpleproblem of believing that theseinvisible micro-organisms exist. Further, the life cycles of someof the more improb&le parasites more likely to be taken asan elaboratejoke than asvital are fact. It is no good growing a culture to show that germsare presentin a particular disease unlessthe audienceunderstandsthe nature of culturing and germs. The teachingof ritual defensiveactions suchaswashingand the useof latrines to children is the start& point in this field, but cannot be expectedto havemuch demonstrable effect assuccessful hygieneleadsto reducedinfection - a medically desirableresult but not a very starthngone to the untutored observer. The essentialmessages relate to the needto get rid of flies, to build a strongbody and to pmctisehygiene. Malariamosquito eradicationcould be usedasan example in the insect field asthe resultsare dramatic providii an initial surveyis done and the improvementpointed out. Nutritional rehabilitation will demonstratethe im ortance of diet. From the resulting interest and confidenceand willingnessto be:: may comethe necessary eve willingnessto believeand interest in the more complexme&anismsof diseases. Much effective basicteachingcould be done through the medium of danceand song. This is the way we washour hands(even) on a cold and frosty morning is an exampleof this method. Similarly, a three teamdance,one team being bacteria, one being too,&paste,one being teeth could demonstratethe effects of oral hygienevery effectively and with maximum involvement. Dancesshowing fly and disease unprotected food and protected food will not be difficult and to organize.

APPENDIX 34 THE NATURE OF DISEASE

APPENDIX 35 From three setsof identical and detailed documentsand drawingsbuilders will often tender three widely different prices. On the other hand, when somekinds of buildings are tenderedfor where either the usual and acceptable cost is known or there is a governmentimposedbudget limit for that kind of building, nearly identical tenderswill be receivedrequiring careful study in order to selecta best buy. In other cases there may be no builders assuch or perhapsonly one. Further, two buildings in the sametown built by the samegovernmentagency more or lessat the sametime and more or lessthe samesizemay vary widely in cost per squarefoot dependingon siting, materials,standards ftish and possibly of air conditioning etc. The Model Centresuggests roof structure only, but makesthis structure on a set a of columnsor wagscloseenoughtogether for most traditional building materials to be effective. One Centre may be built with bricks and mortar, plasteredor renderedinside and perhapsoutside, with steelwindows etc., another may be built with a bambooroof over painted voven timber walls. The planning principles of the Model standfirm in eachcase,but the cost will be subjectto very wide variation. It is therefore unrealistic to offer a singlecost guide. However,the working party hasreceivedthe following information on various building costswhich may assist in estimatingcosts. The costsshould be taken asbeing comparativeand must be treated asvery low in view of price risesin the last two years. 1. Kerala(July 1973) For rubble walled buildings with reinforced concreteroofs To include internal wags To include latrines. doors, windows and lights Rs. 35 per squarefoot* For an un-subdividedbuilding Rs. 30 per squarefoot This is approximately &X)0 per squarefoot.? At the time of writing the cementand iron rods neededwere rising rapidly in cost. 2. Lagos(July 1973) F jr concreteblock walled buildings with iron or asbestos roofs l- 3r a simplestructure NigerianE5.00 to M.00 per squarefoot This is betweenL2.50 and a.50 per squarefoot. Cementpricesare noted ascontinually rising 3. More (July 1973) Building not described Rs. 28 to Rs. 30 per squarefoot. This is approximately E2.00per squarefoot. City buildings are noted as being of higher quality and more expensive 4. Madras(Ju!y 1973) (Rural areas) (Building costsfor structure and fmishesbut not services, water and i.e. electricity not included.) Schoolsand Offices: For stone walls and concrete roof, foundations at 4 feet 6 inchesbelow ground level and cement floor Rs. 24 per squarefoot As abovebut tiled roof (noted assubjectto frequent repair) Rs. 20 per squarefoot As abovebut asbestos roof and falseceilings on tabular truses Rs. 18 per squarefoot COSTS AND MATERIALS

l Multiply cost persquare foot by ten to get cost per square m&e.

Unless otherwise stated E is sterling at 1973 rates of exchange.

(4

:-

I.

This is a variation from &I .50 to E2.00(not including services) Hospitals(rural and urban): Aa abovebut with tiled dado to 4 feet 6 inchesabovefloor level and mosaic floors Its. 40 per squarefoot Aa abovebut without dado and mosaic Rs. 35 per squarefoot As abovebut tiled roof Rs. 30 per squarefoot As abovebut tiled roof with dado and mosaic Rs. 32 per squarefoot. (Asbestosroofed quoted at Rs. 28 but finishesnot noted) This showsa rangeof $3.00 to f.4.00 without services Houses: Concreteroof Rs. 32 per squarefoot Tiled roof Rs: 27 per squarefoot Asbestos roof (falseceiling not noted) Rs. 22 per squarefoot This is CXO to f3.00 per squarefoot (services specifiedasincluded) not All costsnoted asrising continually and steeply. (Costscan probably be assessed about f4.00 to about &MO) as 5. Bandung.kndonesia (August 1973) Usingown concreteblocks(office buiidingj Rp. 1000 per squarefoot (Public works estimateRp. 3000 per squarefoot) Usingown concreteblocks Rp. 2000 per squarefeet. This is betweenfl .OO E!.(w)per squarefoot. (It is noted that the and buildings are now complete,and that building materialshaverisen 100 per cent sincelast year.) It is understoodthat direct labour wasalso partly used,structure. services finishes not statedasincluded or excluded. and 6. Rhodesia(July 1973) Building in rural areas.usinglocal materials $7.00 per squarefoot This is approximately E3.00per squarefoot and is presumedcomplete 7. Ghana(July 1973) Cementblock b:rilding, wi1;1good quality iron roof $ JS.00per squarefoi;: This is approximately fS.COcurrent costs. Cementis noted ashaving ii~arl\ trebled in the last yenr c0nc1usi0ns The cost of a unit can not reasonablybe below El.00 per squarefoot, t5.00 is mentionedasan upper &nit, but only in rural areas. Costsare noted as rising (ii)

Appendix 35 (ctd.)

steeplyand continually nearly everywhere- there is an international shortageof timber, steeland cement. Further, the amount of services- latrines, electrics, water - is not specifted; equipment is not included; proportion of direct labour is not noted; establishmentcosts,e.g.travel, are not noted; South Americais not mentioned at all. The following adviceis therefore offered to people trying to work out a budget: 1. Attempt to assess proper sizefor the unit. the 2. Get a friendly person- architect, engineer,quantity surveyor,contractor, artist, surveyor,estateagent- to trace the appropriate accommodationoff the Model plan. It doesnot haveto be the actual layout you intend to usesizeis what counts here. 3. ~~d~;lan to the inter -ledcountry or askaround if you are there and try

Appendix 35 (ctd.)

a. Approximate squarefoot cost to include sanitary and water arrangement if appropriate b. A#;;priate materialsfor: Walls ceiii (ii any) Roof structure Rooffinish Windows c. Approximate cost per electrical outlet if appropriate d. Foundation depths usual e. Outline of sewerage work f. How long will it take to build 4. Ibis will establishbudget possibilities 5. Proceed with scheme appropriate as
6.

Allow for 15 per cent per annum increase cost throughout the building in period.

Local building regulationsmust alsobe consulted. Requirementsmay lead to upgradingof materialsfor, for instance,reasons fire resistance. Ceiling heights, of water channelsizes,water storagerequirements,sewage disposalproposalsmay also be subjectto theseregulations. Concreteblocks madein wooden, metal or rubber moulds or pressed proprietary in machinesare an important resource. Blocksstackedunder polythene sheetingin humid climatescure in about three weeksalthough up to three months is preferable. Otherwisethe blocks will shrink if usedtoo quickly. An equally good curing systemis immersionin a pond, pool or river for someweeks. A simple mould can be madewith a timber box split up with crossed dividers slotting over eachother. Concreteis poured in, then a timber yrid with taperedplugssticking down from it is put on top. The plugs,when withdrawnleave holesin the blocks which lighten them and saveconcrete. The plugsare oiled beforebeing put in so they do not stick to the concreteand arelightly nailed to the grid. The grid is raisedwhen the concretehashardened,then the dividers are taken out by stages, the plugs being tappedout Iast of all. The dividers and the main box should also be oiled. Individual moulds can be usedon the sameprinciple. A mixture of mud and cementmay be useful and saves cement,but experiment is necessary including sprayingwith a hosefor sometime to test for reasonable stability. Further, mortar for jointing earth-and-cement blocks and render for fmishing will haveto be madein a weak mix, i.e. extra sandshould be put in and the renderapplied somewhat drier than usual. Blockscontaining earth must be well protected with eaves overhangs. If buildings are to be painted the paint must be testedon the specimen
blocks.

(iii)

Presses concreteblocks called the Cinva Ram are referred to . z Cc for ticent Approachesto Malnutrition in Uganda. Ed. Dr. J. PagetStanfield. Monograph No. 13 @suedin conjunction with The Journal of Tropical Paediatrics and Environu-;tal Child Health, Vol. 17, No. 1, March i971.) ref. p. 69. c3s. Plates33 and 34.) Traditional buiMing methodsshould,not be scorned. Thick wailed houseswith a limited number cf doors and windows are the ideal environment in many countries with hot daysand cool nights, or very cold spells. Wattle and daub, madefrom mats of .poven shootspla ;tered with mud, 7% also be used.The wood-work should bc treated againstter ;!.Qes the mat panels and well protected from rain. Mud can be beatenSus UIU&J, then lifted out and left to dry in the sun, making buildmg Mocks which, if protected from rain, will last for generations. Somemud can be mixed with straw and sun dried. The strawhasto be stirred into the mud so it getswell tan&d UP. Anti-termite fluid must be mixed in wheretermites ere a problem. Mud and strawballs can alsobe droppedinto timber formwork idii together with wire or bolts and held apart b : small sizepiecesof timber The mixture is then rammedwith a pole, the formwork taken off and raisedup, the spacingtimbers knocked out, the holes thus left being flied with more mixture rammedin. Bachlift of formwork overlapsthe prev&rsly laid pieceof wall, the formwork standingon the spacingtimbers. At comersa small box is set in the ;cd formwork to makea ncl ch in the wall. The return to m&e the comerfsramri into this notch. The wtis are brought over the comer and notched alternately. A long piece of timber is sometimes mmmedinto eachlift at the top of the formwork in the middle of rhe wall. The timber is then lifted out, which leavesa grooveinto which the next lift is rammedto tie the two lifts together. Local experiment is the only guide to satisfactoryaction. Rammedwalls cansometimes madefrom straight mud. An alternativeis mixing be earth and cement; either fairly wet to makebuilding blocks or fairly dry and rammed. The traditional British namesfor thesemethodsof wall making are: Cob: earth and straw pise: rammedearth or earth and straw Stabilized earth: earth and cementmixed Referencebooks on thesemethodsof building can be found. In many countries &nple lapped boarding walls with shutters insteadof windows will work very well. In hilly country with a good coveringof treesvery simple buildings without ceilingsare cool and comfortable provided that they are shaded by treesfrom direct sun. Wovenand painted bamboowill last well in many areas,but all suchmaterialsmust be raisedout of the ground to avoid rotting and to avoid irresistibly attracting termites. Powderedtermite hill material mixed with water is saidto make an effective plasteringmaterial, but experimentsare neededbeforecommitting to its use. Bundlesof quite small stonesciin be madeup in chicken wire and given a reasonably squareshape. Thesecan be put in place on a mortar bed then renderedinside and out and wet cementmortar poured in. With experiment it will be found that controlled pouring will makethe bundles stable. High walls and load bearingwalls should not be madein this way, and the bundlesneedto be about 12 inchesthick although they can be taperedtowards the top of the wall. The essentialfeature of the Model plan is its useof a 16 feet spanbetweencolumns br walls. It is believedtkzt most countries will provide materialsthat will cope with this span. Wideoverhangs roofs are stressed on both for coolnessand to protect the walls. Roof4 materialsare referredto in Appendix 48.

Appendix 35 (ctd.)

APPENDIX 36

Thesenotes are preparedfor people with limited access professionaladvice. to TheYdealfoundation is good, solid, more or lessflat rock at about 2 feet depth, .but this is alsoabout the worst possiblecondition for drainsor pit latrines etc. The worst possiblefoundations are loose,dry sand,soft vegetableearth, clay which is subjectto drying out periodicaby or soils with moving undergroundwater springs. Work can be built up from solid rock foundations. Cracksor fusuresin the rocks or gapsbetweenthem must be solidly bridged e&her with reinforced concrete or stone, or brick arches. For singlestorey buildings on most soils, rock or strip foundations are satisfactory. For rock foundations dig a trench say 3 feet deepand place (not throw in) good size rocks for about 2 feet, then placesmallerstones,top,with graveland blind with concrete(blinding is a thin layer of concreteover thegravel) and build up from the blinding. Strip footings require a trench about.2 feet 6 inchesdeep, about 9 inchesof concretebeing laid into the bottom. As a generalrule the width of the strip will be three times the wall thickness. Wherethere is frost the footings should be deeper. Wherethere are soft pocketsin the footing basethey should be excavatedand ftied with. rocks. If an old wall or rock ridge is found underground, then the obstruction must be reducedabout 1 foot below the bottom of the footing and earth ftig put in and rammedthoroughly. On very soft soils or sandthe concrete floor of the building must havesteel reinforcing meshput in it, and the edges must be turned down about 2 feet below the undersideof the floor slab. This inverted tray effect holds the soft material under the building. The building should be kept aslight aspossible. On very soft, very wet soils somekind of piling may be needed.Often there will rows of polesare driven be a local method of piling construction. Sometimes into the ground with stones,platforms having first beenerectedto enablethose driving the polesto reachtheir tops. The foundation is then madeof timber, laid in mats on the top of the poleswhich are driven to ground level. An alternative is to build on stilts. If a building startsto move or subside,action must obviously be taken. Dig a narrow trench at right anglesto the building up to what seems be the point of to safe, subsidence. Cut in a 3 feet deeptrench under the foundations asfar asseems say 3 or 4 feet, then fil the trench with concreteequally inwards and outwards from the centre of the wall. Let the concreteset, then do the sameon one side of the new footing; when that hasset do the other side.(seeFig. 1).

FOUNDATIONS AND ROADS

Appendix 36, Fig. 1 Dealing with subsidence

(the crack shown are

arevery much exaggerated)

subsidence third trench will he dug htre --

second trench dug and ready for tilling

wbsidence

(9

.,. , .. .j / .:,

:, Building on a slope-can difficult. Cut a platform out of the hillside and build be wholly on the cut part unlessthere is an engineersdesignfor a retaining wall, in which caseyou can ftll out at the front to makea wider platform. The cut slope at the back should havean adequateangleso that the soil staysup (this anglewill dependon the soil) and it should be planted quickly with grass or any other close growingplant with good roots. Make a curveddrainageditch set back from the top of the slop to carry surfacewater running down the hill away from the new cut face. (SeeFig. 2)

Appendix 36 (ctd.)

Appendix 36, Fig. 2 Building into a slope

Roadson hills should not be steeperthan 1 in 6 and for ambulanceusea slighter slopeis desirable. A reasonable road can be madewith two concretestrips laid in trenches3 feet 6 incheswide and 15 inchesdeepwith a 2 feet 6 inchesgapbetween. Lay in 12 inches of stones,then blinding, then 6 inchesof concrete. Fill the gap in with gravei. Whereroadsare cut into slopesbuild only on the cut part unless there is an engineer-designed retaining wall. Tilt the road back towardsthe hillside and makea dram at the foot of the new cut slopeand line it so that water will not erodethe slope. Get rid of the water at the next comer, continuing the drain lining well beyond the road surfachrgand preferably spill the wareson to a largeboulder so that the splashingdisperses water and stopsthe drab cutting back on itself the and undermining the road. A similar two strip road will d!%i the flat very well, on but drainageditches filled with stonesare advisableon eititer side set about 4 feet outsidethe strips so that the ground doesnot becomesoggy Adequatedrainageis an essentialin road building. Light reinforcement in the rancrete strips greatly prolongsthe life of the road. Someauthorrties recommendmaking short reinforced concretelegsinto the soil on steeply sloping roadsabout 15 feet apart, about 12 inchessquareand about 2 feet deep. Theselegsshould have reinforcing rods stuck into them. The idea is.to stop the pavementslithering down the hill if it is underminedby water. (gee Fig. 3) (ii)

Appenciix 36, Fig. 3 Someprinciples of road building on hills

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Carry drains well beyond corwr~. di$t.harge over a boulder or heap of htww Make side drains hack to hill LW flat ~I?LP. Join strips JI corners and drain crntrt plwtior to drain on run helow Every 100 feet make an inward-sloping dram to clear centre strip On steep slopes set in reinforced legs to stop tracks slipping (hm11 drain 31 fo0t of cut Rank cut at natur;!l angle of rest of suit-. Irld) al! II, rlupe Do not build road on dug out material

The above principles apply for dirt roads on hills. The ~rth falls inside %lr:lin* ma\ underrut thr bank c:tiuuinc on to the road hut these are easy IO clear.

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: __ %xiility, &mi+bibty, mm production and standardizationof-buildings Flexiility, &i+bility, stadardbtion 7 ;j: ;:: &ite complicatedHealth Centresare often planned asa seriesof separate buildings . : .. that can be arrangedin almostany order being linked together with coveredways. ._ -;-I The Model which is the subjectof this report puts forward definite relationshipsso th&thebuildings&nbe expanded,to a programme,intolarger Centresand even to smallhospitals. :. >,. : The report doesnot suggest standardizedbuilding, that is to say one madeup a from a mass producedkit of parts. Buildings madelike this can be cheaperthan loddly madebuildings of the samesort providing there are enough of them, providing there is good transport to deliver the parts and providing the buildings .b :; are not so complicatedthat specialgangs haveto be brought in to put them together. :, $,A :: It is generallythought that at least 150 piecesof a particular sort must be built i:-: . before~itis worth mass producing which is why there must be enoughbuildings in $,, the programme. On the other hand it is no use making 500 roof trussescheaply < by mass production methodsif it is going to cost an enormousamount to deliver 8; : ;. them. If the trussesareheavy enoughto needa cranethe *hole idea of mass >: production becomes irrelevant.
r. __ .

APPENDIX 37 FLEXIBILITY EXPANDABILITY MASSPRODUCTION STANDA%2 ATION OF BUILDINGS

:^

A standardized massproducedbuilding is not automatically expandable. It can obviously be -designed be expandable,but if the requiredexpansionis very small to and the parts haveto be brought a long way small expansionsare very expensive. It is often said that standardized buildings are more flexible than other kids of building because parts can be taken apart and put together againin different the like wayswhen somethingneedschanging. This is true in systems office block partition walls, but thesesystems either very expensiveor flimsy. If the are piecesof wall are light enoughto move they will be thin and possibly unsuitable for a Ural Health Centre. As architects,eng$eersand designers spenda lot of time think@ about mass production, etc. it is worth looking at the basicproblems. If the idea is to mass produce.a systemof making all the piecesfit hasto be found. In simple terms,if acolumn standsin the middle of a wall it will stick out from the wall if it is thicker than the wall. Also, the wall betweentwo suchcolumnswill be a certain length: but on the floor abovewherethe columnscarry lessweight and can therefore be smallerthe wall betweentwo of them will be longer than the samesort of wail below. Making enoughpiecesof wall to fit every casemeansmaking smaller pieceswhich is tiresome: making the columnsbiggerso the wall is alwaysthe same length is wasteful. In the sameway windows needto be in a restricted rangeof sizes,and they haveto be built into walls or lined up together with piecesbetween them. So two windows and a piecebetweenthem haveto relate to wall sizes,the walls haveto relate to columnsand inside division walls haveto comeup to columnsor outside wall joints and cannot hit a window. Makingit all work out is an intriguing game,but the resultsare usually fairly complicated. Also, roomshaveto be the right sizefor the chosendimensionsfor the parts which may not be the right size for the useof the room: asthe room cannot be too small one hasto makeit too big - another piece of built in waste. Finally, it all hasto be put togethervery carefully asit is almost impossibleto changethe sizesof the parts; if you are 54inch out in the wrong placeyou get a lot of problems. With all thesepoints in mind the working party hasdecidedto go for a small span building that usessimple materials,suggests pulling parts of the roof out to get more space, puts the different parts into different buildings so that they can be and expandedwithout interfering with eachother. Weare putting forward a plan which suggests standardsrather than a standardplan.

