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5/27/23
Design Study ReportFor
Gashonyi Clinic
This report is intended to document the facts and assumptions which will be relied upon in the course of the preparation of the Gashonyi Clinic construction documents. Each programming team continually contributes to the report.
This Document Is The Ultimate Authority For Design.
RED means be more specificGREEN means justify
Project Team: Elise Larson – Project Manager (2010-2011) and team member (2009-2011)
o [email protected] o 608-484-0565
Tina Ocepek – Project Manager (2009-2011)o [email protected] o 920-918-0504
Tom Siebers – Professional Mentor (2009 – 2011)o Home: 608-837-4206o Cell: 608-445-2095o [email protected]
Piotr Starosta – Team Member (2010-2011) - Constructiono [email protected] o 414-232-3607
Kaitlin Schluter - Sanitationo [email protected]
Michael Smet, Jim Goetz – Hospital Flowo [email protected] , [email protected]
Rita Argus, Brittany Noe, Kim Hernandez – Energyo [email protected] , [email protected], [email protected]
Gabe Ryan, Keelin O'Neil – Disease/Health Managemento [email protected] , [email protected]
External Resources: (Include names, title, company or NGO affiliation, all contact information and area of expertise)
Name Company/NGO Affiliation Expertise Contact Information
Justin Miranda Partners in Health Medical Supplies
Bruce Nizeye Ex-Partners in Health, Private Contractor
Chief of Infrastructure, Healthcare systems
engineering788301728
Innocent KAMBUNDA Local Builder General Rwandan Construction
Lori DiPrete BrownGlobal Health UW School
of Medicine and Public Health
World Health
John Kenney UW-Madison Student Mechanical Engineering 784142792
Jean Paul BAZANSANGA Kinyarwanda language/Networking 788351034
AndrewState Engineer or Rwanda
(Atelier Central de Maintenance, ACM)
Rwandan Engineering 788508772
Berchmans Headmaster of Hindiro Secondary School Hindiro School 783419487
Igaramaboko (Cao) Head Nurse at Muramba Health Center
Health Care systems and Nursing 788740997
Jean-Marie
Head doctor at Kabaya Hospital and Health
Director in Ngororero District
Rwandan Healthcare structure and systems, Medicine, Connection to Ministry of Health
788650836
"China" Head Nurse at Gashonyi clinic Nursing 788593501
Jean-Paul Ndahiiman Engineering student at Muramba Civil Engineering 788621097
Martin ManziState Engineer or Rwanda
(Atelier Central de Maintenance, ACM)
Engineering 788503762
Mayor of Ngororero District
District Policy and politics 788485627
Jaques J. Umugirameza Ngororero District Engineer District Engineering Projects 785209884
Emanuel Vice-Mayor of District District policy and politics, networking 788457617
Fabrice Technician from PIH Healthcare systems engineering 788510353
Planning Period: Design anticipates population growth for 10 years after construction.Design components (Energy) may not
Schedule: Goal: Create Floorplan, Water Plan, Energy Plan, Construction Plan by December, 2011.
Vocabulary
Political/Social Structure
1. Political Structure:a. Country (Rwanda)
a.i. District (Ngororero)a.i.1. Sector (Matyazo)
a.i.1.a. Cell (Matare)
2. Health System Structure:a. CHK Hospital (Main Hospital in Kigali)
a.i. District hospital (Kabaya Hospital)a.i.1. Health Center (Muramba)
a.i.1.a. Fosacom (Gashonyi or Hindiro)
3. Insurance Class System:a. First class
a.i. 7000 RWF per yearb. Second class
b.i. 3000 RWF per yearb.ii. 2000 RWF per year
c. Third classc.i. 1000 RWF per year
d. Deductibled.i. 200 RWF per visit
Status of the Existing Site/Clinic Building:
Motivation for New Site
Current Clinic Classification: FosacomAdvantages of Upgrading to Health Clinic Facility on new site: government funding for staff infrastructure support some equipment provided by government ambulance service
◦ hospital ambulance will travel to Health Clinic, not Fosacom
The current clinic building is leased from the church located across the square (geographical direction of the existing clinic.)
