Lecture for management students in health

Those doing health management may benefit

1. Management of Physical Infrastructure LECTURE 5 Dr Nicholas Ngonde URE

2. Learning Objectives Participants should be able to know ; how to set health infrastructure priorities process and maintenance of health facilities in order to keep the physical infrastructures operational and to acceptable standards.

3. OUTLINE Setting of health infrastructure priorities Factors that influences the size and distribution of health service at health facilities. Capital investment and recurrent cost implications. Participation of users in the design process. Maintenance

4. INTRODUCTION Infrastructure, as defined by the World Health Organization (WHO), is the necessary services or social investment of a nation, or part of it, which implement the possibility of economic and social actions. Health infrastructure relates to all the physical infrastructure, non-medical equipment, transport and technology infrastructure (including ICT [Information and Communication Technologies]) required for effective delivery of services. In the Uganda Second National Health Policy 2010, infrastructure is described as “buildings, plants, equipment (medical devices, other equipment for health facilities and IT equipment), transport and health care waste management”.

5. Definitions Physical infrastructure refers to the physical availability and quality of public facilities, including the number, distribution and the appropriate mix of facilities, amenities and resources to meet population health needs. Physical infrastructure is a key factor in attaining Universal Health Coverage (UHC). Physical infrastructure can be publicly or privately owned. Public infrastructure is owned by the government. Private infrastructure may be private-not-for-profit (PNFP), mostly faith-based or other private-for profit, also called private health providers (PHPs).

6. Setting of Health Infrastructure Priorities The priority for the Second National Health Policy 2009/10 – 2019/20 is consolidation of health infrastructure (Government of Uganda). The priority strategies for the policy Prioritise renovation, maintenance and rational use of health infrastructure. Ensure evidence-based capital investment to address sectoral priorities. Strengthen planning, procurement and management of health infrastructure according to agreed standards. Supporting the private sector in health infrastructure

7. Priority policy issues on how physical infrastructure can promote universal health coverage In order to bring the infrastructure of health facilities to promote universal health coverage (UHC), there is a need to address certain current constraints. Ensuring the functionality of infrastructure Some infrastructure was constructed but is not delivering the services it is meant to deliver. Some theatres at HC IVs have been redundant for a long time. This is not exclusive to Uganda only. Even in other countries, it is not uncommon to find magnificent structures without the requisite services being delivered. It is critical that there is mapping of the infrastructure and the services offered so that remedies are instituted in those areas where there is redundant infrastructure.

8. When the government assesses access to health care, some of the infrastructure to which people are expected to have access is not functional. People in proximity to these structures ultimately pay high costs to access alternative providers from far-off places. Improving the distribution of infrastructure Most of the private facilities are concentrated in towns and when the government also puts up physical infrastructure in urban areas, this brings about duplication. An example is Fort Portal town, which has two PNFP hospitals and a government hospital yet the surrounding districts do not have any hospital. In some rural areas, however, there are private facilities that could provide specific services, such as diagnostic services, at a cost.

9. The government can procure such services from the same facilities rather than constructing other health facilities to provide similar services in the same areas. There could be collaboration between the public and the private sectors so that services are procured from other providers in places where there are no public providers. The government could establish health facilities in those areas where both the public and private infrastructure is lacking. Alignment of infrastructure with population-level demand The development of health infrastructure according to administrative areas fails to take into consideration the big variations in the number of people that such administrative areas cater to. There should be a purposeful alignment of health infrastructure with the needs of the population. In addition, there should be a strengthening of the referral system.

10. It may not make sense to build a hospital in a place where there will not be an operation over a long period of time. Some of the services are more efficiently offered as referral services. There is a need to separate ambulatory health care from inpatient hospital care. Efforts are already being made to establish a national infrastructure for patient referral and follow-up in Uganda.

11. Upgrading infrastructure to meet the needs of the services to be offered There is a need to standardise the requisite physical infrastructure to the level of a health facility and when the demand for the services a facility offers increases, the infrastructure should then be upgraded to match the increased demand. Many HC IVs were built without wards yet they had theatres and were supposed to carry out operations. Some of the HC IVs over time were conducting many cesarean sections in the range of hospitals and yet they were still labeled as HC IVs, meaning that their financial support and human resource establishment were still at HC IV level.

12. Capital investment and recurrent cost implication Capital investment decisions are among the most important decisions made by firms/governments. They determine the firm's capacity for providing services and commit the firm's cash for an extended period of time. F inancial officers of leading healthcare systems reveal capital investment strategies that generally follow the recommendations of modern finance theory. T here is substantial variation in capital budgeting techniques and methods of risk adjustment. Health care systems face the same challenges as other organizations in developing and implementing capital investment strategies that use consistent methods for evaluation of projects that have inconsistent aims and outcomes.

13. Maintenance of physical infrastructure The main purpose of infrastructure maintenance is to keep the infrastructure in its original condition as long as possible, so as to serve its desired purpose effectively, to minimize production cost, to reduce maintenance time and cost, and to enhance the infrastructure condition. Owolabi and Amusan (2014) stated that maintenance aims to keep all facilities and machines in a condition that makes them operate effectively and at their maximum profit-making capacity. Maintenance divided into planned ( scheduled maintenance) and unplanned maintenance (emergency maintenance).

14. Planned maintenance It is a type of maintenance that is organized and has a predetermined schedule. It is divided into three major types: Preventive Maintenance : This type is executed at predetermined intervals, and intended to decrease the likelihood of failure. Corrective Maintenance : This type arises after failure has occurred and makes an effort to return an item to its normal condition so it can perform its function again. Predictable Maintenance : This type is a normal periodic work that intends to maintain the performance characteristics of a product and to fix the product after it has completed a functional life span.

15. Unp lanned maintenance It is a type of maintenance that has no predetermined schedule (Semi-emergency maintenance). It is divided into three types: : Unpredictable Maintenance : This type takes place when unexpected damage or breakdowns occur due to external causes. Avoidable Maintenance : This type is required to correct failures caused by incorrect installation, incorrect design or the use of improper materials. Emergency Maintenance : This type is executed in order to avoid severe problems. Otherwise, it is referred to day-to-day maintenance.

16. Assignment Discuss the challenges of maintaining health facility infrastructure in Uganda or your Home country and recommend possible solutions. Your assignment should be presented in a structured report format, including the following sections: Introduction Literature Review Recommendations and conclusion Your report should be well-referenced, using academic sources and reputable literature to support your analysis and recommendations. Word limit Your answer should range between 1,500 and 3,000 words, excluding tables, figures and references. Email Assignment to: [email protected]

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