I;

APPENDIX 38 This report conthmally refersto the needfor Health Centre staff being familiar with sanitation etc. Wetherefore set out below the principles of rural sanitation. There will be very many local variations of use. Detailed referencecan be madeto The RossInstitute Information and Advisory Service,Bulletin No. 8, reprinted April 1972, which is thoroughly comprehensible. The WHOalsohasuseful publications. I$qan &age is dealt with hygienically in two basically different ways: 1. water basedsewerage 2 more or lessdry decomposition LATRINES SE?& DISPOSAL

Watersewemge I. Sewage droppedstraight into, or carried by pipe to a septic tank. In the is septic tank bacteriabreak down the sewage, making an effluent which is then allowed to soakaway into the ground 2. Sewage flushed(or pour flushed from a 2 gallonsminimum can) down a pip is to a pit or septic tank 3. Sewage flushed down a pipe to a sewage is disposalplant 4. Sewage flusheddown a pipe to a wastestabilization pond in which bacterial is action and algaedecompose sewage the gitig an effluent which is lead to a soakaway, sometimes fed into a fish pond or can be ised for irrigation can be

Mom of kss dry decompo&Ion 5. Dry pit latrines 6. Fit latrines which get down to the ground water level 7. Urines are now being producedwhich compostfaecalmatter making usablegasat the sametime1 8. Buckets Both waterborneand dry sewerage discussed the end of this Appendix. are at

Priviesusing all thesqmethodsexcept 7 can be usedascommunalfacilities. But the usual unbeatablesocial rule appliesthat the more people there are to usea facility the more it will be misusedand broken up in every possibleway. Sanitary attendantsare a concomitant of facilities for public use. If attendantsare not obtainable do not build communal privies. Seniorstaff members must accepta responsibility for regularand spot check inspections. Doctors visiting Centres must inspectlatrines. This is the only way in which the residentCentrestaff can be persuaded do the same. The better facilities are kept the lessunpleasant is to the prospectof an inspection. All latrines in a medical com$oundmust be inspectedregularly and if instructions are given for work to be done then the work s must be done. Flies It is almost impossibleto control flies in pit latrines and in latrines with no water sealon the pans. Whereinsecti@des used,insecticide-resistant rapidly are flies multiply in ideal non-competitive conditions; one is better off not using them. Cleanliness a clo$eable and cover are the best defences.Aritiseptics must not be usedas they interfere with the bacterial action.
(9 iii, Y

Waterseals There are two commontypes of water seal,P traps and S traps asbelow. Choice of traps dependsonrequired direction of outfall, either more or lesslevel (P) or straight down (S). A further type of trap canbe usedfor pour-flush latrines. Theseare shown in Fig. 1.

Appendix 38 (ctd.)

Appendix 38, Fig. 1 Types of tmp on lavatory

CIeaningmaterids Many communitiesuseleaves,grass,stonesor similar materialsfor personalcleansing. Suchmaterialscan makea nonsense waterborne systemsin a very short time. of An adequateprovision of big inspection chambers(manholes)and rodding eyes (holes for poking flexible canesthrough) for unblocking dramsis essential. Manhole coversmust be concrete,not metal or they will be borrowed very quickly which is unhygienic and downright dangerous the dark. iu ventiIathIgsystems Flushing or ilush pouring systemshaveto havea ventilating pipe otherwisethe load of material going down the pipe sucksair behind it which emptiesthe traps on the fittings. The ventilating pipesmust be carried up aboveroof level and protected with a gauzeballoon to keep out flies and mosquitoes. Light and air Sun and air must be let in to privies. This may lead to rain getting in during storms but the sterilizing advantages sun outweigh slight flooding. Ventilating slots of must be fly-screened,and doors should be madeself closing with a string over a peg or pulley with a weight on the end. The doors should iit well. lt is tempting to prop doors open to ventilate the privy but this only encourages flies. Low level slots left open all round so the floor can be flushedover with a bucket are tempting but bad practice asmeshscreeningrots, collects dirt, getsbroken and then animals and insectscan get in. Generalcleardiness Experiencein any country where Asiatic or squat type pansare usedindicates that their useis noi simple. The wall at the back is frequently heavily soiled to a height of two feet or more, flushescan empty panson to the floor and not down the drain, and the feet are frequently soakedby a flush swirling up out of the pan. Generalsprayingcan alsobe a problem. Frequently the areaof water in the pan is far too small and quite out of the rangeof children; this leadsto heavily soiled pans. Wallsare frequently also soiled. A small shelf for putting belongingson is a greatadvantage, a raisedareaof floor which is slightly tilted so it drains dry also quickly after washing. Flushing pipesmust not be lead down wall facesand particularly not acrossfloors asthey give impossiblecleaningproblems. Where wooden superstructures usedand also on bottoms of door framesthe bottom are 4 inchesmust alwaysbe madein smooth concrete,the timber standingon top. Otherwise,the timber soaksup moisture and rots: Two coatsof 5 per cent silicate of sodawill increasethe water resistance the cementflooring and 4 inches of upstand. In somecountrieswater is indispensablein the personalcleansing

routine. SmaJl canscan bn usedascontainers,but big tubs from which water tin is d&ped should be absolutely bannedasthey can becomeinfection soupsvery quickly. Tapsare often abused,b.:ing left on. A sanitary attendant could deal with t-hisproblem, but a male and ILfemaleattendant would then be necessary in most cultures. The squat pan and its surroundings Flti pipesare bestlead to the front end of the pan where the water fiow conceutrateson the floor of the pan, but water should also swirl round the bowl. Foot restsshould be tilted forwards about 1 inch in their 12 incheslength, never, neverbackwards,and should be smooth (for cleaningpurposes)unlessmadein glazed9reclay in which casethey can havea criss-cross pattern (with smooth edges and valleys) on the foot restsso that they can dry more quickly. The pan needsto be reasonablydeepand long and benefits from a long water area. A reasonable depth and a slight undercutting at the front are good points. The surroundings must be smooth and without dimplesand must drain into the pan. Impervious skhtings should be carried at least 4 inchesup the wall with an easysweep. The sweepcan be formed by running a bottle round betweenthe floor and the wall whilst the cementis stikl wet. The wall behind the pan should be imperviousfor at least 2 feet 6 inchesin height and should be ascontinuous with the floor aspossible. A raisedareaand a shelf havealready beenmentioned. Many commercially produced squat type pansdo not havethesefeatures.(SeeFig. 2 ) Research Research neededto establishwhether easierusewould lead to what can only be is describedasbetter aim. This is a perfectly serious,indeed important subject. It may be that people,particularly older people,might fiid the pan easierto useif someform of hand grip, projecting from the sidewall near the right hand were available. The hand grip would have to project well so that it wasasnear aspossible to the middle of the body for balancing. Someform of projection on the left hand sideand quite well back so that it could be usedasan elbow rest but not a hand rest might also be helpful. The queStionis whether theseaids would lead to extra crossinfection possibilities,or whether a sufficient compensating increasein general cleanliness would be achieved. Compartmentsizeand iayout The back wall should not be ?ess than 19 inchesaway from the back of the foot rests,the front wall or door not lessthat 32 inchesfrom the back of the foot rest. This givesa compartmentlength on the long axis of the pan at 4 feet 3 inches. 4 feet 6 inchesis therefore a reaso.iableminimum length. A 3 foot width gives adequatefree elbow (literally) room. The overall depth can be madeup by hangingthe door on the outside wall facewhich will give a few extn incheswhere fairly thick walls are used. Doors can open from the sideor the front. The parr should be setcentrally in the free width. Doors usually open inwardsso that peoplewho do not like to lock doors or forget to do so havea chanceof increased privacy.

Appendix 38 (ctd.)

Two gallonsis the minimum flush sizeeither for pouring or cistern flushing. Smallerflushescanbe usedwith pressurecisterns. Cisternsshould be mounted high enoughup to give a good flush but not so high that they flood the floor. Front end flushing givesthe best results. Combinedshowerand pivy A showercanbe installed in a privy compartmentusing cistern or pour flushing, but the floor areamust be increasedby at least 3 feet x 3 feet either in width or length, the pan in the former caseno longer being in the middle of the overall width or someone fall down it. Further, the showershould be in a lowered will showersare areaof floor otherwisedropping the+oap is disastrous. Sometimes put straight over pansand a loose duckboard provided for laying over the pan for quickly getsfoul and rotten, and breakingslatscan standingon. The dmckboard to lead to unpleasantaccidents. Somewhere hang a towel and put belongingsand clothesis alsonecessary. In a combined showerand privy the driest end is over the pan. Clothesfalling off pegsover panscan get into an unpleasantstate. Some form of partition to protect clothes is therefore necessary. Thesepoints are (iii)

ecl

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--. . .

fl: /

obviously e:verfussy in cultures where the samesarongor similar is worn to the shower,usedasa flannel and then for a wet rub down (getting washedat the same time) then worn away wet, but in ctilturcs anti &mates where more clothes are worn the essence hygiene teachingcan be totally undermined by the thoughtless of designof facilities. Decid@onasystem Bearingin mind earlier commentsabout communalfacilities, the principal matter bearingon de&ions about sanitation systemsis water supply. The possibilities are tabulated below, water supply being discussed immediately after the table.

Appendix 38 ictd.)

Very little water Big installations Kt latrines

Somewater

Adequatewater

Plenty of water

Direct Aqua privies

cistern flush to pour flush to pits or septic tanks, aquaprivies disposalplant pour flush to septic tanks sewage or stabilization pond.

Small installations Kt latrines Direct Aqua privies pour flush to pits or aquaprivies pour flush to septic tanks cistern flush to septic tanks

The alternativesare shownin Fig. 3.

Watersupplies Cistern flushing calls for about ten gallonsof water per user residentper day. Thus the Model Centre will require for waterbornesanitation: . Two principal staff and families, say Four auxiliaries and families Two assistants families and Assistantand clerk/handymanand families Inpatients lnpatifzntsfamilies Hostel residents,say _ Total at 10 gallonsper head per day 6 people 12 6 8 :: 12 64 640 gallons

To this must be addedat three gallonsper headper day: say200 outpatients + say 100 dependents a total at three gallonsper head per day

300= 9oogallons 1540 gallons

The equivalent amount will be usedfor generalpurposes,the equivalent allowed for outpatients should cover the extra requirementsfor a Health Centre. A Centrewith an assured supply of over 3000 gallonsper day therefore qualifies for I;;;tei;ed sewerage. More than 3000 gallonsper day is, in this respectplenty If irrigated farming land or gardensare attachedthe requirementsfor the irrigation must be added.

Kt latrines will be constructed of timber for easeof moving. Other privies may be of brick. Seealsopage(vii) et seq.of this appendix for further information. .

Appendix 38, Fig. 3 Alternative privies emwnt SW~W~Y if

t0

movable cover

Pit latrine on mound with fexled brick to 2 feet below ound level. B rsful in wet ground.

-.

NW Privy. stra$ht to septrc tmk. Floor 6 inches above ground, water level 6 h~cher below. Can be direct with straight trap or pour flu8h with sealed trap.

Pit latrine where soil Is strong or aides reinforced. Best in dry

rsmonble

cover

using boxed hole. puddled

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For porn &&tg to pits or septic tanks, about four gallonsper headper day is required, the generalconsumption remainingthe same. This gives: , Residents 64x4 pour fluslung 64x10 general MY outpatielits 300x2 pour flushing 300x3igeneral 256 gallons 640 gallolls 900 gsllorls

Appendix

38 (ctd.)

Total

2400 gallons

This meansthat say2400 gallonsguaranteed day is adequatewater for pour per flushing. If no public facilities are offered then 1SO0gallonsper day would allow for residentpour flushing to septic tanks and piped water with 600 gallonsover for generalpurposesand outpatient restrictedgeneralpurposes- .essentialIy controlled drinking water points. Very little water can be accountedasmore than the rock bottom tolerable which is 64 residentsat three gallonsper headper day, is say 200 gallonsa day. Kt c latrines are the only answerhere. Aqua privies, possibleon the borderline of an adequatewater supply, require very littIe water except for initial filling, eachprivy needingonly one or two bucket- -. fuls of water a day. Periodically more water needsto be added,but the extra fti might not evenbe necessary during a dry season. For residentssanitation only 60 gallonsper day for pour flushing-+ 640 gallonsfor generaluse+ 300 gallons a day for medicaland very limited outpatient use,i.e. a total of 1000 gallonsis sufficient. A further 200 odd gallonswould justify public aquaprivies, the extra allowancebeing madefor extra cleaning. Waterusedfor flushing should be clean but not necessarily d&king-clean. Descriptionsof the different systems Local experienceis invaluable and should alwaysbe consulted. Thesenotes are offered to act asa checklist and to help in establishingstandards. Kt Urines Theseareholesin the ground into which faeces drop directly. If there is water in the pit disintegrationwiIl be faster,better and the pit will last longer, becoming, in effect, a septictank. Disinfectants,insecticidesetc. must be kept out of the pit. About 2 cubic feet of pit per residentpersonper year plus 2 cubic feet per 10 visitors plus about 2 feet at the top is needed. The life of a pit and the number required canthus only be calculatedfrom the practical hole that can be dug. Whengrass, rubbish, sticks etc. arelikely to be thrown in then the size of the pit must be increased at leasthalf, i.e. a third of its life will be lost. When by the material in the pit is between 2 feet and 1g inches from the top the pit must be fiUedwith earth and the privy moved,so obviously it should be as light a structure aspossible. About a year after moving the pit canbe dug out and the contentsusedasfertilizer. Holesshould be asbig aspractical, asthe bigger the hole the lessoften must the pit be re-dugand the structure moved. Holeswhich will ffi with water should be 10 feet deepfrom top to bottom; this being sometimes achievedby building the privy on a aound. Moundsshould not exceed about 2 feet 6 inchesin height, the whole of the height aboveground level being built in imperviousmaterial. All holes should be lined with imperviousbrick f for 2 feet from ground level down. If privies arebuilt on a slopethis lining should be deeper, say 2 feet below a point 6 feet down the surfaceof the hill (not 6 feet vertical drop). In strong stablesoils a hole 15 to tii feet deep can be bored about 18 (vii)

inchesin diameter. The,next step, wherean augeris not availableor a bigger pit is required~, a holo 8 feet to 15 feet deep.and as small as can be practically is .dug- sa 3 feet in diameter. A platform the sizeof the privy will cover these will holes; i iggerYholes needstructurally designedcovers. Woodenfloors on wooden beamsare used,but must be-termiteresisting. Falling into a pit latrine is apretty unhappy experience. Timber is not aseasyto cleanassmooth concrete. The floor plate for a latrine is placedon a basewhich can be the imperviouslining carried up to give a finished floor at 9 inchesaboveground level, or on puddled clay, .stabilixedearth or mud brick (seeAppendix 35 on costsand materials), concrete, stone,brick etc. Excavatedmaterial can therrbe sprerrl round the privy and rammeddown firm, ready for shovellingback when the pit is usedup, and also servingto carry rain water away from the pit where regularseepage could cause collapse-ofthe walls. If the walls of the pit are likely to cavein they must be lined with bricks (not mud bricks) or blocks or evenstone,but with lots of openjoints to let moisture out. Timber and bamboocan be usedbut will not last so well; a thorough tarring before placing will prolong their life. A circular hole is very much strongerthan a square one. Lining is parti&larly important with large wet holes. Do not take cbanees. Find out what sizeof hole can be safely dug and left for saytwo yearsincluding through two yearswet seasons. More holes arebetter than too big holes. Concretecoverplatescan be madein wooden shutter@ or in sandor clay (or mixed sand/clay)moulds. In shuttering the hole shapeis madein wood, inverted in a shallowbox and concrete then poured in. For the mould the positive shape is madein wood which is then stampedand packedinto the ground, removedand its impressionfilled with concrete,the hole standingasan island in the concrete. No one makesa rubber mould for this purpose,which is a great ity. Fibreglass will not do asit losesits surfacingvery qui&ly and breaksup. ii asticstend to distort and dimple. The plate will ideally havea turned up edgefor a skirting round three sides,and will be firmly dishedtowards the middle. Foot restsare needed,cantedforward, and are an integral part of the piate. The slabwill be about 2%inchesthick at the edges, will havea 1%inch thick rim 4 incheshigh and round three sides,will be at least4 feet 3 inchesx 3 feet internally, will need reinforcing and will be heavy, weighingat least 375 lbs. Four loops of reinforcing can be left sticking up from the skirtii, one at eachcomer. They cre usedfor pushingpoles through for carrying and placing the plates,and can alsobe usedfor fixing down timber superstructures. The &nforc.mg rod must be painted to combat rust. Many authorities recommendsmallerplates,but the action of bendingforward and then squatting down needsat least the 4 feet 3 incheslength for taller people, though somethingcould be sacrificedon width, 2 feet 6 inchesbeingan absolute clear internal minimum. The hole should not exceed8 inchesin diameteror children can fall down it easily. A good shapeis a keyhole shape,an 8 inches diametercircle with a tapering slat not lessthan 4 incheswide leadingforward from it to give an overall absoluteminimum length of say 1 foot 6 inches,a greaterlength, say 2 feet being preferable. Wherehouseshaveolder people a bar could be put in, hinged from a simplebracket on one wall and dropping into a slotted bracket on the other. This would be just away from the front wall or door, for in about 2 feet high. This is not recommended hygienic reasons communal facilities, and should only be usedwith inward opening doors if the door can be lifted off from the outside in casean occupantcollapses.geeFig. 4. Simpler set ups are almost universally used,thesesuggestions at easeof cleaning,convenience aim and security. Sitting type privies can be madeby setting a strong termite resistingtimber shelf acrossthe pit with an oval hole cut out ,14 inchesabovea hole of at least 2 feet diameterin the floor plate. A timber panelfills the gapbetweenshelf and floor. The inside of the panelneedsto be part lined with an imperviouspanel.This type of privy can be exceptionally dangerous children, so the hole needsa child-size for liner aswell asa lid: better still, keep the door locked with an outsidekey well out of child reachand do not let children in unsupervised. Aqua privies (Direct) Theseare basicallysimilar to pit latrines but the hole leadsby a funnel to a tank directly below full of water (in effect a septic tank which will be describedlater), The bottom ot the funnel is a 4 inchesdiameterpipe about 8 incheslong whosebottom (viii)

Appendix 38 (ctd.)

is4 inchesbelow water level. The walls of the funnel are flushed onceor twice a dayfrom a bucket or can of about two.gallonscapacity. SeeFig 1 for trap. Pour flush aquaprivies Theseare asdirect aquaprivies, except that they useS or open endedtraps (not P traps) and are flushed with two gdons of water from a can after eachuse. Pourflushpits

Appendix 38 (ctd.)