The church is in the process of expanding its primary and secondary school◦ would like to expand into the building where the clinic is currently
located
Current building not built for use as a healthcare facility used as a technical school building better suited for use as a school building
Nurses/community members in the area have indicated that they would like to upgrade the medical services that the area receives
need new building to support a greater number and more diverse medical staff
Current building does not offer sufficient services for its service population; clinics that do are too far away.
health center at Muramba is the closest healthcare facility. ◦ road from Gashonyi extends ~25 kilometers to the southwest to
Muramba◦ it is a dirt road built and maintained by the people in the area
▪ the bridges are made of logs treacherous for patient transport
second nearest healthcare facility is 35-40 kilometers to the north◦ designation, name of community
Specifications/Capabilities of Existing Clinic
Size 23x8 meters = 184 sq. meters (1980.5 sq. ft.)
Rooms/Services in Clinic Laboratory
◦ Malaria rapid antigen◦ Microscope for parasites and malaria
Maternity ward Inpatient ward
◦ 5 beds◦ Mosquito nets
Pharmacy Family planning
Equipment Maternity
◦ Scale◦ Two tables◦ One light◦ Several hemostats and scalpels (about 7)
Room is 4 by 4 meters◦ No sterile water◦ Sterilize equipment by boiling in alcohol
No masks
Medication Available
Gashonyi Clinic Medications1
Medication Size Uses
Paracetamol 100, 500 mg
Ferrous Sulphate + Folic Acid 200 mg + 0.4 mg
Pramethasine HCl 25 mg
Chloramine 500 mg
Aluminum Hydroxide 500 mg
Thiamine 100, 50 mg
Penicillin V 250 mg Antibiotic
Chlorpheniramine Maleate 4 mg
1? This list contains enough medication to effectively treat the majority of diseases found in the area. The lack of general anesthetics, narcotic pain relievers, and cardiac regulators prevents any invasive surgery.Ideally, the expansion of Gashonyi’s fosacom into a health center will include the addition of these medicinal supplies to match the facility’s increasing expectations and available services.
Amoxicillin 250 mg Antibiotic
Ciprofloxacin 500, 250 mg
Diclofenac Sodium 50 mg
Ibuprofen 200, 400 mg Pain relief
Metronidazole 250 mg
Cloxacillin Sodium 250 mg
Mebendazole 100, 500 mg
Aminophylline 100, 250 mg
Diazepam 5 mg
Salbutamol 4 mg
Vitamin A + Vitamin E 200,000 I.U. + 40 I.U.
Metoclopramide 10 mg
Doxycycline HCl 100 mgSulphamethoxazole + Trimethoprim 400 mg + 80 mg, Peds
Medroxyprogesterone acetate 150 mg
Artemether + Lumefantrine 20 mg + 120 mg
Levonorgestrel 2 x 75 mg
Lidocaine 2% solution Local Aenesthetic
Sodium Hypochlorite -
Staff ◦ Two nursing students appointed to the location serve the area.
Nursing staff turnover occurs every year to year and a half
New Site Selection: (Now that the existing building/site is out of consideration any location may be
considered. An analysis of the pros and cons of each location should be completed.)
1. How many and what sites were considered?2. What are the site selection criteria?3. Which site was selected?
Selected: January 2010
Selected By committee of community members existing owners have agreed to leave premises to serve greater good of
community
Location 400 meters to the northeast of the community of Gashonyi located centrally in the area of need hilltop, make map GPS distances to other clinics approximately the same as distances from current site,
25 and 35 km to north and southwest ( See “Status of Existing Site”)
Size approximately 70x70 meters
According to Jean Paul BAZANSANGA in February of 2011, there are no alternative sites
Infrastructure Limitations
The nearest road to is approximately a quarter mile (0.4 km) away from the existing clinic site. It is likely the road will have to be extended to serve the new clinic facility.
A functioning water pipeline does not exist in the area, and the pipeline that does exist is beyond repair (Piotr Starosta, Jan 2011)
nearest reliable source of water is located about 14 km away from the site (community members)
district engineer agreed to send a technician January 21 of 2011 to assess the possibility of providing both water and electricity to the site◦ will write report ◦ follow-up needs to be conducted to determine if such an assessment is in
progress and to stay in touch until we can ascertain the feasibility of water and electric service and when the service will be provided
advice from state engineer◦ we should not rely on the infrastructure to be there and to
▪ plan on implementing solar power and ▪ plan on implementing rainwater catchment tanks f
many smaller tanks can be put up higher for water pressure, (engineer on the Muramba maternity ward site.)
Electricity...