P trapped panscan be flushed v+tb a two gallon can of water down a pipe to a pit which is treated asa pit latrine. Useful with porb& soils. Pour flush to septic tank As abovebut to a septic tank not a pit. cistern nush to septic tax& The cistern discharges sufficient water to carry the reasonable contents of a pan down a pipe to a septictank.

continued on page (xi)

Key to Appendix 38, Fig. 4 Someldus for hygienic latrine construction Fly screeningto ventilation slots Weighton string over pulley (peg with cardboardtube sleeve)asdoor clpser to keep flies out A strong handle at low level to assistolder people Concreteor similar washableupstandat back held on with wooden toggle 4 ir,cheshigh skirting all round Woodenpoststo stand on skirting to reducerot and termite attack . floor plate to slopetowardshole Footrest, Hole Pit. No sizesaregiven here or elsewhere pits. Dig only what you know for to be safeand makesureit is safewhen the walls of the pit are thmoughly wet. Spreadsoil from the mound round the privy and compact. This keepsrain out of ti.e pit Baseof puddled clay, S per cent cement,95 per cent earth, or brick we5 sealedwith mortar. This keepsparasites the pit, particularly hook worm. in Someform of hard surfaceor path to preventpuddles. N. Stonesto catch drips Lifting handlessticking up from plate, can be usedfor attachingwalls to plate In a privy with 5ush a front flush to the pan is best Front flush pipe meansside doou The cistern on the wall can feed n sink Sink. *Nogrease, disinfectantsor detergentsto go into septic tanka sink tap The sink will needa trap on it madeby bending the pipe to form a 3 inches deepU shape A gutter will feedrain water to the cistern Pipefrom gutter to cistern Septictanks needventilating so put in a 2 inchespipe and put a fly screen balloon on top to keep out mosquitoes(not neededfor pit latrine) Access cover to sert.ictank makesgood hard-standingby sink i Extending the roof sidewaysincreases coveredareaand is better for the hygiene

Appendix 38, Fig. 4 Someideasfor hygienic latrine construction

Appendix 38 (ctd.) Septic tanks are impervious tanks, usually b or placedin the ground. They are sometimes availablein pie-castconcreteor fibreglass. The tanks have an inlet and an outlet, and usually someform of baffle. Tankscan be quite simple or quite complicated. Bacterial action within the tank llqu%es solid matter which then drainsaway. The effluent that drains away is not pure, will probably contain infectious organisms such astyphoid, may not be usedfor irrigation and will smell offensively. It hi therefore led to pits ffied with stones(soakaways) down or spreadingfan shapes permeablepipesin ground through which the water can of soakaway. Aeratioll beds Septic tank effluent can be put through aeration bedswhich areheapsof rough stonesin openwork brick boxeswith collection and run-off troughs. Theseturn the effluent into a harmlessbut by no meansclean fluid. The bedssmell and must be at least 150 feet away from buildings and down wind. They attract their own moth-like flies genusPsychoda which can get blown into buildings where they are a seriousnuisance. Grease traps Wherekitchen wastesare run to a septic tank a grease must be put in between trap for the sink and the tank in the pipe run. It must be accessible cleaning and it must be cleanedregularly. sewagedisplxd phumi Theseneedcareful maintenance,construction and insect control. Definitely a specialistsubject. Stabilization ponds Stabilization ponds treat raw sewage preferably effluent from septic tanks or or aquaprivies in two ponds. Slight daily maintenanceis needed,and the resulting water can be usedfor irrigation. It may evenbe possibleto havea fish pond betweenthe secondpond and the irrigation system. Theseshould not howeverbe attemptedwithout local governmentapproval. Areasfor fhther study Stabilization pondsappearto offer a simple recycling system for water. A simple do-it-yourself publication with full details for community co-operativeconstruction is needed. This publication should include notes on laying out new villagesso that they can take advantage this re-cyclingin areaswherewater is a problem. ,. of Further, it Seems reasonable suggest studiesshould be madefor modified to that field septic tanks. Siting Commentson siting are given in Appendix 52 where there is a drawing showingpipe layouts at given falls. The fall is the slopeat which the drainsare laid, English practice differs greatly from, for instance,French practice. In the latter drains are laid at much greaterandesand fewer manholesare used. In generalbigger pipeshavelesserfalls, but big pipeswith insufficient material going down them block up quickly. Very wet areas Waterbornedisease,so often associated with limited water supplieswhich become contaminatedasthere is so little dilution, can be a very bad problem during wet seasons. Latrine pits may flood, effluents cannot run awayin the soddenground and so back up or rise to the surface; streamsand riversmay overflow and broadcast any muck they may be carrying. Paradoxically someform of closedcomposting container may be the best answerwhere there is so much water. Containers are being developedwhich not only compostbut makeusablegases. They are at the presenttime expensiveasin temperateclimates they haveto be kept warm electrically and this is expensive. Alternatively impervioustanks of sufficient capacity could be constructed below ground, usedduring the wet season and

(xi)

emptied into pits or soakaways the dry season. Septic tank effluent from in Ghiings or high ground should be put into soakaways the high ground in areas in subjectto flooding, the soakaways being big enoughto cope with rain getting in. from run-off down the slope.

Appendix 38 (ctd.)

Peoplewishing to do complicatedinstallations should write to the Ross Institute, or should take advicein the country concerned. If writing off for adviceinclude the following information: 1. A site plan, either to scaleor with dimensionsmarked on, and to include slopesacross site and how much the slopeis. the 2. A sketchmap of the locality showingwells, water sources,streams etc. 3. Proposed?r existing layout of buildings and where latrines are required. 4. Amount of water availableand number of people a. resident b. visiting. 5. Information about rainfall and flooding. 6. Information about soil depth, whether it is impervious or porous, and what sizeholes can be dug without the ground falling in. 7. Information on whether a fish pond would be acceptable. 8. An indication of whether a good builder is available. 9. Is a rock-bottom cost installation required or can a more sophisticated -system built? be A householdwith running water and flushing cistern septic tank drainagewill use somethingover 20 gallonsof water per head per day. Half of this is required for sewerage. About 10 gallonsper headper day will suffice for normal useexclusiveof sewerage. About 10 gallonsper headper day plus 4 gallonswill suffice for normal useplus a pour fluah aquaprivy or pit latrine. But aquaprivies are more expensivethan pit latrines, therefore the following is recommended: 1. 10 gallons/dayor less/head- pit latrine 2. More than 10 gallonsbut lessthan 20 gallons/head/day- pour flush to pit latrine (or aquaprivy if money available) 3. More than 20 gallons/head/daybut very litt!e money - pour flush to pit latrine (not cistern flush - the pit will be flooded) or to a soakpit away from the latrine. 4. More than 20 gallons/head/day- cistern flush to aquaprivy or septic tank. Supply is adequatefor communalprivies.

Watersufiply, pdkation

and dosage

APPENDIX 39 WATERSUPPLY PURIFICATION ST%GE

particular referenceis recommended RossInstitute Bulletin No. 10, Small Water to Supplies,obtainableasnoted in Appendix 38 and to WHOMonograph SeriesNo. 42, Watercan be gatheredfrom underground,the ground surface,springsand rain. Undergroundwater can be collected from we&hand lifted, pumped or gravity fed from artesianwells. Surfacewater is collected from streams, lakes or rivers, or from catchmentsmade on the ground. Springsmust be captured. Rain water must be caught by catchmentor by guttering from roofs. Ravingbeengatheredwater must be stored for use. Underground,surfaceand high level tanks canbe used. Undergroundtanks are cooler than surfacetanks but must be guaranteed impervious, assmallleaksare difficult to locate. If they are likely to be emptiedundergroundtanks must be tied down, or they may float out of the earth. High level tanks are usually only feed tanks, the main storage being at low level, the water being pumpedfrom main store to feed tanks. Storedwater may needtreatment. The methods usedfor largequantities are fdtration and chemicaltreatment. Small quantities may be boiled. There is no point in purifying water usedfor lavatcriesonly unlessthis water is an infection source.Waterusedmedically or for drinking should be treated suitably. In a Centrethe sizeof the model with about ten staff and ten bedsand assuming a four month dry season, three gallonsof water/person/daythe storagewould at haveto be 7320 gallonsplus allowancefor evaporation,!say 9000 gallons in order that the utter minimum supply be maintained from a cistern throughout the dry season. This amount would allow, with very careful farming, for survival conditions for staff and inpatients but no more. This samevolume would maintain a Centre usingwater quite lavishly and allowing visitors, outpatients etc. free access for three days. Unlessa certa@minimum of 3000 gallonsof water a day is available, waterbornesewage should not be attempted. 40 residents(including hostel pathnts, staff and inpatients) flushing a lavatory four times a day each,and 200 outpatients plus 100 accompanyingpeopleflushing a lavatory onceeachwill get through approximately 1400 gallonsusing a standardthree gallon Bush. As a three day supply is a good safe&ward, seems 9000 gallonsis both the upper and the it that lower limit of acceptability for main tank storage.If it is felt that 30,000 gallonsa year cannot be Gtnered by one meansor another a Centrewill haveappalling water problems. A fully water suppliedCentrewill use 1,OOO,OOO gallons all in, but this is more safely viewedasan availablesupply of 90,000 gallonsin the worst month. Wherecareful control of water is essentialan indicator of the amount in a tank is needed. Two versionsare shownin Fig. l., one for tanks aboveground, one for tanks below. The principle is that a float in the tank is attachedto a string. The string passes a pulley, a weight on the end rising and falling againsta scale over with suitablemarkingson it. Full is at the bottom of the scale,empty at the top. n / nB

tank IY-I

.,-

e_

f6r string

Appendix 39, Fig. 1 A simple water level indicator

LL----e-3
..a $ :,.. .

--Al

(0

: Rain water can be collected from roofs by gutters and pipes,the rain being collected in cisterns. A method of collecting which alsogivesa readysupply above ground through a tank with a tap. When is shown in Fig. 2. Rain .from theroofs passes the tank is fuJJthe overflow allows the water to pour into the cistern below. Fig. 3 showsthis in diagramform. This diagramis not supposedto showany sizes. Sizes will dependon the amount of water available. Watercan be pumpedfrom the cistern back to the top tank or dipped from the cistern with a bucket when the top tank is empty. Dipping can be unhygienic and is better avoided.

Appendix 39 (ctd.)

Appendix 39, Fig. 2 A lain water collcctlttg and storagesystem

ti ii li F.

Gutters Ramwater pipes Ready-use tank Ovefflow feed to ciste$n r?y Cistern Access cistern to

1 / .kJ/

Appendix 39, Fig. 3 Details of the rain water storagesystem

A-F asFig. G. Tap Tank drain for cleaning u i-! Trough to catch drips wherewater is scarce, leading to bucket J. Emergencyoverflow . K. Rumpto refill top tank Canbe locked to conservesupply L. Indicator asin Fig. 1, Cisternneednot be openedto checkwater level

D
r-P I k I

D K (

qi!i! L A

(ii)

Fig. 4 showsthe systemapplied to the Model Centre, the gutters that can be easily used(including using the coveredway gutters asa high level water carrier) being shown in a dark line, extra ipesbeing necessary acrossthe end of the outpatient9 block. The cistern is near tEe outpatients asthis building hasthe biggestroof,and the cistern will not be too closeto the staff latrine. Undergroundcollecting pipes and should haveits own re?dy-use are not recommended. The garage store areas tank. A collection systemto a tank which must be aboveground, asthe latrines are so numerous,is shown by the laundry.

Appendix 39 (ctd.)

Appendix 39, Fig. 4 Placmga cistern and tank on the Model Plan The usablegutters are shownin thick line with arrowsto show direction of flow.

The gutters will haveto be big to collect all this water, and will haveto have a very slight slope(fall) otherwisethey wth obstruct headroomat the eaves. A consideration in siting buildings on a slopewill be to keep the latrines downhill from cisterns. Rain water should not be collected in open barrelsor drums and then dumped into a cistern. Collecting vessels must alwaysbe securelycovered. Waterfrom a cistern can be pumpeddaily or more often up to a high level tank from which a piped water systemcan NIL On the Model the tank will be placed by the end of the goodsareablock. The pipescan be run under the roofs but over the ceilings,and can go from building to building under the coveredways. Every long run should havean elbow bellows in it, seeFig. 5, to allow for expansion and contraction in the pipes.

Appendix 39, Fig 5 An elbow joint (to be madehorizontally)

expatiion

ahd contraction

(iii)

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I,

:.,

< .../ ,,.;,;

. , -~. ,.

;r ._ ,~.-<.

:,

- .C,, II

Pumpscan either be automatic,workedwith a float switcL,or turned on by hand when necessary. It is easierto conservewater w~tba baud-switchedpump. The ,bottom of a h&h level tank must be at least 3 feet abovethe highest fitting, a greaterheight is preferable. Watertanks must be closedand if possibleshaded. Watercan be collected from hillside catchments. An areais cleared,coveredin stones,blinded with graveland cementthen coveredin smooth cement. A low wall is madeat the bottom in a shallow V shape,water being run off by pipe. I Itc catchmentmust be fencedagainstanimalsand cleanedregularly. Dew will sometimes form on this kind of catchmeht,and will run off if the slopeis steepenough. Well diggingneedsthe attention of an expert, whether a local artisan or an engineer. This subjectis therefore not coveredin this Appendix. Amateur well-diggingis to be discouraged. Waterfrom streams should be taken from deepturbulent parts of the stream; from rivers from the middle, from lakeswell out from the bank. Wherethere is a good slope water may be taken by putting an open-endedpipe into the streamor river and allowing water to flow through. Watercau also be taken from reservoirs madewith dams. If rhe water is muddy it must be cleared,in which casea filter is needed. If the water is very muddy or hasa fine suspension then a settling tank must be put betweensourceilipe and filter. The overall layout is shown in Fig. 6, and a detail of a filter irr Fig. 7. In generaltermsthe filter will passtwo gallunsof water per plan size; a hour per squaretout. 3 feet by 3 feet is the minimum recommended filter of this sizewill only passabout 375 gallonsin 24 hours. This should satisfy two or three households,or more if water is short and therefore usedsparingly.

Appendix 39 (ctd.)

Appendix 39, Fig. 6 A falter bed and settling tank set into a hi side

Source pipe Weir to break flow and spread water Rocks to break up weir current Baffle pleta Filter inlet Filter bed Supply outlet Filter overflow Settling tank drain (for cleaning)

(iv)

5 fee

-$i 1
t R V

18 inchesto 2 feet

r 4 feed6 inches

-I--.
A. ca. $
if g t v: Posit PZ EZ Fill: . kz Outlc Rem The 1

SourI

e. (water supply) liter faulty. water will run away closed wben bypass is opened er box, full of stones (only a few are shown) to catch any big debris r coarse falter lid (lid not shown) :r than A, from coarse filter to falter bed, pointed at, but not touching, the fdterbed wall. Inflow hits the wall and does not the sand bad Ireak further the inflow Fine sand M~%~?enefici~but after they have occupied the top 3 inches or so they will .s!gae which will grow on the s:d he flow. The top sand should then be removed, cleaned and replaced. L. Fine gravel M. Small stones N. Stones up to 3 inches round or square ted porous tiles P. Holes from tile lines to outlet chamber I to outlet chamber must remain at 18 inches to 2 feet above sand bed to keep falter wet S. Overflow e. Height of open end sets water level T. Drainage pipe and tap ) covers, watcrfjght if possible W. Concrete base can be brick, rendered at least twice inside .vith !4 inch strong render each time

Regularcleaningof coarsefdter and regularmaintenanceof the bed are essential

Filters of this design may remove as much as 90% of bacteria in the supply, if well maintained. Animals must be kept off the lids. items B. C, D, E, F, G and H, S and T may be omitted, but are all recommended, particularly T and G.

No water should be assumed lsoble until proved usable. Regular.testingor suitablechemicaltreatment is necessary. No guidanceISgiven in this Appendix as eachcasemust be taken asit comes. Someauthorities statethat rain water colkcted from roofs should be fdtered. It is certain that roofs and gutters should be regularly cleaned,the supply pipe being disconnectedwhilst the cleaningis carried out. Perhaps worst dangerto water suppliesoccursat times of very heavy rain (be it the mual or unusual) and flooding. Waterfrom the ground may then contaminate wells and cisterns,may flood out latrines and causethe wide spreadof infection. Under thesecircumstances only fresh rain water collected in closedcontainers comesbefore the rains then the collecting should be used. If a dusty season systemmust be flushed out before collection starts. If there hasbeena threat of contamination wells and clstemsmust be emptied and cisternspartjcularly cleaned. No wells or ciatemsshould be usedintermittently. If rain is plentiful for part of the year, a cistern necessary the rest of the year, then the cistern must be for regularly usedand refilled during the rainy season.

SummarY

(VI

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ElBe~aIdplant .HealthCentms are not big power users. Wheremainselectricity is availableelectric steamautoclaves be used,but most Centreswill haveonly a petrol can petroleum) or oil fueled generatorusedonly for lighting. Kerosene may be usedfor fueling primus stovesfor cooking and for sterilizing equipment. Generatorsare usually run betweensundownand an early lights-out time. If water is pumped with an electric pump the generatorwill be usedto allow for pumping * enoF@water for the night during the day, being turned over to lighting in the evening. Whereoperating or high consumptioninspection lampsare usedthese may bewired on a priority circuit for daytime useor the generatormay be started for emergency work. Newways of using natural power such asthe wind, the sun and water power are now under study. Wind and water mttls canmaheelectricity by turning generators, the sun canbe usedfor water heating and for space heating (central heating). Grganicwastescan be rotted down to makegaswhich can be burned. Watermills may give a steadysupply of electricity but sun (solar) heating systems wind and mills usually vary in their output. The energymadefrom simplewind and water milIs will be much lessthan that madeby petrol driven generators. Every bit of energymademust be stored if not used. A method of storing enoughelectricity for a night lighting systemis set out below. The systemcan alsobe chargedfrom an ordinary generator. AnightEghtingsystem The idea is to chargea battery or batterieswhen the generatoris running, with enoughelectricity to run a number of very small bulbs in halls and bathroomsfor the rest of the night. The only problem is to balancethe amount of clurrentput into the batterieswith the amount taken out, rememberingthat batteriesare like leaky baskets,and will seldomgive asmuch as75 per cent of what is put into them. The set-up(seeFig. 1 below) consistsof: battery charger,connectedto the mains or generator An accumulatorbattery, of the type usedin cars,usually 12 volts A specialcircuit incorporating a switch and all the night-lights in parallel
A
on/of /A4 switch

APPENDIX 40 ENERGY AND PLANT

Appendix 40, Fig. 1 Batiery systemfor lighting at night when generatoris not operating.

car battery - 12 volts 60 amp-hours

u to 10 amall bulbs in sockets. 12 volt. 0.5 amps. (#he dlagam shows 7 Iamp The example in the text is worked out for 10 amp).

Battery charger. Its capacity will dependon the number of night-lights used,and alsothe number of hours that the main ELzctricGeneratorls run every day on an average. Example: Suppose want to haveten night-lights and usesmall bulbs like we Rash-lightbulbs, but rated for 12 volts, 0.S amperes. Let us further suppose that the electric generatorruns from 7 p.m. until 10 p.m. (three hours) and the night-lights are neededfrom 10 p.m. until 7 a.m. the following morning. A total of nine hours. The amount of electricity neededfor the night-lights is then: 10 bulbs x 0.5 amperes 9 hours = 45 ampere-hours. x This is what we needget out of the battery, but the battery only givesback approximately 75 Per cent of what you put in, therefore you must put in:

(0

45 amp-hoursx 100 = 60 amp-hours 75 If the electric generatoris only run three hours a day, the chargeronly works i3 during that time, and must therefore supply: 60 amp-hours = 20 amperes. The usual electric generator(East Africa) is 220 volts, D.C. 50 cycles. Soin this casethe chargershould be: Battery chargerfor 12 volts batteries Input: 220 volts, D.C., 50 cycles Capacity: .20 amperes Battery. In this casea fairly large car battery would be required, 15 or 17 plates, 12 volts. Minimum of 60 amp-hours. Circuit. Or&nary electric wire (double core 31029)and switch will do, asin this example,only 5 amperesare be dealt with. The socketsfor the bulbs would to haveto be chosenaccordingto the type of bulb chosen. In this examplethe bulbs type, usedin panel boardsof cars: 12 volts, could be ordinary bulbs, screw-base 0.5 amp (or approximately 6 watts). Attention must be givento keeping the battery filled with water to about % inch abovethe top of plates,and keepingall terminals clean. Smearingthe two posts of the battery with Vaseline helps keepingthem free from corrosion. If appreciablymore than ten bulbs are required, for exampleten eachin two or three different wards,it might be advisableto havea complete and independent systemin eachward. sohrhtating Solarwater heatingis describedby MauriceKing in his book Medical Carein DevelopingCountries:l A black-paintedmetal plate on the roof of a building can, in suitableclimates, collect enoughheat to provide a useful quantity of hot water. Sucha plate is set at a slight slope,coveredby a glasssheetand backedby an insulator. To it is brazeda small bore brasspipe; the water in this pipe collects heat from the plate and risesby convectionto be stored in a tank. This deviceis satisfactoryin a wide rangeof tropical climatesand collects heat radiatedfrom the cloudsaswell as direct from the sun. Wheredull weathermight meana period of cold water an electric boostercan be fitted, but this is a luxury. Such a systemwould not be expensiveto instal and should pay for itself in a few years. There are other kinds of collectors. Old radiatorspainted black will work where there is lots of sun, or black.polythene bagsof water. More sophisticatedcollectors suchasthose describedby MauriceKing will take heat from the sun when the air is cold. Most collectorswill work when the sun is coveredin cloud. A very simple form of solar water heater is a water tank painted black with a sheetof glassover the top. Wherehot water is wantedthe panelsand the tank can be on the roof. If a pump is not installed space heatingsystemsmust be set out to allow gravity to push the hot water round. (It is very difficult to explain this, but the hottest water must go in at the top and must be allowed to fall all the way round the circuit asit cools. It must not be madeto go uphill at any point.) Wherewater is suppliedto the systemunder pressure precautionsmust be taken. All thesepoints are illustrated in figs. 2,3 and 4 following.