Waste incinerator must be built
◦ adjacent underground compartment for the ashes sharps must go into a separate tank for pulverization
◦ Such compartments must sustain years of use ◦ large ◦ cleaning the tank would rarely occur
Population Summary1. Populations of the Area
a. Muramba: 13,188a.i. Total outpatient consult: 14,437a.ii. New outpatient consult since last year: 4,449a.iii. Total inpatient stays: 849a.iv. New inpatient cases since last year: 793
b. Hindiro: 10,583c. Gashonyi: 26,893d. Total: 50,664
Muramba “Health Center” Model: Demographics
Demographics Below is a demographic table of treatments in the Muramba clinic collected
from the Ministry of Health, which we may assume is somewhat similar to the demographics and treatment ratios that will be observed in Gashonyi (JP Bazansanga, 2011):
Muramba Health Demographics (2009-2010)
Consult Reason Children < 14 y.o. Women > 15 y.o. Men >15 y.o.
HIV/AIDS 9 37 18
Malaria 133 135 402
Tuberculosis 0 2 2
Gynecological 1 320 0
Dental 168 272 113
Diarrhea 271 45 38
Eyes 177 119 58
Intestinal 97 112 98
Worms 1223 1049 446
Respiratory Infection 1780 1730 939
Malnutrition 87 17 14
Trauma 193 217 216
Sexually Transmitted Infection
6 101 44
HIV Opportunistic Infection
12 111 67
Bone/Joint 28 795 281
Heart 0 47 13
Urinary Tract Infection 28 244 554
Congenital 0 0 0
Other 32 790 279
Total 4245 6143 3582
TOTAL 13970
Gashonyi Clinic Demographics: Existing and Proposed
Service Population: Almost entirely lower class, mostly subsistence farmers with small plots of land and large families
4. Service Population:a. Existing: 26,893
twice that of Muramba current fosacom is unable to properly sustain the region many patients must be taken to nearby clinics for treatment
◦ transport carried out on wood stretcher or by motob. Proposed: 35,515 in ten years
average population growth rate of 2.82% in 2010◦ this population growth rate has increased from 2.78% in
the last two years, indicating that it may keep increasing2.
2? CIA. "CIA - The World Factbook." Welcome to the CIA Web Site —
Central Intelligence Agency. 30 Dec. 2010. Web. 19 Feb. 2011. <https://www.cia.gov/library/publications/the-world-factbook/>.
5. Daily Patient Intake:a. Existing: 30-35 patients per day
according to the two existing nursesb. Proposed: 120 patients per day3
Nurses anticipate this increase upon opening of improved, “Health Center” status facility◦ Muramba Clinic which serves a population of
approximately 13,000 the daily patient intake is about 40 patients per day.
6. Medical Staffing:a. Existing: Two nursing students appointed to the location serve the area.
Nursing staff turnover occurs every year to year and a half.b. Proposed: 10 nurses, 8 supported by MOH
The minimum nursing staff required to receive Ministry of Health support of salaries
Regulatory/Permit Requirements4:
It is required that all public and private health facilities register with the Government.
Completed online through the MOH (Ministry of Health) website ◦ a printable version is also available
Allows access to computer systems with registration ID◦ performance-based financing◦ health management information◦ disease reporting and pharmaceutical procurement
Regulations must be met for structural, electrical, water and ventilations systems.
The health center must have its own buildings, not rent them.
3? This number is an estimation made by the nurses at the current Gashonyi clinic. Their guess is based upon the interest of many people that they speak with while doing community programming. The actual number would be hard to calculate because of the over 25,000 people that live in the area, few venture down to the current clinic because they feel that it does not meet their needs and polling the spread out, rural population would be impossible. None the less, this is the best we can do at the moment.
4? http://www.usaid.gov/rw/our_work/for_partners/images/rwandahealthsectorstrategicplanii.pdf
According to the MOH's preliminary approach to classify health care systems, as of July 2009, to be a health clinic you need:
A total of 20 outpatients 29 staff members (No doctors are required)
According to the 2005-2009 Rwanda Health Sector Strategic Plan (pg. 19) there must be:
Minimum of 4 Nurses at the A2/A3 level ◦ Registered nurse and nursing assistant, respectively◦ 4 other, non-nursing A2s
▪ including but not limited to nutritionist, lab tech, social assistant, or administration
There must be a minimum of 10 nurses on staff. CONFLICTS WITH ABOVE
There must be the one bed per thousand people served in the health center.