Appendix 40 (ctd.)

As conventional fuels get more costly more effort is being madeto usenatural power. In the next few yearsefficient, reliable equipment should becomeavailable. At the moment trial and error is the main method of research.

* SeeAppendix 49, page(i)

Appendix 40, Fig. 2 Solarwater heating. Canalsobe usedfor space (room) heating
/< drew off for hot webr or supply to haems pipe should be insulated

ot water rises to cylinder cold water aup ly to & ce water used \\\ pipeshould be insulated

iii?it%iti:

colder water circulates back down to solar puel

rises up to the cylinder. The panel has to be very much bigger than shown relative to the size of the cylinder. There are many different kinds of collecting panels from that described in the text.

8un heats water in panel so it

enel set to catch suns rays.

pipe should be L-_.L..^l

t-r .

always applies without

a pump

Appendix 40, Fig. 3 Watercirculation under gravity (the difference in weightsbetweenhot and cold water for the samevolume)

O~~Y;~P~CIaspace on heating

Where no pump is used the hot UPFLOW must be UP only, and the cold DOWNFLOW rnuLlt be DOWN only. The cold return downtlows must fmish at and not below the reentry levels. A last little jump of only 3 inches up till stop the gravity circulation. Where a pump is used the levels cm be igndred.

:. _.., _.. ,.. ;:-;y:*+.~. i .. . .(_,.:

.,,

^ ./

.z, ,.-

._, ..%:...

~3;

:,:

--

__

Appendix 40, Fig. 4 Precautionsagainstpressure build up

supply to open tank

cylinder ,

hot water from panel

cold water to panel cold r&I!

A. :: 2

Cold supply from high level tank. Highesttap to be 3 feet below bottom of tank. Water escapes this pipe if pressure up builds up. Tapsto cut off supply or radiators. Pressure off valveif fed direct from mainsand not tank (asA). May let out water if pressure cut builds up. Draw off for taps whereradiatorsare installed for heating. Draw off for taps where no radiatorsor radiator piping is installed.

Site sixes Seediagrambelow. Selectinga site is describedin Appendix 47, Setting up a Centre. The overall site sire neededfor the Model Centreis shown on the fold-out drawing at the end of this report. The Model plan site doesnot include: 1. extensivecar parking 2. helicopter landing pad or $r strip 3. sewerage works 4. extensivegardenor demonstrationareafor husbandry 5. fish pond&c. 6. staff housing I best entry

APPENDIX 41 SITE SIZES

465 ft. 140 tn.

I
I _~ 1
lis-be A hosp#tai .-.._.. __ _--. ~. ~-.-_~.-...--.----.--._-I . ~-bx~bo%@el---.-- __.__ --- _____ - ____ ------

_. -I

The abovedimensionscan only be taken asa generalguide. Soil conditions, contours, site shape,orientation and access points wili all require consideration.Seeroom lists for explanation of letters.

.____ - _-_..._ _....~.. .-._._

- -

urbrncullia~ Centresin largetowns will differ from those under study. Where,however, towns are effe, lively agglomerations largevillages,a Centrerun on the samelines asin of a village appears suitable. Assumingthere is an areahospital, urban Centresshould be small and scattered through the town rather than centralized. Staff will probably be one nurse and one midwife and auxiliaries. A few maternity bedsmust be provided. The Centre could with advantage sited closeto a school. The medicaljob will be the same be asfor a rural Centre. The clinic should be visited by the areahospital medical staff at least once a month, The social areais seenasbeing of greatimportance; but owing to pressureof land shortage,double usemay haveto be madeof a waiting area. The urban social area will needmore sophisticatedteachingaids. Storageareascanbe reducedto cope with regularmonthly supplieswherethe areahospital holds bulk stores. Apathy, disease, poverty, filth, hopelessness, of food, opportunities, recreation, lack etc., etc., are typical of the problemsin slums. If conditions are improved the towns becomemore attractive and the pressures build up againuntil improvements are swamped. No one hasan answerto theseproblems,official action may be inaction, any improvementmay lead to a worseproblem. The provision of jobs is well outside the powersor possibilitiesof Health Centres,but they may be able to assistin making a community focus, providing an environment in which hope may grow. Ideally, auxiliaries will be drawn from the community that is to be sewed. They should also be trained asmuch aspossiblein the community, and the community should be drawn into the work of the Centreaspossible. Liaison with any governmentsocialworkers is obviously essential. Food, hygieneand family planning remainthe key areasfor action. Sanitation and water suppliesare problemsthat will only respondto governmentor municipal action.

APPENDIX 42 URBAN CLINICS

very

sInaII clinics

One-room and lock-up clinics are popular notions, but it must alwaysbe rememberedthat two-way contact is essential. Doctors must visit the smallestclinic reguiariy. A waiting area,a consulting room of somesize for group visits and staff training sessions room also having somelaboratory and treatment (this facilities) will be needed. A latrine and a water point are very desirable. Good communicationsshould come high on the list of priorities (seeAppendix 23. Communications,whereit is suggested someclinics will needno other that facilities than a radio telephone). It hasbeenfound that farmerscan be given the necessary basictraining to look after a small clinic on a part-time basisin an isolatedareaprovided they have communication facilities. Tire part-time worker will bear the local responsibility for hygiene and sanitation, will be the main channelthrough which diet improvementswill be madeand will be required to havea good idea of the generalstateof health of his community including new births. immunizationsetc. He will report to visiring doctors or other qualified staff,havinga vital role in lesseningthe introductory problemson eachvisit, thereby exteuding the usefulness the visit. of

APPENDIX 43 VERY SMALL CLINICS

Numbersof peopleserved,the distribution and grouping of Centresand somewider phming problems The working party hasrepeatedlybeenaskedto suggest how many people the Model Centrecanserve,and how many Centreswill be neededto reacha population. The following ls offered as a guidebut needsfree interpretation. Numbemof peopIe We have felt throughout this study that the Centre will probably serveabout 20,000 peopleat ideal staffmglevel, that is to say two principal staff and three out of the four auxihariesseeingpatients, the fourth auxiliary beingmuch involved outside the Centre. Weattempted fmt to justify this more or lessintuitively asfollows, taking asa guidethe field experienceof membersof the working party: 1. Probablybetweenthree and four visits a person a year on average the to Centre- bearingin mind one is usedto seeingfamilies asopposedto individuals only. This figure is very suspect. 2. Principal staff can seebetween40 and 60 people a day if meaningful contact is to be made. 3. Auxiliaries, involved more with return patients, immunizations,dressings etc., seebetween60 and 80 peoplea day, 10 per cent being passed the principal to staff, this 10 per cent to be included in the principals figures. 4. Assistants not seepatients in the termsof this calculation, being involved do with assistingthe other staff. 5. Allow one and a half principals only to account for involvementelsewherein the Centre. 6. AssumeSundaysare not worked, that a fortnight is spent training, that a fortnight is spent on holiday and that one week a year is lost through sickness or other causes. 7. Assume two principals daysa month are spent seeingreturn cases that with the doctor. __ 8. Assume that the equivalent of a quarter of one auxiliarys year is lost through recruiting.
Then

APPENDIX 44 Numbersof peopleserved, the distribution and grouping of Centres,and somewider planning problems

Principal 1 365 days,less52 Sundays,less 12 daystraining, 12 daysleave, 12 days with doctor, 6 dayssickness, say 270 days Principal 2 Half asabove Total for principals Auxiliaries 1 and 2 As principal 1, but 12 extra working daysnot lost with doctor, total 282 dayseach, Auxiliary 3 .I As auxdliaries nos. !..and2 !esz25 per cent !osson recruitment Total for auxiliaries (8 564 days 135 days 405 days -

212 days 776 days

Contacts made by principals 405 days - between 40 and 60 people seen per day average Contacts made by auxiharies 776 days - between 60 and 80 people seen per day average less10 per cent Total contacts,average 69,138, say 70,000.

Appendix 44 (cad.) = 16,2Otlto 24,300 = 20,250

= 4tjStjO to 62,080 = 54,320 = 48,888

At betweenthree and four visits a yeqr this shoti between23,300 and 17,500 population served,au average about 20,400 per annum. of This figure confiied our conviction, but wasbasedon an average per annum visit Ggurewe could not support. Wetherefore tried againasfollows: 20,009 people may well include asmany as4,000 children under five. The under fivesvisiting ten times a year will give 40,000 visits. This leaves30,000 visits from the total contact figure of 70,000, that is to say, two visits per annum average from eachof the remaining 16,ooOpeople. This seems be reasonable. Thesefigures to Indicate, incidentally, six trained people per 20,009 population. Alternative calculationsrun asfollows: 1. Assumeeachfamily haseight people in it 1 grandparent 1dependentadult 2 parents 3 children over five 1 child under five 2. Allowing ten visits per annum to the child under five and one per adult gives seventeen visits per family. With 70,000 visits availablewe could serve 70,000 families = 4,100, which at eight to +hefamily is nearly 33,000 people 17 served. 3. The samefamily but with two of the children under five gives26 visits per family is 70,000 x 8 = 21,500 people served. 26 4. The samefamily asin (2) with two adult visits per annum gives24 visits is 70,000 x 8 = 23,309 peopleserved. 24 5. The samefamily as(3) with two adult visits per annum gives34 visits per annum is 70,000 = 16,500people served. 34 6. The family with two lessadults, at one adult visit per year and one child under five gives70,000 x 6 = 17,500 people served. Is Thesecalculationspoint to two important facts: 1. The proportion of under fives in a population is very important in assessing sizesand populations covered. 2. If an Increasein survival rate of children can be tied to reduction in family size,and asa population getsolder, Centresoriginally establishedon an under fives calculation will be too big. This loose fit should allow for an expanding trade in adult outpatients. As outpatient treatment takeslonger for adults

(ii)

.than for under fives it is not unreasonable hope that thesevajing factors to will keep themselves balance. in

Appendix 44 (ctd.)

High or very low population densities,difficult terrain, and difficult communications,the existenceof supporting units or existingCentres,seasonal variations causing,for instance,flooding which may annually severcommunications,haveall to be taken into account in addition to the availability of staff and funds, when sitting a Centreinto a countryside and into a population; and a suitable sizehas to bejudged againstpopulation density. Cultural patterns,personalities,training and training responsibilitiesare further variableswhich will act principally on the number of peoplewho can be seenin a &YReasonabIe taaveldistauccs In reasonablyopen, reasonablyflat country a high proprotion of the population will travel three milesto a Centre and good cover will be achievedin this area. Within five miles in reasonablyopen, reasonablyflat country experienceshows that coveris adequatein the generaltermsof the current reasonable rossibilities of headthdelivery. Beyond five miles, attendanceis sporadic. Theoretically, therefore, a Centre is required in every ten mile squarewhere the country is reasonablyopen and flat,

It hasbeententatively suggested a rural population of 50,000 people seenby that Centresof the type offered in the Model will keep one referral doctor busy. This suggests doctor to every two-and-a-halfCentresof the Model.size,that is to one say one doctor to every fifteen trained Centrestaff. Five Model Centrescould be servedby two doctors in a District Hospital. Better still, four doctors in a hospital teasonablcto state asan absoluterule that onecould serveten Centres. It seems doctor hospit& must not be allowed.

Wenote that a bullock cart can be readily adaptedto a stretchervehicle. and can travel at 3mph without halt for six hours giving an 18 mile radius of travel by this form of transport. Wenote later that 20 miles from a Centre to a District Hospital seems be an average to practicabledistance. Whilst evervCentrewould ideally havea fastertransport system,.it may be that groupsof:centres should be pushed out of balanceso that asmany Centresaspossible. within the 18 miles,,the fall others then being too far for a bullock cart and needingsomeother form of transport. A further feature offered for considerationis that a time of six hours between emergency referral and reeeption at a hospital is reasonable practical terms. in JknsIty of popuktion The Model Centreideally lies at the centre of a ten mile diametercircle within which the population is 20,OOO people,i.e. somethingover 200 people to the squaremile. As densitiesrise abovethis level more staff must be addeduntil the of point wheremore buildings are needed. Similarly, in areas lower population density the Centrestaff wili first reduceand then at a certain pq&t fewer buildings will be needed. Somecommunities,for instancethose spreadalong river banks, posetheir own specialproblems.

The Model Centreideally lies in reasonablyopen, reasdnablyflat countryside. As terrain getsmore difficult so the distancethat people will be willing to travel will reduce. Mountains, forests,swamps rivers are all factors that will discourage and attendances the Centre. The worsethe terrain the more Centreswill be needed. at (iii)

i I:, :, :

.,.

.:,

comiliunications

Appendix 44 (ctd.)

Existing roads,railways,navigablerivers and coastalwaterswhich are reasonably navigablewill alter the ideal evenspreadof Centresover the country. TIE relationship betweenthe District Hospital and the Centresit serve3 The District Hospital must be located with an eye to the sameproblemsof land .. form and travel.. It may be that the District Hospital will not be in the most easily accessible placebut in the placethat is equally accessible from everywherein its catchment. This principle could obviously be taken too far, but it should be bornein mind. Mobile clinics ad radio telephones In a region of open countryside but very low population density the catchment areaneededto give a Centreenoughpatients to justify the Centremight be ridiculousIy large. In the sameway a population living In a region of mountainous junglesmight be so restrictedin its travel that a ridiculous number of Centreswould any and be needed. In thesecases built facility may be meaningless, a helicopter work best wherethe popuor aeroplaneservicemay be essential. Suchservices lation servedcan communicatewith the baseunit. Radio telephoneswork well in this context. The most distant units needthe most complex communication systems. Inversion of soph&ication The principle that the most inaccessible units need the most sophisticatedcommunicationscan be developedfurther. Health Centresnear the supportinghospital should be the least sophisticatedasthey can expect most support. This idea seems contrary to most developmentpractice wheredevelopmentis outward from the centre of gravity of existing facilities, the SophisLication the units decreasing of as the distancefrom the middle increases. The implication is that,instead of being - usedto hurry people round the towns in the district concerned&e available vehicleswill havemost effect where the longestdistancesof travel are found. The more denselypopulated towns and their surroundingscould be adequately servedover the relatively short distancesby bullock carts or similar slower methodsof transport. haling with the miable factors As eachcountry may well adopt quite different staffmglevels,gradesand numbers; aseachcountry builds different sixesand numbersof Centreswith different distribution criteria; asthe form of the land varies; aspopulation densitiesvary; as disease patterns vary; asso many different factorsvary in themselves in and relation to eachother so it seems be extremely difficult to comeup with any to formula which will be of significant usein assessing number of Centresneeded the and their distribution. The working party in consideringthis problem have attempted to treat it in a very broad manner. Tlbemacrwmit Wefeel that a District Hospital with four or so doctorsis a worthwhile medicalunit. If one doctor will be kept busy by referralsfrom Health Centresat the approximate rate of one doctor per 50,000 people, and if eachCentre serves 20,000 peoplethen ten CentreswilI needthe support of a hospital. Taking ten such district groups (quite arbitrarily) and relating the ten groupsto a RegionalHospital we havea macro-unit which coversso large an areaand is so generalizedin its structure that it may be a useful planning tool. Tie stnu%weof the mamanit The Regional Hospital will not necessarilybe in the middle of its macro-unit. Its siting will be subjectto the samepressures land form etc. asare District Hospitals of and Health Centres. Taking the layout of the macro-unit asan ideal circle, we might fmd the very generalized layout. shown in Appendix 44, Fig. 1. At the centre is the RegionalHospital. Ring A is a ring of Health Centresrelating to the RegionalHospital. Ring C is ten District Hospitalswith their dependent Centresin rings B and D. The RegionalHospital and eachring of Centresand District Hospitalshasits own satellite systemof subCentres,not shownhere.

0 Regional Hospital A. CentHrespreeted to Regional to District 0 o@o 0

0 0 *\ / District unit 1 * @ ) 0 0 0 O ood 0 A 0 BC,D o

Appendix 44 (ctd.)

O@;y

o/

0.

0
B and D. Centresxelated Hospitals Cand@j District Hospitals

0 0
a@

0
0 *O

Appendix 44, Fig. 1. An idealizedmacrwmit. Sub-Centres drawn in. not

Oo

@.O

@O.

O@

0 O 0

@ 0 0 0

The subCentres Sub-Centres (very small clinics, seeAppendix 43) havebeenintroduced asa major componentof the macro-unit for the following reasons: 1. The ideal density of 200 personsto the squaremile is unlikely to hold good over the largeareaswe are discussing with the macro-unit. Higher densities can be copedwith by making biggerCentresor more of them: the travel problemsare probably slight. Lower densitiesor difficult terrain will force solutions away from the ideal, making smallerunits essential. Our conceptual pattern must include thesesmallerunits. 2. The macro-unit is so generalizedthat it must be allowed to developits own rules. Thus where the circles,within which the variousunits conceptually lie, meet,gapsareleft. Sub-Centres fiu theseconceptualgaps. can 3. As sub-Centres inevitably be built, it seems be advisableto take account will to of them. The district groups Ten district groupsmake up a macro-unit. Referring to Appendix 44, fig. 1 and looking at ringsC and D, dnd assuming a sub-Centrewill attract people from that 2?4miles away II becomes possibleto start plotting sizeson the macro-unit, see Appendix 44, fig. 2.

Appendix 44, Fig. 2 Distances the district in unit.

I
sub-Centre sub,Centre Health Centre

Centre

-30 mites

iv)

T&e sizesgiveus a District Hospital centred circle diameter60 miles which is an areaof appioxikately 2,825 squaremiles. Weare still assuming four doctors each servicing50,000 people. Wemust therefore assume a number of the Health that Centres,and sub-Centres indicated will not exist becausethere is a moun$in or a river or a desertin the way, or the doctors will be overloaded. Agaia, higher densitiesmeana bigger cashand manpowerproblem but a simpler planning problem. Allowing the geometry of the circular district group to take over we mu1draw Fig, 3 which sets the actual number for the sub-Centres. Wherethe ten circles that makeup the macro-unit abut, sub-Centres be shared will or lost. Wetherefore account40 in eachdistrict group. ,

Appendix 44 (ctd.)

Appendix 44, Fig. 3. Number of units in a district unit

49 b sub-Cent%

Health Centre I

L-

19

District Hospital

In areasof high population many more people will be reached,which meansthat the hospital will haveto be bigger,and that it will needmore staff. Wecan seeno point in making the district unit smallerand multiplying hospitals. This whole report is promoting Health Centresasa good solution providing they are supported by hospitals,not the reverse. Numbersof peopleservedby the macreunit Eachdistrict unit has + and 10 Centres 1 Centrebasedon the hospital 1 hospital

Appendix 44 (ctd.)

The macro-unit therefore has 110 Centres and 11 hospitals and 1 Centrebasedon the RegionalHospital As eachdistrict unit covers2,825 squaremiles, eachmacro-unit will cover 28,250 squaremiles. Allowing for a zone of influence round the RegionalHospital, and for other units that may be in the area,the macro-unit can be consideredas . coveringsay30,000 squaremiles. The basicunit in our calculation is the Model Centreserving20,000 people. As we have 110 in eachmacro-unit, eachmacro-unit canserve2,200,OOO people. Taking one district unit, we have220,000 peoplein 2.825 squaremiles. an average density of 77.7 per squaremile (seeAppendix 46, Somegene& statistics.) This is the average density the macro-unit can serve. Staffhg requirementsof a macro-unit EachCentrehassix trained staff, and there are approximately 40 sub-Centres in eachdistrict unit eachneedingtwo trained staff. Assumingthat eachDistrict Hospital hasfive doctors(this is discussed later) eachmacro-unit needs50 doctors 1~sthe RegionalHospital doctors, eachRegionalHospital needingfifteen doctors this later). This is a total of 65 doctors. Wethus haveone doctor P is discussed for every 33,846 people,and one auxiliary for every 1,500 people. As the minimum tirne it would take to establisha macro-unit is probably ten yearsthis forecastdoesnot seemtoo impossible. Moreover,the macro-unit is proposedon a density only 30 per cent of the Model Centredensity. It must therefore foilow that the trained auxiliary and nursing staff requirementscan actually be reduced. Further, the 50 District Hospital doctors could attend to 2,500,OOO people,not the 2,200,OOO proposed. On the faceof it, therefore, at this level one doctor per 35,000 people seems be the to target. Therewill then, however,be doctors almostwholly involved in research, trahkg and complex proceduresservingvery few people. It will be seenthat 25 doctors in a National Central Hospital are going to reducethe availabledoctors to population figuresto a very great extent indeed in a small country. On the other hand, to maintain the correct doctor to population ratio a country with an average population density of 200 to the squaremile is going to needthree timesthe number of doctorsper macro-unit, and will therefore havefifteen doctors basedon eachDistrict Hospital, eachDistrict Hospital servicinga population of againthat this whole fabric relies on com750,000 people. It must be stressed munications. It is not so much doctors training and attitudes that needchanging aspoliticians and plannersattitudes to nationa! spending. It is our purposein intruducing the macm-unit to give a h&b facility network framework for estab patterns,baaedun health care,which will makeHealth liahing comnnunicrtitu~~ Centrebasedcommunity carean tasaembkreality. The staff of the JXstrict Hospital Wehavesuggested four doctors can seepatients from ten Centres. Wehave that alsosuggested thesedoctors will havesubstantialduties outside the hospital. that (vii) I I I

-Eachfour-doctor District Hospital has following in its orbit i0 Centres 40 sub-Centres not including mobile clinics. This nieans50 visit points to be servicedin a working year,( which can be judged as having 250 days),and implies, (at tweive.visits/centre/yearmaximum, assuming that a visit can be madein a day), 600 doctor visiting daystaken from a total of loo0 doctor days, i.e. eachdoctor has 100 daysper annum or two daysa weekin the District Hospital. This giveseight total working doctor daysper weekper hospital, which indicates a maximum of say 120 bedstolerable, w&h at 70 per cent occupancyis 90 beds. This indicates a load of 60 patients/doctor/day. Assurniriga five day average stay we can expect 365 x 90 i.e. 6,510 admissions from 200,000 people,sayone S admissionfrom every 30 people at 75 per cent occupancy. Carry@ this calculation further, at 60@atients/doctor/day,with say 30 medical and 30 surgicalpatients, if eachof the surgicalpatients hasan operativeprocedure of someform (somewill havetwo or more, somenone) then, on a five day average stay we have 30 = 6 proceduresa day, i.e. up to 9 per day with a SOper cent. S fluctuation, which is not impossiblebut would probably prove intolerable for one doctor with no houseman,no registrar,no anaesthetist,but possiblytwo students a&sting. This indicates a very clearneedfor good theatre auxiliaries. Without suchauxiliariesthe systemcannot work at all. There is an areafor manoeuvrein thesecalculations which is that it may be possibleto visit more than one Centreor subCentrea day. Howeverwell the visiting roster was organizedwe seesickness, weather,leave bad and recruiting spoiling the doctor/day/occupation calculation, and believethat it is essentiaI add a fifth doctor. to If in a denselypopulated areathe basicfour doctor unit becomes twelve or a sixteen doctor unit, then it may not be necessary add a fifth doctor to eachunit to of four. Tlw DistIict Hospital It seems be necessary point out that the District Hospital we are being forced to to to consider will havesomenovel features. 1. It is closely associated with its home Health Centre,but will haveno outpatients department. 2. It may havea high proportion of hostel type bedsto traditional ward type beds. It may be very like a chalet hotel. 3. it is going to receivepatients from all sortsof placesand may needisolation admissionroutines. It is fairly certain that patients coming in will haveto be given a fairly thorough diagnostic session. History taking may be a pro~~n~sd interrupted business,one which could well be done by trained . 4. Patientsare going to arrive in a fairly bad state. It may be that quite sophisticated diagnosticand life support apparatuswill be called for. Weshould not think of thesehospitalsasbeing primitive and secondclass. Nothing quite like what is neededyet exists, but we urgently need to know what we need. In ten years time - about the time it would normally take to get up an experimental unit sponsored somecollection of international bodiesby we are going to needseveralhundredsof thesehospitals worldwide, and they will needstaffing, equipping and running. Wehave to work uut what we have to do and start doing it within the next two to three years. Otherwise Health Centrebuilding is only going to build up worseproblemsthan we have (viii)

Appendix 44 (ctd.)

,. .

-..

>

,.,\_

now - a diagnosed untreatablepopulation conditioned to ,expecting but health care. 5. Average hospital population figuresare likely to be quite useless. Seasonal demands the hospital wiJl be madeand wJJJ to be met. Perhaps on have training programmes be organizedout of season. wiJJ 6. All hospitalsare training establishments effect, but the District Hospital is in going to haveheavy and specifictraining duties for nursesand auxiliaries. Much of the-work done over many yearsby many peoplein promoting the idea of the Health Centrehasbeen prompted by the unsuitability of big Westerntype teacJting hospitalsto the problemsof developingcountries. The effect hassometimes beenthat peoplecoming new to the field, readingthe availableliterature and talJringto thosewith experienceassume all hospitals are a bad thing. Wewrite that on pageone of this report no one should be required continually to perform a ta& which someone qualified can readily be taught to do competently. The less new District Hospitalsshould similarly be planned and established do only that to wJricJt cannot be competently done in Health Centres. Hospitalstraditionahy havea full and expensivecomplementof equipment and staff which is inefficiently usedto deal with minor work. The majority are established do nearly every medicaljob from treating a smalJ to major to cut surgery,from complex diagnosticroutines to prolonged minimal careco11 --alescence. Very much more precisedefinition of aimsis neededso that the new Lzsp~lals can do their job unencumbered unsuitable traditions. by The wider implications of training programme for Health Centrestaff

Appendix 44 (ctd.)

Doctors, it is clear, neednew things addedinto their current standard(i.e. Western that based)training. It seems theseextra matters can only be built into the already long courseby pruning the standardcurriculum. Also, asthe new systemtakes effect a whole generationof doctors may haveto be retrained. Nursesand auxiliaries wJlJneedcarefully tailored training. Weare going to need many different kinds and in eachof the disciplineswe aregoing to needteachers. Weare going to needdistrict and regionalorganizationand co-ordination, and some form of central diagnosticreference,organizationsfor training rosters,etc. Weindicate below how thesevariousthings could be tagged,in balancedbatches, to eachof the ten District Hospitalsin eachdistrict group, eachhospital having its own distinctive responsibility and character. The aim is to recruit, train and use local peoplelocally.

Somepossibletrain&
I AuxiUarieo,drewrs Building planning Midwifery 2 Nurses . ^. .. . sitennzmg Communications 3 Theatre auxiliaries Anaestnesta

groups

for District Hospitals

4 Hospital. . .auxilaries . . . . Group narary anci alagnost8c reference 5 Pharmacists and Dispensers Cardiology

Possiile train& responsibilitiesfor RegionalHospitals

Radiotherapy Immunology Neurosurgery 6 AuxiUar@generrl Rejects centre Paediitrics 7 Laboratory as&tents X-ray assistants Trrumatology Neurology Mental 8 Teaching hygiene Water supply Ante-natal etc. Family planning Nutrition Schools involvement 9 NUlSG8 Agriculture Sanitation Public health assistants Community development workers Advanced surgery Opthalmology Etc. 10 Records Administration Maintenance Burns Planning co-ordination Statistical analysts and surveyors

Weproposethat considerationbe given to the basictraining of auxiliaries in one sub-disciplineplus a generalbasicfamiharization course. Thereafter, and perhaps partly by correspondence courses, specialist coursesare added,the total number of coursestaken and passed being the qualification of the auxiJJary, salarybeing his qualification related. The better quaMed auxiliaries wiJl, presumably,go to the small Centreswheretheir wider experiencewiJJservebest.

Appendix 44 (ctd.)

Within the rural network only, not including regionaland central facilities, the figuresfor the Model and the macro-unit are: 1 doctor/34,000 people 1.05 beds/1000 people Ignoring the fact that the bed spaces eachCcltre could be increased, can in we reasonablyexpect &at the RegionalHospital, drawingpatients from its own immediateorbit, wiJJhavetwelve bedsfor thesepatients, and will havereferrals from ten District Hospitalswith 120 bedseach,i.e. 1,200 bedsin the group. With ten per cent referralsand a longer stay this means240 referral bedsplus 120 local is a minimum of 360 beds. Webelievethe RegionalHospital should also support at least one National Speciality Unit. This will bring the total of bedsto say SSO (thesefgures can only be very sketchy). This hospital can hardly run properly including specialization,training and research with lessthan fifteen doctors, allowing them to haveno outside duties. Including the RegionalCentrewithin the macro-unit we find 111 Centreswith 10 bedseach 10 District Hospitalswith 120 bedseach 1 RegionalHospital with 550 beds Total 111 Centresserving20,000 people each 10 District Hospitalswith S doctors each 1RegionaJ Hospital with 15 doctors Total Tllisis 1 doctor134,lSOpeople 1.29 beds/1000people 1,110 1,200 550
2,860

beds

2,220,OOO people so 1s -

Wehavefigures which suggest the current average that figures for twenty develop ing countries in Africa show 1 doctor/ 17,400people and 2.2 beds/l000 people The macro-unit must thereforebe seenasproposinga skeleton service. The numberof doc&rsand the nu.mberofbeds could be doubled wJthou1the unit becomingIncurious unlessexisting average African conditions can be considered On the other hand, figures are not availablefor auxiJkuies. How many luxurious. auxiliaries are worth one doctor? This question must be answeredsomehowif statisticsare to remain useful in conununity medicine. Setting a Centre into the countryside Appendix 47, on getting up a Centrenotessomeof the detailed problemsof actuaJJy getting a Centrebuilt. Before a site can be selectedhoweverthe riJ#t generalareafor the CentreJtas be located. Appendix 44, Figs. 4, S and 6 attempt to to show someof the factors that could act on a district group to distort its simple flower-like ideal form. The mapscannot be comprehensive, they illustrate that the District Hospital may but be sited better if at the focal point for travel facilities rather than in the centre of the area.

-- -____T i
G-10 MILES+ 10 MILES I

I
OUTLINE OF A DISTRICT UNIT --c--3_

f .I +* 1, \ # j. 6 , \

-------

- --

.---___

I \ i\ \ -- \ \ \

I -. :

.- _ Ii \

SU

---t;

Appendix 44, Fig. 4 Showspart of an imaginary country. It can be assumed there will be that an existing hospnal tn tlarhour Town, - smallhospital existing or proposed in River Town, and clinics existing or proposedin Plantation Town and Fisher Town. Drawn over the map are ten mile squares also a and district unit. It is assumed the district unit has appeared on this that piece of map asa result of moving a seriesoi district units drawn to scale on transparentmaterial round on a map of the whole country.

10 BEDS, CILITIES

-_-- ._. ....-.. EN& I .___._._

6B

Appendix 44, Fig 5 Showsa possibledevelopmentplan on traditional lines for increasinghealth facilities and also showsan improved road betweenthe Delta Swampand the Agricultural Uplands.This road is proposedso that the new hydro-electrlc scheme more is accessible, associated and works will relate Fisher Town and Harbour Town more closely. The main developmentin medical termswill be in Harbour Town or in River Town, probably in the former asitis biggerand hasmore people to justify the development.Sucha developmentwill not favour River Town over Plantation Town. (xii)

-----

/ I

I :

I ._S

18 WE
1

SUB CENtRES(TOT4 3b)

Appendix 44. Fia. 6

Shows a qolrmon-amved at by following the principles discussed in tlli\ Appendix. 11115 wlutw mealIs a IICW road brtueen MI&& 1IS II ,I,; the Hjdro-Hectrlc Scheme and Agricultural Uplands. The cost t~f the traditional scheme against the cost of the macro-unit scheme can he worked out. the cost of the new road against the improved road in Fig. 5 ~;ln 1~ worked out, and the cost benefit to the communit) 1~~ new tile road can also he wlked out. II must be seen from this example that the macro-unit boiution is very great11 preferable to the traditional solution.

.I

-.. :_ least,in this case.Fisher Town is not well served.but it is right on the edgeof it . -., the area,so the next door district group may offer an answer.River Town is also nearthe edgebut is very well servedby the new hospital. If the district unit is shifted so that the centre lies over Harbour Town so the existing hospital (wh$h is.obvlously a problem) can becomethe District Hospital. then the Agricultural Uplandsarebadly servedand the improved road is still neededand .. a new bridge will be neededto the plantation area.River Town is 35 miles away by road, Fisher Town is 50 miles away and Plantation Town, evenwith the new bridge,is still 30 miles away. This exampleattempts to &w that the macro-unit and the district unit can be used asa method of tl&king about planning in real terms without expert knowledge. It is suggested Interestedreadersshould copy the map in outline, but assume that that it is at haIf the scaleshown,i.e. that eachsquareis 20 miles by 20 miles. Four district units will then be neededto cover the map, and the problem becomes quite different. Alternatively it could be assumed four district units had come that to rest, centred one on eachcomer of the map, leavinga gapin the middle. This againgivesa completely different problem. The solutions to theseproblemsare alwaysstatedin medical terms. Appmachesto planning Whensetting out to produce any form of overall plan at a national level planners havea rangeof planning methodsfrom which they can select. They can start from a certain point, usually the existing facilities, and expand outwards, they can start from a whole seriesof suchpoints and fti in the gaps,or they can makesome form of idealizedstatementand adapt it to existing .circumstances. method The chosenis more a matter of emphasis than anything elseaseachof the systems must take accountof the others. The approachof this report emphasizes thiid the method. It is currently believedto be essentialto conduct surveysbefore beginning to plan. The resultsof thesesurveyswill, it is hoped, indicate the nature of the problem that is to be solved. The fallacy of this approachis obvious: the results of the survey will dependon the skill of the surveyors,how the questionsare phrased,askedand answered, how the resulting answers lack of answers processed. To give and or are an obviousexample,the answerto the question is leprosy a problem in your district?*could be No for four totally contradictory reasons: 1. There is no leprosy in the district , 2. It is rife, alwayshasbeen,we haveno methodsof treatment for it and no interest in attempting to treat it, 3. Wehavea leprosy problem, the disease not widespread, have it contained is we and are doing very nicely, thank you, 4. Yes,we do haveleprosy, we think we ought to be treating it although we are not and haveno Mention of telling you about this failure. In countrieswith very well developedhealth systems reasonablyprecisesurveying to establishreasonablypreciseendsis Important, but in any country with a less well developedsystemit can usually be said that any facility will be welcome. The questionthen is, what kind of facility can we afford in staff and money terms? This question can only be answered securelywhen someone said how much has money can be afforded and how many staff are likely to be available. Wehope to haveput forward in this Appendix in the form of the macro-unit the bonesof a completeorganizationwhich canbe applied at a national level. Poorer countries will be forced to build smallerCentreswith fewer staff than we propose: richer countriesmay build more elaborateCentreswith more staff. But the object remainsthe samein all cases, we stressand re-stress the planning problem and that at the root Is not one of money and staff but one of travel and communicationsand geography. Few national plans are producedinitially entirely in ideal terms. The planners instructions arelikely to read,How many Health Centrescanwe haveln the next somany yearsfor so much money in such and suchan area? The idea of more or lesspublic forward commitment to very large plansis not one that is receivedwith joy in political situations. In the medicalplanning field this thoroughly practical tendencyto drag the feet receives apparentsupport from the often repeatedidea that it is actually rather a wasteof time planning anything in the medical field because everything is going to havechangedso much by the time it is built that it (xw

Appendix 44 (ctd.)

will not really be worth building it anyway unlessit is flexible and amenableto change. If adequateforward policy planning is carried through this problem can be greatly diluted. The fust question remains; where betweenwalking and helicoptersare we to set our communicationssystemsover the next f&een or so years,and can we relieve our medicalproblem by tying it in with other programmes suchasroads,land reclamationand the siting of industrial areas? We try to show that health is very marchbound up with education and note that health and education absorbvery high proportions of most national budgets. We are in fact suggesting health planning and management and should be seen that can asthe principal social function of the state. Usingthe nmcra-ti to establishan overall outline plan

Appendix 44 (ctd.)

Peoplewith limited experiencein developingcountries or an entirely theoretical understandingshould understandthat the solutions to the problemsdiscussed in this Appendix are very, very complicated. The complication works two ways. Fig.7 below showsthe mainland of the British Islessatisfiedby two macro-units. A country the sizeof Englandneedsonly twenty four hospitals. This is obviously nonsense terms of population density, but in terms of a much smallerdensity in this suggestion should bring home the appalling communicationproblemsin terms of simple distancealone. Two district units side by sidewould reachfrom the centre of Bristol to the centre of London. Fig. 8 showsthe samenumber of units in the bottom part of India, In terms of coveringthe ground the problem in India is immense. India, like the UK, has areasof high density; but alsohuge tracts of wilderness. One cannot squeeze solutions from the macro-unit like toothpaste from a tube. 9 shows.thesameunits on a sketchmap of Africa. Herethe problem is very often one of very sparse populations which complicatethe issueby being nomadic. The macro-unit works asan idea down to an average density of 77 peopleto a squaremile, and can thereforebe usedoverall asa calculator,but the average resultsmust be readjustedareaby areato the facts of geographyand population, people and money.

Fig.

al Hospital

One

district

unit -

7
1, \ -A

Regional Hospital

Appendix 44 (ctd.)

Appendix 44, Fii. 8 A map of India with the sameMnlber of unita al~paedaaill Fii. 7.

Appendix 44, Fig. 9 A map of Africa wiih the samenumber of units superimposed in as Fii. 7 and 8.

-. ^ ::.,.._ .,

.,: ;1, ._ ;-,,-- , 1 , .

A seriesof macro-unitscould be drawn on transparentmaterial to the samescaleas a mapof the country concerned,and then laid over that map allowing not more than 30 per cent wastage overlapping,or for parts of the tracing overlaymg for the seaor neighbourhrgcountries. Usedwith a good will thesetracingscould give a rapid and tolerably accurateprediction in generalterms or in somedetail of almost any aspectof the health delivery network. The figuresresulting from such a study would haveto be adaptedby referenceto approximate densitiesbut these can be further adaptedto any particular country by adjustingthe working partys basefiguresto suit the desiredor practical staffing conditions for 1 given country. The resultsof an initial exercisecarried out in this way may be very unhelpful. The~implications may be that many Centresand hospitals are neededin totally unpopulated areasor in vhtually inaccessible mountains. By removingthe tracings from suchareasand reshuffling the remainderto cover gaps,better resultsmay be obtained. It may be found that geographydictates one-and-ahalfmacro-unitsin one placeand one-third of a unit only somewhere else. This still givesan answerof somesortand someuse,this answerbeing phrasedIn terms of a medical organization and not in terms onlv of are-existlne facilities.
__ ____ -~--_----, --a ----__ ----~-_-

Appendix 44 (ctd.)

Without attempting the immenselycomplex task of positioning, sizing and working out individual Centres,then working out staffing and then fmdhrg the resulting _ proposalsgiverequirementsthat cannot be met, the trachrgapproachmay offeruseful initial generalanswers. The macro-unit coverspopulation densitiesaveraging to 77.7 persons/square mile. It appears work 30 per cent down, i.e. at an :iverage of SO/square mileand 400 per cent up, an average 2OO/square of mile. As the basic Model Centreworks bestin its own immediateorbit at 200 personsto the square mile the macro-unit will clearly cover very wide variations of population without the basicmathsbecominguseless. In theseterms the macro-unit can be seenasa predictive tool. As a planning tool the macro-unit requiresvery thoughtful handling. It may proposea District Hospital fifteen miles awayfrom an existing hospital, and a RegionalHospital ln an inaccessible area. The existing hospital obviously calls for an intelligent compromise, if the but RegionalHospital seems, medical and organizationalterms,to be in the right in sort of place although currently inaccessible, may be that the placeshould be it madeaccessible. In view of the high proportion of a national budget that health delivery absorbsthis otherwise silly-soundingproposalmight repay study. Clearly there are many parts of many countrieswhere the macro-unit is quite useless. Widely dispersed desertcommunitiesor extended river bank communities are specialproblems. What we haveattemptedis the production of a planning tool which will allow for the plotting on to a map of health facilities which will make overall asopposedto piecemealdevelopmenta reality! At least the macro-unit setsan overall standardwhich, if it cannot be met by other means,should obviously be adopted. Moreover,it may form a basisfor useful international discussion. Even if no one likes it at least everyonecould discussthe problem in the sameterms. It must be remembered nothing in this report attempts to account for mobile that clinics, including for instanceflying doctors, or for qualifted medicalstaff of any sort whosetime is principally involved in (1) teachingtheir dlsciplhres,or (2) special. ization benefitting a limited number of patients, or (3) research, (4) medical or ancillary services suchasblood product work. In a country with a comparatively small population acceptinga high ratio of patients to fully qualified doctors these latter groupscan makean alarming reduction in the number of doctors available to servea population. cMllnunity can6ewationin phulnlng
,-

Throughout the more highly developedcountries there is a growing attempt to establisha new balancebetweenman and nature. Whetherthis is to do with identity or with the dignity of appearingto be self-supportingor with a mere wish to escape from the crushingmachinesinto which our cities are turning it is imposspossiblethat the backwardness rural communities of ible to say, But it seems

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maybe their major asset. It is to be hoped that health plannerswill respectthe structure of communitiesand not try to drag them into the middle of that kind of tcivilizatio~ we arelearning to mistrust. Wheretowns are salubrious,reasonablyaffluent and can offer goodjob opportunities there seems be no point in attempting to keeppeople out of them. Where to towns are overcrowdedand unpleasantand unhealthy, then anyoneinterestedin the overall health of a rural community wilI want to offer to members that of community good reasons not leavingthe community and goingto the towns. for This meansproviding an income equal in overall terms to that availablein the towns, and distractionsthat at least equal the apparentdistractionsof the towns. Sports,agricuIturaIImprovementsand the encouragement local crafts and of manufacturingare all that one can suggest. Weshould think about thesesubjects and attempt to extend the range. In many countries theseproblemsand the possibility of dealingwith them must seemmany yearsaway. In others.however, action can be taken now. R6bIems in the future : ongtiing case Rural health services needat least ten yearsto reachmaximum effectiveness, wiIl which givesten and probably twenty yearsto copewith the bonesof the problem. During this time communicationsshould improve and the overall picture will alter generahy. But specificahy,asthe lesscomplex aspects the health problem are of dealt with, the generalstandardof carewill haveto rise. Training programmes must look forward to this happening. As child health and family planning maketheir impact, the problem for Health Centreswill shift from maternity and child careto more standardadult problems. This shift must alsobe anticipated. Further, ascommunicationsimprove so the posting of patients to larger hospitals becomes easier. There canbe no doubt that the District Hospitalswe are looking at may be small and could at least double in sizebefore becomingat ail unwieldy. They should be plannedto accommodate expansion,and doctors should be this trained to work in this kind of hospital. Reducingfamilies and increasinggeneralhealth breaksthe poverty bondsthat stick families together. This, classically,resultsin a movementto the towns by the younger people,leavingincapables,the aged,the infirm and the mentally disturbed zeF,e handsof the community. What will be the District Hospitalsresponsibility Will Health Centrestaff be trained eventually to copewith this problem of changing socialstructure? Will the relianceon the Health Centrefor so many forms of guidancewe are encouraging lead to an emasculated population unable to cope with its own problems? It seems likely that the Health Centre should disengage to someextent from the population it serves the quality of health careincreases. as The current tide of opinion in favour of Health Centresmay possibly be seenasa passingphase. The success the Centresshould lead to their progressively of losing importance. The next phaseis the extension of our thinking into making an on-goingcommunity health carestructure. This is a complex subjectmuch involved in politics. But it seems worth while askingif there is anything we can do now to ease into this next phase. First, there is the expressionof the community asa community - the making of asocial environment to which one not only belongsbut of which one is proud. The socialareais the beginning of sucha transfer of community from a ritual to a more formal basis. Immediately one must think of a Youth committee whoseuseful object is to engage maintain the interest of schoolchildren in the and kind of serviceto the community to which we hope they will becomeconditioned. Thereis also a responsibility in food growing. Well managedcropsmeancash,cash is mobility. Mobility is important in a society changingfrom a family structure!to agriculture can be improved,but making an individualiitic structure. Subsistence peoplestick to fairly hopeless land wherethere is an alternative is not acceptable. A national layout of he&h facilities should rightly take account of possiblerural resettlement.

Appendix 44 (ctd.)

I I

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. :

i 3.

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(xviii)

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Tlii designof simple operating thutres It is commonknowledgethat the ideal operating theatre is a new table of somesort in a fresh sunlit field on a cool summerday, using new instrumentsand apparatus and throwing everything away at the end of the-procedure,moving to a new field for the next procedure. Eachsuccessive patient in an operatingtheatre is a dangerto himself and the next patient, and is exposedto infection risk from the previouspatients and the staff, the goodsin the theatre, the fabric of the theatre itself and the air. The more theatresthere are in a group, the more complex the layout, the-greaterthe risk of infection, crossinfection and re-infect!.an. The ideal theatre doesnot exist. The best theatre for an unsophisticatedhospital is an easilycleanableroom with good crossventilation from a non-infected area, well separated an open lobby from infective sourcesbut closely related to an by areawherepatients recoveringfrom anaesthesia surgerycan be visited by the or anaesthetistor his equivalent without breakingwhat the organizationin question decidesis a reasonable safescrub routine. and Traffic in and out of the room during a procedureshould be kept to the absolute attendantswalking from theatre to theatre with a jug of minimum. Onesees sterile water topping up bowls. This is a lethal practice. One sees floor the sparselymoppedwrth a mop from an inadequatebucket of disinfectant between procedures. No mopping would possiblybe preferable. One sees conditioners air recycling air through filthy filters, concentratingand broadcastingorganisms through the unit. If air conditioning is usedit must be very simple,the plant must be duplicated againstbreakdown wherethe plan relieson the air conditioning, the air must o&-be usedonce and drawn from a clean source(just abovethe roof or at the eaves very wrong - wind pressure is causes concentrationsof organismsin theseareas)and the air conditioners must be kept going all the time at low speedso that organisms cannot get into the ducts and breed out of hours. No air conditioning is infmitely saferthan an incompetent amateurinstallation. In particular, air conditioning cools the building fabric. Whenthe machineis turned off there can be bad condensation. The bestpossibleoperating room in a small hospital or Health Centrewill stand more or lesson its own in a cleanpart of the site, weBsurroundedby air that will disperse incoming and outgoing infections. An acceptable method of cooling is a moveablefloor-standing fan outside the theatre blowing in through the window in the samedirection asany breeze. A reasonable for a theatre is 15 feet x 18 feet, a good size 18 feet x 18 feet; size 20 feet x 20 feet is a big operating room. 10 feet is a good height, and the height for which most lampsare designed. Quartz iodide lampsare cooler than traditional supporting lampsfrom high cool ceilingscatch dirt and infection. lamps. Beams Big spreading overhangingroofs outside the cleanablespace promote a large will shadevolume and makea cooler theatre. Anti-static boots arebetter than anti-static flooring asthe latter, in alI its forms. is difficult to lay. Anti-static flooring plasticsmay not stand up to rough wear in primitive practice. High humidity rendersexplosionsunlikely. Well laid terrazzo is very satisfactory,but denseand well laid cementscreedwith a proprietary antidust additive is easyto repair and replaceand can be ripped up if not satisfactorily walls and ceilingswith washable laid in the ftrst place. Smooth cement-rendered good quality paint are very acceptable. Tiles havejoints which get dirty. Very finely jointed marbleis availablecheaply in somecountries. This makesa good imperviouswall finish, but it must be put up with no hollows behind it (fmd out by tapping with the knuckles and listen for a hollow sound) and should be thoroughly testedfust with the proposedcleaningcompound. Sterile suppliescan safely comein simplepacksin linen on cafeteriatrays providing there is a pressure-steam autoclaveto the specificationsnoted in Appendix 15 on a sterilizing. They can be carried in this way safely and over reasonable distances autoclavea flash sterilizer (see but must be kept dry. If there is no pressure-steam Sterilizing Appendix) can be usedbut wrappedgoodsare safer. If there is no autoclaveof any sort a large stock of infrequently usedinstrumentspreparedwith very great caremay give adequateresults,but proceduresattemptedmust be kept uncomplicatedand well spaced,three or four in a day probably beinga maximum

APPENDIX 45 THE DESIGNOF SIMPLE OPERATINGTHEATBES

in any given room. A doctor visiting and anticipating he will haveto do operations could carry hospital preparedtheatre packswith him. With carevery few instrumentsare needed. Thesenotes may appear to be offensively simple, but if there is almost nothing to go wrong lessthings can go wrong. Modem operatingtheatre Jesignattempts to pack lots of theatresinto a manageable with the object of feeding. of area lots patients through the systemwith an acceptableinfection rate. Thesecriteria 6re totally irrelevant in Health Centresand rural small hospitals. Isolation, good natural ventilation from a cleansource,radical simplicity and commonsense the principle featuresof unsophisticatedtheatre design. are

Appendix 45 (gtd.)

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APPENDIX 46 PRODUCING, HANDLING AS&&G STATISTICS

:.

population density of Figures.in themselves be !true or not. The average may *somewhere 180 peopleto the squaremile may be true if the count was is right, if the areawasmeasured right (did they Include lakes?)and if the mathswas done correctly. Gnly in the broadestterms is the figure any use. Weneedto know the proportion of urban againstrural population, any virtually uninhabited areas their sizeand how many big towns there are before the figure becomes and population density of truly use&I. Setting up comparisons useful. The average is somewhere 180 per squaremile, and somewhere which is similar geographicis else ally is only 105: if the readerknows one he knows a lot about the other from the a economy,hasan average simplefigures. Alternatively somewhere, grasshrnd rumI population density of 10 personsto the squaremile whereassomewhere else, a plantation-economy,has 105 average rural population density tells us a great deal that could be useful without referenceto the countries concerned. Facedwith the lack of the most basic organizedstatistics for all the countries where the Model might be usedthe working party hasevolvedthe macro-unit to cover a big enough areaand sufficiently widely varying population densitiesto make the theoretical planning exerciserealistic (see Appendix 44). Welist at the end of this Appendix the kind of generalizedfigures we haveused,or, in somecases, guessed a . Wehavefound it encouragingthat the auxiliary basedHealth Centre network we discuss respondsto changes situations in a way which traditional hospital in ( basedcaresystemswill not. Wehavefound that somestudieswhich would, we thought, be helpful in putting together a Iist of usefirl figureshavenot beenhelpful. Too often the studies, howeverwelI intended, havenot beenplanned or published in a form which stands questioning. It is no good setting out to study The Effect of Auxiliaries on Health CareDelivery. The study would take far too long and is lacking in definition. A study of four samesizedareas with similar problemsof malnutrition and similar populationsto comparethe effectson the problemsof malnutrition introducing: 1. a hospitat basedsystemto areaone 2. a mobile clinic systemto areatwo 3. a resident auxiliary to areathree 4. leavingareafour without care (in order to establish control conditions) the comparison to be made with reference to cost (which is taken to include...........), to efficacy, which sh& be judged against improvements in ............. deficiency and apparent number of new cases of the following diseases................ and with referencti to long term benefit over the next ... .......... yearswhich doesnot form part oi thi: presentstudy but hasbeenallowed for i planning the study is preciseif complicated. Sucha study would have to indicate why the areaschosenare similar, wou:d. haveto defmecost (doesit include costs of training personnel?) Whatthe current deficienciesare (not might be) and how the diseases are to indicate progressare to be categorizedand what constitutes that a new caseand what the incidenceis at the beginningof the study in all four areas. The method of treatment should be the samein eacharea,asshould teaching methodsand the methodsof collecting information. Specially cleverpeople and extra specialefforts and equipment should not be used. The study is set to test the comparativeeffectiveness auxiliaries in the community asopposedto visiting teams of or hospitals. All three groupswould have to do everything in their areas- not just dealwith nutritional problems. The study would cost quite a lot and would hwe to nin for at least two years,but at the end of the study clear if limited answers would be available.

The study outlined abovemight haveuseful sideeffects. It might be found that the hospital and doctor orientated areasdid much better with someconditions and not so well with others. This might indicate the lines for a further study, but should not confusethe limited aim of the study. The answerto the study might be that resultswere equally good in the chosenfields but that the audiary did the job at a much lower cost. This would, in the terms of the study, show a preference for the auxiliary. If, on the other hand, the auxiliary did desperatelybadly on other matterssuch other mattersshould be reported in the published resultsso that the readercan havea chanceof interpreting the results. Another kind of statistic we havemet is Fluctuations in admissions hospitals to by age,disease throughout the year. Such figuresare very Interestingif you etc. know the country, how travel is affectedby rains,when is seed-timeand when is harvest,when are most children born, is there a migratory population etc. This

1.

_ r

kind of statistic should be the starting point of a study entitled Would treating the ..following conditions ...... at village level stop the annual peak of hospital admissions ~ in suchand sucha place and culture and would suchprior treatment be more or lessexpensivethan dealingwith the peak at hospital level. Doctors in hospitalshavetraditionally set out to treat almost every known condition. Only facilities and qualifications havelimited the rangeof work that canbe done. It hastherefore beenpossibleto build a hospit&and open its doors to whoevercomeswith whatevercondition. Auxiliaries wiIl havemore liited aimsand facilities. Whena new Centre b openedit is very important to. set clear aimsfor it. Unlessclear aimsare set it will not be possibleto judge ihe Centres effect. Within eachset discipline measnrableaimsare needed,and the possible effect should be assessed before the Centre startswork. If a detailed prior surley cannot be carried out, then an experiencedpersonor teammust sit down and list probableproblemsand possiblesolutions and meansfor putting the solutions into effect. The costsand resources shotdd be listed and numbersof staff and their appropriatetrain@ estimated. Theselists then form the statistical basisfor the 1 future internal evaluation of the scheme- is it running behind or aheadof forecast? Ideally a schemeof a different sort servingthe samekind of population will be recordedand analysedin very much the sameterms. Given theseconditions it is possibleto ask are we doing all right, are we doing the right thing, and perhapswe ought to try so and so? Unlessstatisticscan servethesepurposesthey are not much use. Finally, statisticscanbe bent. The bending canvary from auxiliaries 100 per cent successful surgicalwork (what were they doing?)to major study revealsthat in auxiliaries causedmore deathsin certain fields than malnutrition (what fields brain surgery? or how doesan auxiliary causemalnutrition? or doesan auxilia not trained to removeappendixescausethe death of a patient he cannot treat? 7 Insufficient information is given. Graphscan alsobe usedto makepoints that do not exist or elsethe graphitself can be describedasopposedto the subject. Thus a graph showingsmvivaIrateswill dip when deathsincreasein number and frequencygiving the possibleinterpretation l kiIler disease dramatic drop shown in Ministry tables. Similarly, a graphwith two lines, one showingnational birth rate the other specific treatmentsgiven could lead to treatment fails to keepup with growing population when the fact is that progressivelyfewer treatmentsare neededbecause condition is well under control. Graph scales alsobe used the can to dramatic effect. This is shownin Fig. 1 following, where the last 20 items in say 10,000causea dramatic rise. Fig. 2 puts the samerise into proper perspective. The statisticsgivenin this Appendix are very broad indeed. Wehope this wiIl makeit difficult ta prove things with them that they were nevermeant to prove.

Appenoix 46 (ctd)

j. ,~ ,. II. >,I :.: ..

10,010 10,005

1972

19j3

19$4

1972

i9i3

1674

Appendix 46, Fig, 1 Dramatic Rise! achievedby starting at 10,000,then going in fies.

Appendix 46, Fig 2 The truth behind the Dramatic Risein Fig. 1.

(ii)

somegatemlstatistics 1. Sizesof Health CareBlocks Iudia from 80,000 - 200,800 people dependingon density N&es+ (1965) 1 dispensaryper 15,000 - 25,000 people 1 maternity home per 30,000 people 1 leprosy village per 100,000 - 300,000 people 1 Centreper 20,poOpeople 1 district group per 200,000 people

Appendix 46 (ctd.)

llllareport 2. 3.

Sizeof population seenby auxiliaries in Health Centreswhosereferralswill keep one doctor acting traditionally busy - 50,000 Acceptabletravel distancesfor patients to Health Centreandhospitals: This leport Zunbh to Health Centres,5 miles in reasonablyopen, reasonably flat countryside to hospitals 1 patient in 2 from 3 miles average distance 1 patient in 3 from 4 miles average distance 1 patient in 5 from 12 miles average distance 1 patient in 17 from 16 miles average distance 1 patient in 46 from 23 miles average distance 90 per cent of patients camefrom within 20 miles 8 per cent of patients camefrom within 30 miles 2 per cent of patients camefrom within 100 miles (most, but not all, were referrals)

4.

Travel& speeds lllis report Allowing six hours for referral trip by availabletransport: Walkingat 3 milesper hour - 18 miles (very good walking!) Bullock cart, 3 miles per hour - 18 miles Vehicle - 30 to 300 miles dependingon roadsetc. Wherethe terrain is very difficult thesefigureswill be very much reduced. In high altitude mountainous country in a cold season three miles might be an impossiblejourney for a sick personon foot. Biver travel will dependon craft and current. Travelling down a swift flowing streama canoeor dugout may achieve12 - 15 miles per hour but might find the return journey impossible.

5.

Population distributions Generalized Developingcountries - urban 25 per cent rural 75 per cent - urban 75 per cent rural 25 per cent Europe

6.

Age distribution Generalized Developingcountries: under fives five to fifteen adults Europe: under fives five to fifteen adults under fives five to fifteen adults 5 per cent 15 per cent 80 per cent 40 per cent 15 per cent 45 per cent 20 per cent 25 per cent 55 per cent

7.

Attendancesand Admissions Outpatient attendances typical Centres: at approximately 10 - 15 per cent adult mate adult female approximately 30 - 40 per cent children including under fives approximately 40 - 60 per cent Inpatient admissions typical Centres: at adult mate approximately 5 per cent adult female approximately 70 per cent children including under fives approximately 25 per cent Thesefiguresrevealthe bias to maternity and child carein existing Health Centresand should prompt hard questionsabout training and intentions. Attendancesat urban hospitals in developingcountries: 25 per cent adult male adult female 30 per cent children including under fives where suchclinics 45 per cent Nn Admissionsto urban hospit& in developingcountries: adult male adult female children in&ding exist
l

Appendix 46 (ctd.)

30 per cent 48 per cent under Bveswhere adequatefacilities 30 per cent +

This figure can be very misleading. Exported Westernpractice takes little account of children, with well under 20 per cent of the population qualifying for a potential placein a childrens hospital (seesection 6). in somedevelopingcountries about half the population arepotential childrens bed occupiers. 8. Proportion of patients seenat hospitals that could havebeendealt with by auxiliaries if seenearlier. lndia (Contact, 17th October 1973) Outpatients + 50 per cent Inpatients + 45 per cent N.B. Thesearehospitalsunder great pressure. Also note that this study, as published, did not defmeeither what the auxiliary wasto do or what proporuon of those,diseases which auxiliaries could have.treated earlier (called preventable)could havebeenfurther reducedby sanitation projects etc. But note further that approximately 50 per cent (in very round terms) of the patients going to the hospital needed,in the terms of the study, to see a doctor. Given a wider spreaddiagnosticnet more doctors cases (called non-preventable)would appear. Clearly hospitalsare of vital importance unlessauxiliaries are to be given wide rangingskills. Conversely,some authorities claim that curative work in hospitalshasonly a negligibleeffect on national mortality figures,quoting figuresas!ow asone-and-a-half per cent which is ridiculously low when set againstthe cost of the hospital serviceand the figuresquoted above. Wheredoespropaganda and fact end begin? 9. Ratios of doctors to patients Generalixed world-wide better off countries worst off countries 1:2500 1: 1008 1: 500,000

Thesefqures are often usedto show the imbalanceand injustice of the worldwide distribution pattern of doctors. Whetherthe facts are fair or not, it is certain that many countriesmust either acceptnil effective health delivery or go for an auxiliary system.

10. Redsper 1000 population: world-wide better off countries worst off countries - 2.5 to 3 bedsper 1,000 - 8 to 9 bedsper 1,000 - 0.5 to 1.5 bedsper 1,000

Appendix 46 (ctd.)

Bearingin mind the admissionfiguresgiven in 7 where 70 per cent of Health Centrebedsare essentiallyfor maternity work and bearingin mind that the worseoff countries tend to rely on Health Centresit %viSl seenthat the be fact is much worsethan the fmres reveal. Somethinglike 5 per cent to 15 per cent only of the bedsper 1000 shown will provide for the adult male population. in thesecountries there is no possibility of a hospital based carestructure. 11. Training times in developingcountries 6 - 7 yearstraining from 18 yearsold 5 - 6 :/earstrainii from 16 yearsold 4 yearstraining from 16 yearsold 3?4 yearstraining from 16 yearsold 3 months to 1 year training from 16 yearsold - Doctors - Nurses,Radiographers, lab technic& etc. - Midwives* - Assistantnurses - Junior lab. assistants, auxiliaries etc.

*Midwife training is beinglengthenedin many countries at the presenttime. Doctors training doesnot necessarily meanfully qualified. It is very difficult to believethat 7%months average training from 16 years will adequatelyqualify an auxiliary. Principals in this report are experiencednursesin most cases, with a five or six year training.

SettinguPaCentre Traditionally, governments providing health facility buildings tend to sendofficers to a place(possibly having askedsomequestionssometime before) to start erectinga-building., Whenit is fwed the equipment arrives,then the staff in arrive and open the doors. This approachis wasteful of the human resources the neighbourhood. -It clearly makesbudgeting more diicult if local people are going to help, but it se&s doubtful whether the extra administrative costswhich may arisewill exceedthe possibledirect money saving,and it is probabld that this early constructive involvement will form a good basisfor future co-operation essentialasthe betweenstaff and patients. This kind of co-operationbecomes emphasis shifts from curative to preventive and community medicine. Staff can get a Centmgoingwell before the buildings are completed. Early local contactscan be made,the schoolshaving a particular role to play here, and the staff can get to know the district and its problems,meet agricultural advisers and establishcontacts with the local hospital if one exists. Ideally we wouldlike to seesomeof the eventualstaff starting right in at the beginningof the.project. To this end the following noteshavebeenprepared bearingin mind peoplewith restricted building experienceand limited access to professionaladvice. As somepeopleworking for non-governmentbodiesmay wish to establishCentres,the notes go into somedetail.

APPENDIX 47 SETTING UP A CENTRB

You will be working with, or will need, the following: Exist@ Public Health Services Agricul~ Advisory Services ~he&aal Structure and the Community Knowledgeand understandingof the problem Eples to be adaptedor followed Building materials Water Beads Bridges Accessibility Money
Avoid

Too small sites- seeAppendix 41. Siteswith a high water table, that is to saywith standingwater in the soil to within two feet or three feet of the ground surface. To test for this dig a hole in the wetter season when it is raining) and seehow it iills up. Drainageis (not a problem with a high ground water table. Sitesthat will or may flood. Sitescloseto an existing fly sourceor, for instance,just downstreamfrom a village latrine point. Sitesunduly shadowedfrom the sun by.hills. Sitesnear the most difficult river crossing. Disputed land and land which is unacceptablein the local culture. Siteshemmedin with hills wherea radio-telephonewould not work. Inaccessible sites,howeverjolly the view tfrom just a little higher up. At a centre of communications. Associatedwith an organizedvillage with a clear social organization,a sense of responsibility and a school. Slightly elevated. Well drained. Havinga good water sourceor possiblecatchmentor piped water. With a good disposal,burning and possibly a sewage treatment areadown the prevailing wind. With its longer axis suited to the layout proposed. Big enough for an airstrip if possibleor near a pieceof road that can be usedfor this purpose. With access mains electricity if available. to (0

Appendix 47 (ctd.) Whenresources money - need_- staff - havebeenascertained: 1. Work out site size 2. Sketcha plan and put sizeson it in generalterms; usesquaredpaperfor this and allow 20 per cent minimum over what seems be a good size. to 3. Look for a good centre of communications,or at least the best available- do this on a mapwith someone,anyone,who knows the catchmentarea. 4. Rough on to a map approximate population spreadand density. Inspired guesswork better than siting a Centreby a stab in the dark. is 5. Go to the areathat seems be best and review the vihagesand the people, to the chiefs,the schools,the local agricultural advisers. 6. Choosea reasonable in or by a village that is somewhere site nearthe bottom of a list of villagesheadedby the niast and best run village, but one that you think will be reasonablycooperative. The best villageswill help themselves 7. Checkfor water resources, then work back up the list of possiblesitestill you find adequatewater by drilling, by spring or by run-off and storage. 8. Useany local adviceyou can. 9. ebe; land ownership,cost and availability, then havea meetingwith the

ThefimtsltemeetillgThis is to be a community effort and a community responsibility. Havingmadea preliminary selection of the site, the possibility of a Centreshould be discussed with chiefs, teachers,agricultural advisers, other leadingmembers and of the communities. It may be advisableto include any folk doctors in these discussions, it is clearly extremely important that any representatives the and of governmentin the areashould be fully informed of what is going on and should be given every chanceto comment. The ideal object of this site meetingis to get the local people actually to ask for the Centreto be in their area,to tell them in simple outline what the Centrewill do and what the community must do and to leave ~~r~fmation in somesuitable form for the local community to discuss . . . You should then take home with you answers questionslike How much does to the river flood? or How much rain can be expected? Ideally you will know the areain wet and dry seasons. At this stageyou should also stressthat the Centremay well be built, not that it positively will; you should avoid promiseson programmes you possibly can. if Few communitiescanmaintain long-term enthusiasmabout a project which is to in them highly theoretical. There is perhapssomeadvantage getting things moving on the ground at a comparativelylate stagewhen you are sureof finance, staff, programme,etc.

Following initial site selectionyou must establishlegal ownershipof land, costs, availablemoney and staff, plans, equipping, availability of builders etc. It is suggested at this stageyou can usethe Model plan or part of it. Whilst that it may not be what you intend to build, it givesyou somethingconcreteto discuss with government,donors,builders and friendly peoplein the medical and building designprofessions. Whenyou know more about the project, you should return to the site againand give it a cold reappraisal seeif it really suitsyour needs,which you should be to beginning to know in very much more detail. Implementation of the projzct Havingworked out your requirementsfrom the Model plan and having decided either to usethe Model or having drawn up your own version,it is time to return to out the site and work up local enthusiasm. The site should be pegged and cleared; leaveasmany good treesaspossible,remembering that somevery attractive large old treesmay drop brancheson your new building. Clearly this setting out should (ii)

: :: .) bed&e with local help. The social area-a&the host&ma, whitiare very much the cCuhunitys contribution, should be given prominencein theritual of setting 2, . out, aitd.it is important that an adequateappmachroad,be&ured. The sinking 7. of wells, the drain@ of land, and the diggingof sewage lines canwell be put in ha&early asthey requirelirnlted technology and arevery visible achievements. 2,. I If water is to be collectedby catchment,the catchmentareamust becleared and suitably prepared,and cisternsor water towers erectedearly aswater will be needed during the building process.
-;.-.-.

$;..

__

Appendix 47 (ctd.)

Wehavesited the store on the&de1 plan at the entranceto the site so that it is easy. get at without having to go through what maywell be a rather muddy site, to and suggest this is the i%st~building that that should be built ascement,building materials,block process@etc. can be stored.securelyand dryly. Additionally, if mud bricks are being used,they must be stored out of the rain. If e building period is to extend through a rahry season, shouhl programme you pessmMdy so far asworks in the ground are concerned,otherwisethe soil in trenchesgetsvery wet and losesits strengthleadingto later subsidence foundof ations and the cavingin of trenches. The following sequence building hasmuch to recommendit: of 1. Securedelivery of cementand stones,dig foundations, lay in foundations and stonesover the areaof the building putting smallerstoner on top and fm with cement. This initial Mshing cementcan be quite thinly and-unevenly spreadproviding it hasa reasonablysoundtop surface. It doesnot matter if it cracks. Do not forget to put into the groundwork any pipesthat you need for electricity, water and drainage. 2. If you are going to havea steel or wooden framebuilding, makethe small bases stone,brick or cementon which the columnswill standup to their in prreew&.~ards the end of theseworks securedelivery of the frame . 3. Now erect the frame and the roof structure and put the roof on. If you are going to hold the roof up with walls and not columns,usetemporary timber or bamboostruts to hold the roof up and completethe walls up to it later. From this point on the building sequence very much a matter of choice. The is following points should be borne in mind: 1. If concreteblocks areusedthey benefit greatly from being soakedin water for not lessthan three weeksand if possiblelonger, the sameapplying to pm-castreinforced concretelintels over doors and windows. 2. If you are using a cementscreedfloor, lay it on at least two inchesthick and preferably thicker, lay it all in one go, and turn the edges asa skirting not up lessthan four inches. As soon asthe cementis reasonablyhard, pour water over it to the full depth of the skhting and leavethe water for at leastthree days and preferably longer. This cures the cement. You will obviously have to block up outside doors to stop the water pouring out and you will hazeo build internal partitions to at least skirting height beforelaying the . 3. All timber should be treated with an anti-insectfluid. It is essentialthat a coloured fluid be used,and if the only availablefluid is clear, then put ink or dye in it so that everyonecan se-e what hasbeentreated and it becomes unnecessary ask. Wherethe endsof timbers are being built into the walls to it is necessary standthe timbers on their endsin buckets of preservative. to 4. The Building Research Station in Englandhassuggested a concretesill that sticking out all round the building, six inchesto nine inchesoff the ground, protruding four inchesor five incheswith a substantialrounded groovein its under side, will discourage termites. 5. No wood should be left in the ground. 6. Drains at ground level round buildings that do not have gutters are essential asthey catch water nmning off the roof and stop it churning up muddy (iii)

puddles. If the precast concretevariety, common in most countries, or someequivalentlocal product cannot be afforded, lay bandsof stonesand. gravelaround the building in trenches,the bottoms of the trenchessloping away to soakpits or surfacedrains. 7. Whereyou thh3k there will be a lot of traffic on a particular line, there is much to be saidfor laying someform of hard surfacein wet countries. A simple form is a trench with a crossslopingfloor filled up with stonesand gl?ivCl. 8. If you havea thin roof material you must ventilate the roof space,and aluminium faced foil, either plastic, paperor thin metal sheetshould be laid over the top of the ceiling. This reflectsheat very ef%ciently. Insulation, suchasfibreglassquilt, unlessit is foil-backed,is unless. Occasionalboards should be laid over the foil so that dust can be swept off it periodically with a feather duster. Whereclimateshavea wide rangefrom hot to cold, insulation to keepthe heat in will be necessary during the colalseason. The ideal material is foil-backed fibreglassquilt over the ceiling foil tide up. Fly screeningto keep out insectsand birds, bats, rats and mice, must be put up to cover the ventilating slots at the eaves.

Appendix 47 (ctd.)

In generalterms the most important thing to achieveis community co-operation. This will cut the initial and maintenancecostsradically and lead to a more meanmgfuldelivery of health care. In practical terms,the most important r-son is the builder or the personin chargeof the building work and unlesshe is or viously a rogue,his adviceon structure, timber sizes,drainageetc. should be soughtand followed. The sooneryou can get the builder or building supervisorinvolved in the plannhrg stage,the better.

Orientation of buildings, their construction and environmental considerations

Appendix 48 Orientation of buildings, their construction and environmental considerations

Appendix 48, Fig. 1 The main futures of a building in a hot coulltry

nin water channels under ewea

Appendix 48, Figs. 2 and 3 Alternative meansof roof support

Fig 7. Roof supported on welts ,/ , /

Fig. 3 Roof supported on columns

(9

Appendix 48 (ctd.)

Many stmplc materiats such as bamboo or .. otner types orwooaen pole 9 span up to 16 feet. but not much rmc

H\\

Appendix 48, Fig. 4 sizesand mate* for simplestNctum

Fxg. 4

16 fior

\ 5 mb, 4 -\ _-c-

_I -16 ft. or 5 m.

Jc,\

Attern+~ly fairty rimple roof trusses can be made u to span longer diitances. Trusses coat more and nquw more rkiU to construct. The simplest roo P truss will give a span of about 24 feet, 7 metres which is not realty sufficient for a more complicated building. A truss can have an overhang c beyond the supporting column or watl.

Appendix 40, Fig. 5 Roof trusses

Still 16 ft. or 5 m. \ to. the next column \

If buttdIngs am being mass Produced, steel trussaa which will span 32 feet 10 metros, will *PlifY construction, but witi be more expensivefhan local building methods.

(ii)

DimenslonEi in the Model

The Model is designed with columns every 16 feet along the cutside walls and is 16 feet or 32 feet wide. Wallscould be put in instead of columns. The clinics. building is 32 feet wide, the wardsand central facilities are 16 feet wide, as shown in the diagrams below. Trusses not needed. are

Appendix 48 (ctd.)

Fig. 6 Wards

Appendix 48, Fii. 6 and 7 Dimensionsin the Model

Appendix 48, Fig. 8 An examination room

Fig. 8 The size chosen for the Model givea a good aizs examtnation room. Ch tkb she?& the whir are rhown buiit into the walk

(iii)

, ..--

Appendix 48 (ctd.)

Fig. 9. 16 feet generous room down one aide p;rz for

gives a very width for beds only. but is beus down

0\\ n
Appendix 48. Figs. 9 and 10 Spacingof bedsin the wards

Fig. 10. If one wail is put outstide the columns then the beds can be put on both sides. omitting beds where necessary.

\ HY

If it is necessary to move the WAS ou@vards the roof must be extended. This makes the building more complicated but the diagram below shows how this can be done whist still using simple materials.

Appendix 48, Fig. 11 Roof extensions

Extensions can aiso be made at a leaser angIe than the matn roof to give better height at the outer edge

Fig. 11. The edge of the roof can be pulled out to give extrashade or extra s ace inside as required in %- 10. lg. A row of small extra columns wiU be needed to carry the extension.

(iv)

Appendix 48 (ctd.)

Fig. 12. A ceiting with a ventilated space over it makes a building very much cooler. Aluminium foil laid over the ceiIing supports reflects heat very effectively. The celling adds to the cost but makes a big difference to living and working conditions. Good ventilation of the roof space above the ceiling ts essential.

Through ventilation of roof space /I

Fiymesh is necessary to keep out birds, insects, rats and bats

ceiling can be of board, whitewashed At I&t 9 feet high, more pmferred

Appendix 48, Figs. 12 and txllngs ,

Scmening may be necessary where small rooms abut a bigger space

srea Examination
room \ \ I--

\ \ \
%

Fig. 13I. W_hereB big space abuts a number or smaller room&as in a clinic, screening may be necessary to 1 xoteci the-ceilings of rhs smaller *cw?--

Appendix 48 (ctd.)

Fw 14

Roofs may be :or asbestos sheet at about 15 degrees pitch; tiles at 30 to 35 degree pitch; thatch. either on its own or laid over metal sheettng. This is cool and stops rain noise.
Zinc, iron, aluminium

Appendix 48, Fig 14 Materialsusedin construction.

Floors tg; %IIa $a.;.bL :concrete block orebnd mud inud and c&tent blocks woven bamboo, painted wattle and daub Wmdowa may be metat or wooden framed, louvrea or wooden shutters.

be :-

cement beaten earth mixed $;ko;tnent, rf money

\\ \ Q
pmniliag wind A number of buildings should be laid out in parallel rows running esst and weet, L and U sbgped buddings and square buildings do not gtve the best conditions for venttlation.

Appendix 48, Fig 15 Orientation and ventilation

Fig. 15 I

0 I I I I 1 1 I

Ideally the buildings are aligned east and west, facing north or south, and have a north or south prevailing wind blowing through. In the tropics the east - west alignment is most important to keep the sun out, but a compromise in alignment may be desirable in order to make use of the prevailing wind for ventilation.

I A building facing due west suffers the most severe exposure to the sun.

(vi)

Shadeand environment Unlessair conditioning or other artificii cooling is installed, shadetemperatureis the iowest temperatureadable. Treesplanted round the buildings increasethe shadepool, but they can encourageinsects. Grassround the buildings stopsthe reflection of the sun into them, but it must be kept well cut io discourage insects and animals.

Appendix 48 (ctd.)

Through ventilation

Fig. 1.6. Where the need for rooms makes it necesmry to build on both sidea of a central corridor the buikliog will bo poorly ventilated. Ventilation will be tmoroved bv towing an unenclosed spice bore ind the& to givo through vonti.lrtton.

Appendix 48, Fig. 16 Through ventilation

The Model Plan is basedon a very simple structural grid Of 16 feet by 16 feet so that simple materialscan be used. The choicebetweenwalls or colunms, whether trussesare to be usedor not, the selectionof materialsfor roofs and walls etc. can only be madeafter seeingwhat is available in a given place. There is a detailed drawingat the end of the report showinga roof structure. The dimensionsshownare for middle quality sawntimber. Poor timber will haveto be bigger. Good quality timber could be smaller. A local carpentershould know the strengthsof his own kinds of timber.

(vii)

General
A collection of erticlos, including all CONTACTS (CMC CUSCO READINGS @UHEALTH. paper) related tobasic health care and incorporating project reports. Compiled by Canadian University Service Overseas. (151 Slator Street, Ottawa, Canada KIP 5H5) 1973. Sections II - IV inclusive are particularly relevant. Topics included are: nutrition; hatornal and -;lild health; family planning and population control; education and training projects. COMMUNITYHEALTH GD THE CHURCH. Edited by J.H. Hellberg, MD. Christian Medical CornmIssion. (World- &ouncil of Churches, 150 Route de Ferney, 12 I 1 Geneva 20, Switzerland), 1971. HEALTH AND F DEVELOPING Ithaca h London, 1969. * MEDICAL CARE IN DEVELOPING University Press, 1966. WORLD. By John Bryant, MD. Cornell University Oxford KhuriPress.

Appendix 49 Reference readingin didion to a Model Redth Centre

COUNTRIES.

Edited by Maurice King, MD.

Description and analysis by Salwa FAMiLY SERVICE CENTRE PROGRAMME. Otaqui, MD. Near East Ecumenical CommIttee for Palestine Refugea, 1971.

AUXILIARIES IN HEALTH CARE PROGRAMMES IN DEVELOPING COUNTRIES. By N.R FendelL John Hopkinn Rem. Baltimore and London. 1972. (Publlahed for the I& Macy Foundation.) NOTES ON STERILIZATION AND DISINFECTION. (Miaalon Hospital Bulletin No. 38. May 1971). * CLINICAL MEDICINE Y.K. Seedat, G. Daynor. By J.C. Kelasy and I.M. Manaor

IN SOUTHERN AFRICA. By G.D. Campboll, Churchill Livinlptono, Edinburgh. London School of Hygiene

SMALL WATER SUPPLIES, Bullotin No. 10. The Ross lnatitute, and Tropical Medicine (Keppel Street. London WClE 7HT). THE AR&Y MANUAL ON HYGIENE AND SANITATION

RURAL SANITATION
l l

IN THE TROPICS.

Bulletin No. 8. The Ross Institute.

OXFOkD

POCKET DICTIONARY NURSES DICTIONARY Baiiro, London.

BAILLIERES

byA.E.S. Alcock and H,M. Rlchardr. Longman. HOW TO BUILD SERIES How to bw to size and shape,. Reading Plans, How lo btuld for climate, How to plan your market, How to plan your village.

Nutrition
MANUAL ON FEEDING INFANTS AND YOUNG CHILDREN. By hf. Cameron and Y. Hofvander, Protein Advisory Group of the United Nations Systom. PAG Document 1. 14/26. 1971. For apptication in the developing areas of the world with special reference to homemade weaning foods. CHILD NUTRITION IN DEVELOPING COUNTRIES. By D.B. Jolllffo. Health, Education and Welfare, Washington. D C, 1968.
l

US Department Oxford Univorslty

of

NUTRITION IN DEVELOPING COUNTRIES. Ross. (PO Box 72532, Nairobi, Kenya), 1972.

By Maurice King, MD.

CONTACT NO. 23 - A GUIDE TO NUTRITION REHABILITATION. SCM. Publiihsd by the Christian Medical Commission. Tho tield of nutrition obtained from: OXFAM, is a very extensive ono.

By Joan Koppart. SRN,

In addition to the above, material may be

274 Elanbury Road, Oxford OX2 7DZ. England. United Nations, Villa delle Fermo di University of the West Indies. Mona,

FOOD AND AGRICULTURE ORGANIZATION, CAracalle. 00100 Rome, Italy. CARIBBEAN FOOD AND NUTRITION Kingston 7. lamaica. CANADA/DEPARTMENT Publications 1973. WORLD NEIGHBOURS 73112. USA.

INSTITUTE,

OF AGRICULTURE, (Newsletter)

Information

Division, Ottawa KlA OC7,

5116 North Portland, Oklahoma City, Oklahoma , Federal Extonrion Sorvice,

THE VISUALIZER (Newletter) Washington D C 20250, USA.

US Department of Agriculture,

TAICH NEWS Technical Assiitance Clearing House, 200 Park Avenue South, New York, NY 10003. USA. This material is of background use for specific areas. ENERGY AND PROTEIN REQUIREMENTS. PRIORITIES. April 1973. IN TROPICAL The Journal of the COUNTRIES. WHO Chronicle Vol. 27, No. 11, Nov. 1973.
Christian

Appendix 49 (ctd.)

NUTRITION Vol. XLVIII. *NUTRITION

Medical Association of India Oxford University Press.

By H.F. Welboum.

Maternal and Child Health

MOTHER AND CHILD HEALTH - DELIVERING THE SERVICES. Derrick B. JeBIffe. Oxford UnIverslty Press, 1972. *PEDIATRIC PRIORITIES IN THE DEVELOPING WORLD. Institute of Child Health, University of London, 30 Guilford Butterworth and Co.. Publishers. 1973. By Cicely Williams and

By David Morley. MD. MRCP. Street, London WClN IEH

.CHILD HEALTH CARE. IN RURAL AREAS - A MANUAL FOR AUXILIARY NURSEMIDWIVES. Asia Publlshlng House, 420 Lexington Avenue, New York, NY. USA.
l

CHILD HEALTH MANUAL FOR COMMUNITY HEALTH NURSES. Department of Public Health. Papua, New Guinea. (Published 1956 and revlsed by D.P. Bowler, 1970) PRACTICAL MATERNAL AND CHILD HEALTH PROBLEMS IN TROPICAL By G.J. Ebrahim. East African Literature Bureau. Nairobi, Kenya, 1972. AFRICA.

FAMILY PLANNING AND PAEDIATRICS - a manual of practical OBSTETRJCS, nunagemenr for doctors and nurses. By R.H. Phllpott, ICE. Sapbe, J.H.M. Axton, Family Planning Aasocirtion of Rhodesia. CHILD HEALTH IN THE TROPICS. By D.B. Jelllffa Arnold. 2nd Ed. 1965. By J.V. McNiven and

*AIDS TO GYNAECOLOGICAL REM. Wwne. Bailliere.

AND OBSTETRIC

NURSING.

T&dug and Utilization of Pammel

INTERMEDIATE TECHNOLOGY DEVELOPMENT GROUP - HEALTH, MANPOWER AND THE MEDiCAL AUXILIARY. Cinrral editor Oscar Gish. Published by Intermediate Technology Group, 197 1. Famei1 House, Wilton Road, London SW1 *ABC OF FIRST AID. A manual of instruction with illustrations arranged in alphabetical order. Published for the Brltlsh Red Cross by Educational Production Ltd., London. 1968. *MANUAL FOR VILLAGE Republic of Vietnam.
l

HEALTH

WORKERS. HEALTH

Health Development, WORKERS.

Ministry of Health,

METHODS MANUAL FOR COMMUNITY Health and Welfere, Canada, 1970.

Department of National McGraw-Hill

Bv G.B. Wyatt and J.L. Wyatt. MEDICAL~ASSISTANTS MANIJAL. International Book Company, Singapore. HOW MUCH OF THE DOCTORS WORKLOAD UNICEF/WHO. INDG-DUTCH 1973. CAN BE TAKEN

OVER BY THE A.N.M.s. UNICEF/WHO,

PROJECT FOR CHILD WELFARE. FOR MEDICAL

By Dr. Helen Gideon.

*OXFORD

HANDBOOK

AUXILIARIES:

a) Medicine. By F.1. Wright and J.C. Gould b) Swgerj. By W.G. Kerr c) Midwifery. By M. Fenson d) Anoesthetics. By J. Vaughan Oxford University Press.
l l l l l

NDS TO SURGICAL AIDS TO TROPICAL AIDS TO PRACTICAL NDS TO MEDICAL

NURSING. HYGIENE NURSING. NURSING.

By K.F. Armstrong and N. Jemieson. AND NURSING. By

M.

Ballllere.

By W.C. Frerm. Ballllem.

Ballllere.

Houghton.

By M. Houghton and hf. Whitfon.

Balllierec.

MIDWIFERY MANUAL FOR COMMUNITY HEALTH NURSES. Maternal and Child Health Section, Deprrtment of Public Health, Papua, New Guinea, 1958 (Third Revision).

MANUAL FOR TEACHING MIDWIVES. Illustrated hy A.M. Jonea. Federal Security Agency, Social Security Adtrdnistntion. ChRdrens Bureau. 1948. This book is now conridered Jmost a classic as it was wrttten for nwse-midwives to instruct Alaska and the traditional midwives. It ha6 been adapted for several communities, inChIding is reduced to a mInimum. Captions and illustrations tell the story. Haiti. Use of Ianpage MIDWIVES. By H. Cox. McGraw

Appendix 49 (ctd.)

. MIDWIFERY MANUAL - A GUIDE FOR AUXILIARY HIB Internationel Health BerIes. Singrpom. 1971.

GUIDE FOR THE TRAINING OF NURSING AUXILIARIES IN LATIN AMERICA. SdentiAc public&on No. 96. Pan-American Health Grganixation. Regional Office of WHO, (52 W 23rd Street, WashIngton D C. USA). THE HEALTH AIDE. By J.H. Slotten and A. Elman. Little, Brown and Co., Boston, 1972.

Published by Department of Social MANUAL FOR COMMUNITY HEALTH WORKERS. and Preventive Medicine, Unlvsrslty of the West Indies, Mona, Kingston, Jamaica.

Somesourcesof TeachingAids and Audio-Vii

TALC, Institute of Child Health, University of London,

Material which might be helpful:

30. Gullford Street, London WClN 1EH.

Edited by Langford CATALOGUE OF FILMSTRIPS FOR RURAL DEVELOPMENT. Dantiger. MD, 1971. Order from Peace Corps Development and Training Centre. Eacondido. California, 92025. USA. Prepared by the Food and Agriculture FAO FILMS AND FILMSTRIP CATALOGUE. Organixation of the United Nations. 1968. Film and TV Section, (via delle Ferme di Caracdla, 00100 Rome, Italy). INTERMEDIATE TECHNOLOGY DEVELOPMENT GROUP, Rwal Health Panel, Materials for l uxUIary teaching. Cameron David Morley, publkthad by ITDA Ltd, Parnell House, Wiltop *_ Road, London SW1 , & Q

..a

Recordsand Evaluation

-.s--

EVALUATION OF PAEDIATRIC CARE FROM ROUTINE HOSPITAL RECORDS. By P.N. Swift and P.J.S. Hamilton. Journal of Tropical Medicine and Hygiene Vol. 76, Dec. 1973. OBSTETRIC CARE. An ante-natal record card for use in developing countries. V.I. Hartfield. Tropical Doctor. No. 4, 1973. By Agency

PATIENT RETNNED HEALTH RECORDS. By Murray Langssen. Co-ordinating for Health Planning (c/45 South Extension, Part 11, New Delhi 110049)

laboratory and Dispensary

l

A MEDICAL LABORATORY University Press. TROPICAL DISPENSARY

FOR DEVELOPING HANDBOOK

COUNTRIES.

By M. King. Lutterworth.

Oxford

By C.C. Chesterman.

AN INTRODUCTION TO MEDICAL LABORATORY TECHNOLOGY. By F.J. Baker. Butterworth. A LABORATORY HANDBOOK OF BLOOD TRANSFUSION TECHNIQUES. By A.D. Farr. Heinemann.

* Thesepublications should be availablein the Model Health Centre. The Publisherswould welcomeany information which would improve the accuracy and adequacyof the above list of readingmaterial.

(iii)

Examplesof Diagnosticand Tmtment routines serializedfor usein liealth Qatres Reproducedbelow are two examplesof a method of teachingand reachingdiagnostic and treatment sessions designed assistauxiliaries. Thesesheetsillustrate the to benefits to be obtained from stating a problem preciselyand setting about solving it. The limit to the auxiliaries competenceis set by the send to doctor entries. Thesesheetshavebeenpreparedby and are obtainablefrom Management Sciences for Health, 1 Broadway,Cambridge, Mass.02142, USA. Examples: 1. Severe dehydration 2. Nutrition As the originals usecolour they have beenadaptedfor singlecolour printing in this has report. The originab are easierto read. The series been further refried and developedsincethe examplesshcwn here wereproduced.

APPENDIX 50 Exampiesof Diguostic and Treatment routines serialized for usein Health Centres

Key to symbols : Condition and starting point follow arrow condition bad - abnormality condition good - normal

action, treatment, medicine

condition in question

go to relevantpage

j-\

sendtoorfordoctor

MODERATE DEHYDRATION

.i.
child-care Page I

I Yes
Worse:Stupor, high fever,
1

Got0

Tetracycline ;;e=&lY x 3.

Uncontrolled vomiting (over 3 x per hour) More dehydrated, weight less.

I (no mik except breast) i

-1

* Ge-sol= Glucoseelectrolyte oral mixture (powder madeup to 1 litre solution)

NUTRITION

; Nutrition i examination ---+

i

Meaiure mid-arm circuit (Mac) and height. * Record on chart

-_

Follow-up in 2-4 weeks I Sendto vaccinator for BCG/SPif not pet given

More than 60% I 1 ! ! \ $ Over 80% No edema

Yes

Yes I

Go to appropriate pages and then to 3mmunize

Health, food preparation, dietary and hygiene education ---

Yes

r8cD, vitamin A1 Give iron and

\// Y

No

1 * In domeAfrican countries mothershavekept the card and this hasproved successful

food supplement. Return in one month (earlier if sick)

A description of a small NNI Health Centre This report concentrateson a description of the Model Centre. Wehavenoted that someCentresare run with smallerstaff complements,and also note that smaller Centresare a necessary of the macro-unit (seeAppendix 44). This Appendix part describes small Centre,its staffing, the work it wasestablishedto do, its equipa ment and construction. The description is included without commentbeyond pointing out that more than twenty yearsagothe foundations for modern interest in Health Centreswere being firmly laid. ThesmalIruralHedthCentre In many countries of the Third World, particularly those in which the density of the population is of the order of 10 to 25 per squaremile, a small rural dispensaryor Health Centrehasto provide both curative and preventivetreatment for about 5,000 people. Sucha Centremay be in the chargeof a medical auxiliary who has from one to five yearsof training. Supervisionis undertakenby a doctor or qualified nurseworking from a central can hospital, clinic or office. Few dispensaries count on sucha supervisoryvisit more frequently than oncea month. Drugsand dressings suppliedfrom governmentor missionstores. The variety are available,and Lheregularity of rep!enishment,vary enormously. Accommodation: In an areaof about 6,000 squaremiles in the former Belgian Congo,completecoverage the population wasensuredby a programmeof 18 of central Health Centres/dispensaries, which were attached36 rural treatment to clinics. Most of the former developedfrom small and unpretentious wattle-anddaub clinics, situated in the principal village of eachgroup, and originally servedfor the control of sleepingsickness yaws. They were built and maintained by the and local communities,under the tispiration and supervisionof the paramount chiefs. They weretransformedinto buildings of brick and iron roofing sheets; the brick presses were lent by the missionhospital (the medicalsupervisoryagency)and all local labour wassuppliedby the able-bodiedmen whosefamilies would be the first and obviousbeneficiariesof the Centre. Whenthe CongoWelfareFund was created,grantsweremadefor the transformation of ten of thesedispensaries into rural Health Centres. Population servedat a typical Health Centrewould numberabout 5,000 most of them living within a radiusof five miles. Staff. One infiiier diplome who had had a training of five yearsat the Yakusu Hospital. His wife wasoften an aideaccoucheuse, with a governmentdiploma givenafter a supervised training at Yakusu of two yearsduration. Eachsatellite treatment centre wasunder the care of a helper who had had a training of three months at the Health Centreand regularperiodsof in-training subsequently. Programme. The infumier wasresponsiblefor the implementation of the general medicalpolicy asapplied to the rural areas. This comprised: a) Treatment of commondiseases b) Diagnosisand treatment of endemictransmissible diseases yaws,leprosy, (e.g. tuberculosis,venerealdisease) c) Investigation of suspected cases possibleendemicdiseases typhoid, of (e.g. smallpox, poliomyelitis) d) Weeklyclinics for: i. babiesunder two yearsold, or under ten kg. in weight ii. toddlers clinics for children of three to five years iii. ante-natalclinics e) Education and lecture demonstrationsat the clinics, in the outpatient departments,and in the nearby elementaryschools; cookery classes the for women f) DemonstrationLU! gardeningmethods,composting,new varietiesof seeds, etc. g) Encouragingthe construction of more hygienic dwellings,latrines and rubbish dumps Buildings. Severalplanswere followed, accordingto the availability of money to

APPENDIX 51 A description of a small rural Health Centre

6)

cover costsof materials(cement, roofing sheets,steel window-frames,glassetc). Fumishhtgs: Waiting hall Consulting room Benches Wall-charts Table Chairs Examining couch Cupboards Shelving(for records) Microscope (completewith oil-immersionlens) for blood, sputum, skin smears, gland puncture, etc. Stains Reagents Table Chairs Primusstovefor sterilizing instrumentsand dressings Syringes,etc. for intra-muscularand intravenousinjection Deliverybed Primusfor sterilizing dressings instruand ments 6 iron bedsteads (completewith sponge rubber mattresses, blankets,etc.) 20 iron bedsteads bedding,asabove. and

Appendix 51 (ctd.)

Laboratory

Operatingtheatre

Delivery room

Maternity ward Generalward

Sucha Health Centreservedits purposeadmirably: it was a) Inexpensiveto build (twenty yearsagoit would havecost about E2SOO) b) Cheapto maintain: it neededno residentguard, or boundary wall. UI rlrttmg c) Convenientfor consultations,clinics and demonstrations d) Conformableto the type of building that wasbecomingacceptable the in villages e) Not obviously imposedfrom above,or from outside f) Largeenoughto deal with the patient-load of Volume of work. The Health Centrewould seeand treat an average 100 patients daily. This figure takesaccount of the specialclinics forleprosy, yaws,etc. The average number of mothersand babiesattending the infant welfare, toddlers and ante-natalclinics would rangefrom 50 to 100 a week. The common laboratory examination would include: blood (malarial parasites, trypanosomes, haemoglobin,blood counts); stools(intestinal worms): sputum (for M. tuberculosis); skin smears M. Leprae,Sp..pertenue,fungij; urine (for (chemical and microscopic); gland puncture (for trypanosomes,M. Leprae).

_,

Appendix 52 Further drawings SeeChapterIII, page9

. . .. .

l-l Appendix 52, Fig. 12 The Model asa 25 bed hospital

40

80 feet

Seeroom lists on page10 and in Appendix 20 for explanation of letters.

(9

Appendix 52, Fig. 13 The Model extended to a 125 bed hospital

0 tI...1 0

40 . r... . 20

80 feet .a 40 mete3

Seeroom lists on page10 and in Appendix 20 for explanation of letters.

Appesdix 52, Fig. 14 Drains, sewers, and sevagedispod mea. Seealso appendix 38

Earth closets shown, plus areas for moving to new pits. A good pit 18 to 20 feet deep with reasonably porous ground will last for 2 years.

where water is available for water-borne sewerage, the disposal area (pan+ septic tank, sewer plant) wifl have to be down ~III. and preferably down prevailing wind. On this plan two of the main possible diupoall areas are indicated as A and 8. The ncceasary elope from the furthest manhole (M/H) to the disposal point dictntes the fall over She whole length.

---i----r--1 e+-LIJz~----' -i -

.--.To sewage disposal oint A, say 100 I eet from building

To sewage diaposd lntB,Myloo p from buikliig eet

n
9 F: I -I ItilfI* I
--w
-.Drains should run down hill 1 r 40 for 4 inch pipes. I : 60 for 6 inch pipes Examples:

1
I T I p t- 0 5 t - ,P I-- E I --t I l-F
To sewage disposal int A, my 100 p from building est 9 /

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pipe pipe pipe pipe et et at at 1 1 1 1 : : : : 40, 60, 40, 60. Iti fall fell fail is is is is 11 feet 345 inches 7 feet 6 inchen 13 feet 2% inch8 feet 9% inches Earth latrine for extended warda

4 inch 6 inch 4 inch 6 inch 0 r 0 40 ---10

80 feet 20 rietrea

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tta T~SE SIZES ARE mt3iwsowu WALrTY SUTWOO. luRwcul5cAN
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