In a Health Center, there must be enough space for the following, minimally:
Maternity
Pediatrics
Internal Medicine
Lab
Toilet/showers
Incinerator
Wound care
VCT/ARV (HIV center)
Maintenance room and generator
Psychiatric consultation/medication may be offered (NOT required)◦ such problems are reportedly uncommon; help is sought
from social workers or psychologists that may not reside in the clinic
In a Health Center, the minimum package of Activities includes: Preventative measures
◦ supply patients with pre-marital consultation
◦ pre/post-natal consultation◦ voluntary consulting and testing◦ family planning◦ vaccination◦ epidemiological surveillance◦ hygiene◦ environmental health
In a Health Center, diagnostic medical services include Lab Tests
◦ Blood smear◦ tuberculosis testing◦ pregnancy testing◦ stool/urine culture◦ pneumonia testing◦ serology testing: HIV, syphilis, glucose, creatinine, urea, amalase,
bilirubin, sed Blood typing
In a Health Center, curative measures include primary curative consultation (CPC) clinical IMCI management of chronic care care/treatment for people living with HIV/AIDS hospitalization minor surgery pharmacy management of gender violence nutritional rehab laboratory equipment/skills
In a Health Center, health promotion activities needed include IEC/health education growth monitoring psychosocial support support groups community mobilization maternity care deliveries post-abortion care.
In a Health Center, administration and management requirements include:
Resource management
Inter-sectoral collaboration Formative supervision of health workers in health posts and in the
community Supplying continuous training
What kinds of laws can I expect in Rwanda that would surprise me?I asked this question to make sure I didn’t do anything that would make me stick
out. Turns out smoking is illegal, punished by a steep fine (about $100 or so), Helmets for motor cycles are required ($25 fine), fighting is not allowed at all, punished by beating, jail, and fines. Even if you get into a heated argument with someone, a militant can take you to the police station for several days (stay peaceful). Eating beyond the boundaries of a restaurant/bar/store is prohibited, meaning you cannot eat while walking down the street. Punishment for eating in public is a fine and possibly a day in jail. Littering is extremely prohibited, if caught an officer can force you to community service, jail, and a fine. Walking on city gardens is not allowed, fine will be established. Injuring a pedestrian with a vehicle is six months in jail, no questions asked, and a fine. Bicycle riding in the city is illegal (but not as strongly enforced).
Current and Proposed Healthcare System Details in Gashonyi:
Total 13970/365 ~= 38 patients treated/day, in a clinic that serves 13,000. Gashonyi will serve 26,000, so by direct comparison we could expect 80 treatments/day. Estimated population growth in ten years to 35,515 people; 35,500/13,000 = 2.73*40 treatments/day in Muramba = 109 patients treated/day 10 years from now in Gashonyi. These estimates do not include patients seen but not treated, though we suspect that there will be no significant difference in estimates if this circumstance is included (see #12 of this section, Total Outpatient Consult) They do not include phycological response of the community to a new clinic facility, which might increase number of patients initially after opening. We suspect that this will significantly contribute to inpatient numbers, as inpatient numbers have seen jumps larger than those attributable to population growth with recent improvements to their services (See # 12 of this section, New Outpatient Consult since Last Year) make sure that this is a correct interpretation of subheading meaning! Nurses in Gashonyi estimate 120 patients/day after new clinic opens, if it opened immediately.
Are any of these seasonal trends to these demographics?Confirm with Jean Paul that Muramba/Gashonyi Demographics are comparable.
Suspect that standard of living is higher in Muramba than around Gashonyi.
7.
Patient Safety, Privacy and Infection Control Design Criteria:
Building Footprint:
1. How much physical space is required – Today/Tomorrow?2. Circulation and open space requirements
a. Air circulation is an important component of disease and infection control in the treatment of tuberculosis. Rooms designated for TB treatment must
a.i. Minimize air circulation between the room and the rest of the facility
a.ii. Maximize air circulation between the room and the outside environment
a.iii. Require exhaust from the treatment room to discharge as far as possible from any air intake areas including doors, windows, fresh air intake areas or publicly open areas so that infective particles may be neutralized by open air/sunlight before reaching potential victims.
a.iv. Maximize amount of sunlight that can come into roomb. These requirements may be achieved respectively by
b.i. Placing a seal around the (always locked) door so as to make the room relatively airtight
b.ii. Using large windows and/or skylights on (if possible) opposing walls/ceilings and a sloped roof to encourage convection,
b.iii. Placing doors far from the treatment room while placing windows near the steep outside hill, creating positive air pressure in non isolation rooms/areas and negative air pressures in isolation rooms/areas.
b.iv. Placing only one door that leads to the outside, not to the inside, of the clinic
3. Special constraints and requirements4. User requirements5. Number of rooms, function for each room and room size?6. One or two story?7. Room layout/bubble diagram8. Depict future addition(s) to accommodate expanded services and patient
population
9. Schematic -- Bubble/Pod -- Design10. Furniture:
Utilities:
1. Electrical – Power Requirementsa. Electricity has been slated to assessment by a district technician
a.i. Report was due to EWB members in February of 2011, must follow up
b. Primaryb.i. Grid hook up? (was mentioned at past meeting) including
opinion as to when the service will be available
c. Emergency c.i. Solar
c.i.1. Solar energy is available in Rwandac.i.2. Use if grid not available/ under repairc.i.3. Serve as an emergency back upc.i.4. Regulate amount of power to medical equipment
(i.e. during heavy load time)c.i.5. Possibility of selling excess solar energy back to
company that runs the grid (done in the US, unsure if other countries would do this??)
c.i.6. District engineer highly recommends solar energyc.ii. Four large banks of solar panels are found at the Muramba
site, assess possibility of using these in Gashonyi, but keep batteries in Muramba for back-up (use wired electricity to charge…)
c.ii.1. Banks of deep cycle batteries are available in country (154,000.00 Rwandan Francs or about 258.82 US Dollars)
c.iii. Generatorc.iii.1. Separate building/maintenance closet
2. Watera. Potable Water – including opinion as to when the service will be availableb. Plumbingc. Sanitary Waste Disposald. Medical Waste Disposal
3. Ventilation4. Lighting Requirements 5. Site Improvements:
6. Access Road7. Landscaping8. Main Road Improvements: – including opinion as to when and what level of
service will be available
Schematic Design:
Design Development/Project Delivery: (Who will provide the following services – EWB personnel, purchased from in-
country professionals, other?)1. Preliminary Design2. Final Design3. Construction Documents4. Contract Documents5. Contractor Selection6. Construction Observation and Contract Administration7. Commissioning
Cost Budgets:1. Construction
a. follow up with in-country engineer 2. Furniture3. Medical Equipment4. Medical Supplies – initial inventory
Medical Supplies: (line up sources for medical supplies and equipment)
Funding Types/Sources For The Following:1. Team Travels – Design through Construction and Start-up2. Construction Document Preparation3. Construction4. Equipment5. Medicines6. Furniture
Operations:(Develop post start-up paper/plan identifying the source and money for operating
the clinic all aimed at sustainability)
1. Medical supplies2. Medical equipment3. Maintenance
a. Who will be responsible for repairs to building and mechanical equipment, electrical, medical equipment?
Governmental Funding/Costs
National Budget decided on last Friday of January (Mayor of Ngororero Dist)Estimate must be submitted by last Thursday of January in order to be considered
Infrastructure Costs
Costs associated with running water and electricity are covered by the district (district engineer, Jan. 2011)
Construction of a rough road would be provided by the community members. an improved road would eventually be provided by the district/government
◦ this improvement will need to be justified by increased traffic and need
Clinic Costs The district will pay for a portion of nurses wages (at Muramba, 8 out of 15
nurses are funded by the government). All other supplies and maintenance requests go to the Kabaya district
hospital.◦ Contact the head doctor, (currently Jean-Marie), six months ahead of
scheduled date of the building project completion for supply stocking◦ The national insurance plan helps cover medication and some supply
costs. Anti Retroviral (ARV) medication is provided free from the government.
EWB USA Reporting/Documents:
1. 521: Pre-Assessment Report: Due 2.5 months prior to travel; Sunday, June 192. 522: Post-Assessment Report: Due 30 days after return3. 521: Pre-Assessment Report: Due 2.5 months prior to travel
4. 522: Post-Assessment Report: Due 30 days after return5. 525: Pre-Implementation Report: Due 3 months prior to travel6. 526: Post-Implementation Report: Due 60 days after return7. 530: Pre-Monitoring Report: Due 2 months before travel8. 531: Post-Monitoring Report: Due 60 days after return9. 527: Program Close-Out: before 1 year after monitoring trip
Politics:(Memorandum of understanding and contracts made through engineering with
the district as well as NGOs)
Appendix:
