HEALTH EXTENSION PROGRAM

OPTIMIZATION: BASIC HEALTH POST

REFORM IMPLEMENTATION
GUIDELINE
 HEALTH EXTENSION PROGRAM OPTIMIZATION:
BASIC HEALTH POST REFORM IMPLEMENTATION GUIDELINE

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CONTENTS

Acknowledgments...............................................................................................................................................3
Acronyms................................................................................................................................................................4
Foreword.................................................................................................................................................................6
Context....................................................................................................................................................................7
Introduction to the Guideline............................................................................................................................7
Objectives of the Health Post Reform Implementation Guideline........................................................8
Guideline development processes..................................................................................................................9

HEALTH POST REFORM CHAPTERS..........................................................................................10

CHAPTER 1: LEADERSHIP, MANAGEMENT AND GOVERNANCE.............................................11

Operational standards..................................................................................................................................... 11
Implementation guideline............................................................................................................................... 11
Verification checklist......................................................................................................................................... 13

CHAPTER 2: HEP SERVICES......................................................................................................14

Operational standards..................................................................................................................................... 14
Implementation guidance............................................................................................................................... 14
Verification checklist......................................................................................................................................... 18

CHAPTER THREE: INFECTION PREVENTION AND CONTROL (IPC) AND CLEAN

AND SAFE HEALTH FACILITIES (CASH)......................................................................................22
Operational Standards for IPC/CASH.......................................................................................................... 22
Implementation Guide..................................................................................................................................... 22
IPC/CASH standard and Verification Checklist......................................................................................... 37

CHAPTER FOUR: COMMUNITY ENGAGEMENT.........................................................................38

Operational Standards..................................................................................................................................... 38
Implementation Guides................................................................................................................................... 38
Community engagement standards and verification checklist........................................................... 41

CHAPTER FIVE: HEALTH INFORMATION SYSTEM AND PERFORMANCE MONITORING......43

Operational Standards..................................................................................................................................... 43
Implementation guide...................................................................................................................................... 43
Implementation checklist and indicators................................................................................................... 53

Reference............................................................................................................................................................. 55
Appendixes.......................................................................................................................................................... 56

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ACKNOWLEDGMENTS
The Federal Democratic Republic of Ethiopia’s Ministry of Health would like to acknowledge the
following individuals and their organizations for their participation in technical working groups and
contributions to the development of this document.

• Israel Ataro Otoro .............................................. MOH

• Woldemariam Hirpa ........................................ UNICEF- FMOH

• Chala Tesfaye ...................................................... JSI/ L10K- FMOH

• Kasahun Sime ..................................................... JSI/ L10K- FMOH

• Desalew Emaway .............................................. JSI/ L10K

• Biruhtesfa Bekele .............................................. JSI/ L10K

• Berhanu Tamiru ................................................. AMREF

• Mesele Damte.................................................... USAID/TPHC

• Wondosen ............................................................ USAID/TPHC

• Fasil Walelign ...................................................... MERQ

• Wondesen Nigatu .............................................. FMOH

• Dr Zelalem Tadesse .......................................... FMOH

• Dr Wondesen Mengiste ................................... FMOH

• Kiflemariam Tsegaye......................................... FMOH

• Firew Solomon.................................................... FMOH/USAID-TPHC

The Ministry is grateful to all the above individuals and other partners who have participated in the
production of this guideline. Special thanks go to our key partners (JSI/ L10 K, MERQ PLC, USAID
TPHC and UNICEF- Ethiopia) for their substantial technical contributions and financial support
throughout the development of the guideline

Lastly, the development of this guideline would not have been possible without the inspiration and
on-going technical and leadership support from the FMOH and RHBs’. Therefore, we would like to
thank all management and technical teams at the FMOH and RHBs for their invaluable contributions.

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ACRONYMS
AMC Average monthly consumption
ANC Antenatal care
ART Antiretroviral therapy
ARV Antiretroviral
AYH Adolescent and youth Health
BHP Basic Health Posts
CASH Clean and Safe Health Facilities
CDC U.S. Centers for Disease Control
CHIS Community health information system
CHP Comprehensive Health Post
CSC Community scorecard
CSS Client Satisfaction Survey
DHIS2 District Health Information System
DM Diabetes Mellitus
EHPRIG Ethiopian Health Post Reform Implementation Guideline
EHSP Essential Health Services Packages
FMOH Federal Ministry of Health
HBV Hepatitis B virus
HC Health Center
HCAI Health care acquired infection
HCP Healthcare personnel
HCV Hepatitis C virus
HCW Healthcare waste
HCWM Healthcare waste management
HEP Health Extension Program
HEPA High efficiency particulate air
HEPO Health Extension Program Optimization
HIS Health Information System
HIV Human immunodeficiency virus
HMIS Health Management Information System
HP Health Post
HPRIG Health Post Reform Implementation Guideline
HR Human Resources

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HRM Human Resources Management
ITN Insecticide Treated Net
IMAI Integrated Management of Adolescent and Adult Illness
IMNCI Integrated Management of Newborn and Childhood Illnesses
IPLS Integrated Pharmaceutical and Logistic Supply
IUCD Intrauterine contraceptive device
IP Infection prevention
IP&PS Infection Prevention and Patient Safety
IPC Infection Prevention and Control
LQAS Lot quality assurance sampling
M&E Monitoring and Evaluation
MDT Multidisciplinary team
MFI Mater Family Index
MHP Merged Health Posts
MOS Months of stock
NCD Non Communicable Diseases
NTD Neglected Tropical Diseases
PEP Post-exposure prophylaxis
PHC Primary healthcare
PITC Provider-initiated HIV testing and counseling
PMT Performance Monitoring Team
PPE Personal protective equipment
PRM Performance review meeting
PVC Polyvinyl chloride
STI Sexually transmitted infection
TB Tuberculosis
VEN Vital, Essential and Necessary
VHL Village-level Health Leaders
WDG/A Women’s Development Group/ Army
WorHO Woreda Health Office

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FOREWORD
The recent roadmap which is intended to guide the implementation of Health Extension Program
Optimization (HEPO) for the coming 15 years, has identified key transformative strategic objectives
to address the challenges identified by the HEP assessment. These objectives include the
stratification of HPs into three categories, redefining the health service packages, changing the
professional mix, rethinking community engagement strategies, using innovative methods to
ensure sustained financing, and ensuring the resilience of the HEP and ability to maintain essential
service delivery during public health emergencies.

The Health Post Reform Implementation Guideline (HPRIG) builds on the HEPO roadmap and HEPO
Implementation Manual to set minimum management standards for the Health Posts (HP). The
HPRIG focuses on selected management and PHC service functions such as HP leadership,
governance and management, HEP Service Packages, Infection Prevention & Control (IPC), Clean
and Safe Health facilities (CASH), Community engagement and community Health Information and
Monitoring and Evaluation

The guideline is primarily developed based on the requirements for the basic HP and must be revised
in a timely manner to accommodate emerging developments and concerns.

We hope this guideline provides an important resource for effectively managing the HPs. Therefore,
it is frontline health staffs must properly utilize this guideline

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CONTEXT
In Ethiopia, the Health Extension Program (HEP) has been a flagship platform for the provision of
rimary Health Care (PHC) services to all notably the rural communities with limited access to health
care services. As a result, promising results have been achieved for the last 15 years in terms of
ensuring access to basic primary health care services at the community level.

A recent HEP evaluation revealed, however, persistent health system challenges related to
leadership and governance, human resources, HEP financing, logistics, Community Health
Information System (CHIS) and service delivery, all of which have contributed to the HEP’s stagnation
in recent years.

To overcome such challenges, the Federal Ministry of Health (FMOH) has developed a long- term
envisioning roadmap to transform the HEP in the next 15 years (2020-2035). Several new initiatives
are included in this roadmap such as restructuring service delivery modalities, advancing HR
allocations and quality, upgrading and modernizing infrastructures and expanding essential health
service packages. Besides, the roadmap has recommended the revitalization of governance
structures, HEP financing, and community engagement functions as well as the establishment of
proper management standards for the HPs as part of implementing HP reform.

These sets of standards will serve tools to improve performance quality as well as create consistency
or uniformity across the health posts in the country. Moreover, the implementation of management
standards can help managers identify areas for improvement and the proper allocation of resources.

INTRODUCTION TO THE GUIDELINE

This guideline is organized in to five chapters; namely,

• Health Post Leadership, Management and Governance

• HEP Health Services, ,
• IPC and CASH,
• Community Engagement
• Health Information System and Performance Monitoring.

Each chapter provides a minimum set of performance standards to be implemented at the HP level
with a detailed guidance on how to implement those standards. For every chapter, there is an
embedded checklist to track the application of the standards. This provides an opportunity for the
HP to do self-assessment as part of retaining accountability

HP Leadership, Governance and Resource Management: Based on the HEP Optimization roadmap
(2020- 2035) recommendation the HPs are classified in to three different categories. Comprehensive
health post (CHP), Basic Health Post (BHP) and Merged Health Post (MHP). Each health post is
accountable to and governed by the HC. The kebele’s administration can be part of the management
body using a matrix management principle. The inter-sectoral team of each kebele is responsible for
the management of all community, institution, and household level essential health services.

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HEP Services: HEP services are packages of promotive, preventive, curative and rehabilitative
services that are categorized under four major packages (Family Health; Diseases Prevention and
Control; Hygiene and Environmental Health and Health Education and Promotion). These packages
cover a range of interventions to be provided at HPs, in household, in the community, at school, or
through outreach, and mobile posts based on the revised Ethiopian Essential Health Services
Packages (EHSP). The type and number of these services and interventions vary depending on the
category of the health HPs (weather a-comprehensive HP or basic HP) as outlined in the HEPO
roadmap.The BHP is designated to provide all basic HEP service packages.

Infection Prevention and Control (IPC) and Clean and Safe Health Facilities (CASH): The potential
for the transmission of infections in the health care setting is high. Both those receiving and
providing care in a HP are at risk of acquiring and transmitting infections through exposure to blood,
body fluids or contaminated materials. Establishing an infection prevention and patient safety
program with the aim of stopping the transmission of infectious agents is the only way to reduce
the occurrence of Healthcare Acquired Infections (HCAIs).

Community engagement: Community engagement (CE) entails involving communities in planning,

design, governing, delivering services, and making decisions, enabling them to increase their control
over their lives. Empowering families and communities to produce their health outcomes has been
the driving philosophy of the Ethiopian community health system, the HEP. This is achieved through
engaging individuals, families, and communities. Therefore, to apply well-planned community
engagement as part of a community and primary health care system across the country, a set of
operational standards, monitoring checklists, and implementation guidelines have been prepared.

Health information system and Performance Monitoring: The Health Information System (HIS) is
where health data are recorded, stored, retrieved, and processed to improve decision-making.
Ethiopia has introduced different health information system reform agendas to improve the use of
quality data production for performance improvement and evidence-based practices at the HP level,
such as the community health information system (CHIS), electronic CHIS, data-quality assurance,
and information use culture.

Performance monitoring is a system that helps track and follows up on priority routine information
about a program and its expected results. Performance monitoring in the implementation of HPRIG
will provide information to the ongoing process that focuses on reinforcing high performance or
improving substandard performance.

OBJECTIVES OF THE HEALTH POST REFORM IMPLEMENTATION GUIDELINE

The Health Post Reform Implementation Guideline (HPRIG) has the following objectives:

• Set minimum standards for HPs;

• Provide guidance on the implementation of complementary standards;
• Ensure accountability for the actors;
• Help health workers provide quality health services to their clients;
• Help program managers monitor the progress of HP reforms.

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GUIDELINE DEVELOPMENT PROCESSES

The HPRIG has been developed in tandem with the revision of the Health Center Reform
Implementation Guideline (HCRIG). Doing so helped the developers align the chapters and sub-
topics of HPRIG with those of the HCRIG and thus avoid redundancies, discrepancies, and
fragmentations. The design of the HPRIG was primarily embarked upon by the TWGs at the national
level. In the process, however, key stakeholders were engaged: partners, Regional Health Bureaus
(RHBs), Woreda/Town Health Offices (WorHOs/THOs), HCs, and HPs.

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Health Post Reform
Chapters

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Chapter 1
LEADERSHIP, MANAGEMENT
AND GOVERNANCE
OPERATIONAL STANDARDS

1. The representative of the Health Post participates actively in the inter-sectoral kebele
committee.

2. The Health Post has annual, quarterly, and monthly plans approved by the kebele steering
committee and supervising Health Center

3. The performance of the HP reviewed regularly at kebele and PHCU level

4. The HP should have key job-aids/tools to guide a day to day activities of the health post.

5. The Health Post has the required number of staff

IMPLEMENTATION GUIDELINE

The kebele, the smallest administrative structure, is led by a team of inter-sectoral bodies called the
kebele cabinet. The main sectors available at the community level are: agriculture, education, youth
association, women’s association, and religious leaders. The kebele councils are mandated to
provide guidance to health professionals and community mobilization, resources mobilization and
promote institutional health. The kebele administration must participate actively in the planning in
the planning process of the HP. This includes examining the HP’s strengths, weaknesses,
opportunities, and challenges. In addition, it is expected to approve the annual plans and report of
the HP and ensure that the community’s health priorities are part of the kebele plan.

The major role and responsibilities of the kebele include but are not limited to:

• Actively participating in and providing overall guidance to the annual plan’s development process.
• Facilitating the implementation of social-accountability tools, a community scorecard, and the
measurement and use of information generated from focus group discussions.
• Conducting community discussion forums that encourage households to seek basic health
services and implement HEP packages at the household level.
• Organizing health bazaars and arrange open house event to improve health literature
• Mobilizing resources useful for, e.g., constructing health workers’ residences, running maternity
waiting homes, and constructing fences and latrines.
• Facilitating the availability of a model HEP packages corridor in, e.g., school health, water supply,
and hand washing facilities.
• Mobilizing communities to enroll in community-based health insurance (CBHI) schemes and
encouraging their timely renewal.

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Managing HPs: HPs should be overseen by a PHCU management committee and have a coordinator
who leads and directs its day-to-day operations; this person will be assigned by the PHCU director
in consultation with the WorHO and kebele administration.

Some of the duties and responsibilities of the HP coordinator are:

• Establishing strong relations and linkages with the HC;

• Liaising between the HP and HC and community structures;
• Ensuring the application of HP standards;
• Managing the human, financial, and other resources of the HP;
• Coordinating and providing directions to staff;
• Facilitating the annual plan’s development activity;
• Preparing and submitting facility report on a weekly, monthly, and quarterly basis;
• Facilitating the approval of reports from the kebele administration;
• Facilitating community–facility discussion forums.

Human resources required for BHP: To provide quality HEP services at the community level, a
team composed of different disciplines and gender mixes for BHP is required. As it is clearly
indicated on the HEPO roadmap, two HEWs and one nurse are required for BHPs.

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VERIFICATION CHECKLIST

The following Table can be used as a tool to record whether the main operational standards outlined
above have been implemented by the heath post.

Table 1: Leadership, Management and governance

Implementation Yes (√) Met=1

SN Verification criteria Remark
standards No (x) Not Met=0
There is evidence that the
representative of the HP is Letter of assignment from
officially assigned to a member kebele steering committee/
of the kebele steering cabintet or Supervising HC
The representative committee
of the Health Post
participates •Check whether it is
1 documented in meeting minutes
actively in the There is evidence of that the
inter-sectoral that the HP is represented on
representative of the HP
kebele committee. attends regular kebele the regular meeting
•Check the health and /or
committee meetings and health
multi-sectoral issues discussed
issue discussed regularly
at least once in the last month’s
meeting

There are comprehensive

Check the availability of the plan
The Health Post annual, quarterly and monthly
and its content is comrehensive
has annual, HP plans
quarterly, and 1)Check the availability of the
monthly plans There is a separate multi-
plan and its content is
2 approved by the sectoral plan agreed by key
comrehensive 2)Check
kebele steering sectors (health, education,
if there are pieces of evidence
committee and agriculture, water, women &
that the plan is implemented
supervising Health child----) and estabilished
and executed jointly ( Joint
Center system platform working
supervision report, review
together
meeting report…)
The performance of the health
sector has been presented and
Check the meetings minutes
The performance reviewed at the regular (at least
from
of the HP quarterly) kebele steering
3 reviewed regularly committee/ cabinet meeting
at kebele and 1) Check feedback from the
PHCU level The activities of the HP
supervising PHCU 2)
reviewed on monthly basis at
Check (electronic or manual )
the PHCU level
report submitted to the PHCU
ü HEP optimization
implementation manual
The HP should
ü HP standard
have key job-aids/
tools to guide a ü Referral protocol & sheet
4
day to day ü Family health card
activities of the
health post. ü HPRIG
ü Community engagement
guideline
The Health Post Check the HP has at least two
5 has the required HEWs (at least one of them is
number of staff leve 4 HEW)

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CHAPTER 2
HEP SERVICES
OPERATIONAL STANDARDS

1. The HP shall provide health services at facility, household, community-outreach, schools,

mobile posts and other work places

2. The HP should provide routine services on weekdays without any interruption

3. The Health Post provides maternal health services and interventions
4. The Health Post provides Essential new-born care and child health services and interventions
5. The Health Post provides FP and AYH services and interventions
6. The Health Post provides nutrition services and interventions
7. The Health Post provides communicable disease prevention and control health services
8. The Health Post provides Non-communicable disease prevention and control health services
and emergency and first aid

9. The Health Post provides NTDs prevention and control health services
10. The HP conducts Community-based surveillance regularly
11. The Health Post has functional referral and emergency services
12. The Health Post provides comprehensive hygiene and environmental health service
13. The HP provides comprehensive health education for communities/clients using standard
materials/ tools

14. The HP has a supply and management system for drugs and medical supplies

IMPLEMENTATION GUIDANCE

HEP service delivery outlets

The health extension service packages are delivered through different service delivery outlets such
as household, community, schools and HPs. Staffs are expected to use several job-aids and tools
while providing services at these outlets. The coordinator of the HP need to review the HEP
implementation manual to rearrange services and interventions in accordance to the service delivery
outlets.

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Household level services: Almost all kinds of service packages can be provided at household level
notably family health services. This ensures accessibility to essential health services and enhances
health service seeking behaviour of an individual and the family. Health promotion, disease
prevention and rehabilitative services are widely exercised at household level based on the health
need of the family. Such interventions require committed and passionate health workers.

Community level services: The HP staffs are expected to facilitate training of community health
agents, organizing community conferences and dialogues, providing community level services such
as immunization, family planning, growth monitoring, mass drug demonstrations, community
based disease surveillance and campaign based environmental health activities. The HEP is also
provided at workplace, schools and religious institutions.

School services: As a great majority of young people spent their time in schools, it could be a good
opportunity to create and cultivate healthy and productive generations by engaging and working
with school communities (school clubs and school teachers). Therefore, HP staffs need to implement
the school health packages as indicated in the HEP optimization implementation manual.

Mobile service delivery mechanisms: In the geographic areas where access to health facilities (HP
and HC) is limited notably in pastoralist settings/ regions a mobile service delivery modality will be
institutionalized.

Health Post Level Services: Based on the current categorization of health posts, there are
comprehensive and basic health posts (CHPs and BHPs). The types and number of health services
entirely depend on the category of the HP and the availability of the required number and professional
mix of the staffs. The BHPs are meant for providing some out-patient clinical and basic health
services as outlined in the HEPO implementation manual

Essential Health Extension Service Packages and interventions

Essential Health Extension Service Packages include four major packages and eighteen and above
sub packages based on the type of the HP with a total of about 305 interventions in BHP and more
than 405 interventions in CHP. See Table 3 below.

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Table 2: List of essential Health Extension Service Packages

No. of Common SD
Major package Sub packages Remarks
interventions outlet

• Maternal and new-born care

including FANC and delivery
services • HP

• Child health • Household

Family Health 190
• FP and AYH services • Out-reach

• EPI • School

• Nutrition

Refill of
• Prevention and control of
medications for
malaria
• HP chronic
• Prevention and control of TB communicable and
and Leprosy • Household non-
50
• Out-reach communicable
• Prevention and control of HIV/
Diseases diseases with
AIDS and STIs • School
prevention and adherence
control • Prevention and control of monitoring can be
NTDs done at CHP only
• Prevention and control of
Major NCDs
• Mental health Services
• Emergency and First aid 105 HP Laboratory services
• Treatment of common adult
and adolescent illnesses

Multi-sectoral and
community
• Healthy housing
engagement is vital
• Food and water sanitation to effectively
Hygiene and • Household
provide such
Environmental • Institutional hygiene
19 • Community services
Health
• Personal hygiene The involvement of
• School
private
• Solid and liquid waste
organizations are
management and disposal
also equally
important

Health • HP
Education and • Household
Health Education and
promotion 52
communication • Community
• School

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REFERRAL AND EMERGENCY SERVICE
Referral Service: Referral is a two-way process and ensures that a continuum of care is maintained
to patients or clients. It is done from the community to the primary care health service and to
hospitals and within hospitals and vice versa. The referral process begins by the referring health
professional communicating to the receiving health professional. The receiving health professional
communicates back to the referring health professional with information and plan for continuum of
care thereby completing the referral process.

ESSENTIAL ELEMENTS OF A REFERRAL SYSTEM

• Directory of services and organizations within a defined territory

• Standardized referral format
• Feedback loop to track referral
• Documentation of referral

Reasons for Referral: The criteria for referral should be medical, objective and in the best interest
of the patient or client. The following are considered good reasons for referrals:

• When a patient needs an advanced care as determined by the attending health professional
• When technical examination is required that is not available at the HP
• When intervention that is beyond the capabilities of the facility is required
• When patients require inpatient care that cannot be given at the referring facility

MANAGEMENT OF REFERRALS
Roles and responsibilities of the referring health professional and referring facility

• Should know what, whom, when and where to refer

• Should fill the referral form with all the necessary information and attach relevant documents
• Explains to the patient the rationale, reasons for choice of doctor or facility, preparation, expected
cost, and possible outcome of referral
• Should be available to answer queries from the referral coordinator or receiving facility about
the referral if necessary
• Ensures continuous supply of standardized referral forms are available
• Keeps directory of health services and facilities in the defined geographic area
• Ensures proper recording of all referral activities
• Facilitate ambulance /transportation in emergency conditions

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MANAGING PHARMACEUTICALS

The supply of medicines and other inputs needed for the health post shall be provided by the health
center and woreda health office in accordance with the integrated supply management system.

Therefore, the health center must ensure that the resources are provided in a timely and adequate
way. Proper recording and reporting are one of the major logistics activities the HP. Therefore,
recording of medicine should be done carefully on daily basis and updated regularly proper tools.

Each pharmaceutical product on the shelf should have a Bin Card. This card provides essential
information on the quantities of stock on hand of that product, any losses or adjustments to the
inventory, and lead time.

VERIFICATION CHECKLIST

Table 3: HEP service operational standard and Verification Checklist

Met=1
Implementation Yes (√)
SN Verification criteria Not Remark
standards No (x)
Met=0
Check the availability of
Services are provided at facility
the schedule and
(HP) level,
activity report
Services are provided at Check the weekly
The HP shall provide
Household and community- records of assigned
health services at
outreach, professionals
facility, household,
1 community- Check the availability of
outreach, schools, Services are provided at schools the schedule and
mobile posts and activity report
other work places
Customized service delivery
Check the availability of
approaches are employed
the schedule and
(mobile clinic, outreach..) for
activity report
mobile pastoralist communities

1) Observe activity schedules

The HP should
and daily service records
provide routine
2) Randomly interview clients
services on
2 or surrounding communities
weekdays regularly
weather the HPs are open all
without any
the weekdays and working
interruption
hours

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 ANC supported by rapid tests
The Health Post for laboratory needs (essential
provides maternal lab
and child health tests in HC)
Check Registration
services and
Post-natal care (facility and books, Family folders,
interventions
home based) forms, tally sheets and
3 Note: Please refer
referral records and
the HP optimization Perinatal and maternal death other relevant
implementation surveillance and response, documents
manual for the Identification of Fistula, uterine
details for each prolapse and cervical cancer
interventions identification and referral
service
Essential new-born care Check Registration
The Health Post
Child health (iCCM/iCMNCI/ books, Family folders,
provides Essential
CBNC) forms, tally sheets and
4 new-born care and
referral records and
child health services
EPI (all antigen) other relevant
and interventions
documents
FP including implants
Check Registration
The Health Post AYH services (Adolescent sexual books, Family folders,
provides FP and AYH and reproductive health forms, tally sheets and
5 including adolescent friendly FP,
services and referral records and
interventions Prevention of teen age other relevant
pregnancy, Comprehensive documents
health education about GBV..)
Nutrition promotion-growth
monitoring, breast feeding and Check Registration
The Health Post screening ( maternal and books, Family folders,
provides nutrition children nutrition problems) forms, tally sheets and
6
services and Management of moderate referral records and
interventions malnutrition other relevant
Supplementation and de- documents
warming
The Health Post Prevention and control of
provides Malaria
communicable
disease prevention Prevention and control of TB Check Registration
and control health and leprosy (DOTs, referral, books, Family folders,
services health promotion) forms, tally sheets and
7
Note: Please refer referral records and
the HP optimization Prevention and control of HIV/ other relevant
implementation AIDS and STIs- health documents
manual for the promotion, prevention,
details for each counselling and testing
interventions

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 Health promotion and
The Health Post prevention HPTN including
provides Non- screening, referral
communicable
Health promotion and
disease prevention
prevention of Diabetes
and control health Check Registration
including screening and referral
services and books, Family folders,
emergency and first Health promotion and forms, tally sheets and
8
aid prevention of Cancer including referral records and
Note: Please refer breast cancer screening and other relevant
the HP optimization referrals documents
implementation
Prevention and control of
manual for the
mental illness-screening,
details for each
referral, health promotion.
interventions
Emergency and first aid
Health promotion and Check Registration
The Health Post
prevention (SBCC) on NTDs books, Family folders,
provides NTDs
forms, tally sheets and
9 prevention and
referral records and
control health Mass drug administration other relevant
services
documents
Community surveillance is
The HP conducts conducted by actively using
10 Community-based community level structures Check reports
surveillance reguraly Disease under surveillance
notified/reported regularly

Check availability  of a directory • Check if a feedback

The Health Post has of services and organizations loop in placed to track
functional referral within a defined territory;
11 referral;
and emergency
•Check documentation
services Check availability  of a of all referrals.
standardized referral format
Promotion of Food and water
sanitation
The Health Post Promotion of Healthy housing
Check registration
provides Promotion of Institutional books, Family Folders,
comprehensive hygiene
12 reports and other
hygiene and
Promotion of Personal hygiene relevant documents
environmental
health service Promotion of Solid and liquid
waste management and
disposal

The HP provides
comprehensive Check registration
Check materials availability and
health education for books, Family Folders,
13 application for health education
communities/clients reports and other
materials/tools such as FHG
using standard relevant documents
materials/ tools

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 The HP has separate Check the dispensary
dispensary corner/shelf for corner/shelf and
medicines storage of medicines
The HP has a facility specific
The HP has a supply drug list as outlined in HEPO Check the list
and management Implementation Manual
14
system for drugs
and medical supplies Essential drugs of the HP are all Check the availability of
essential drugs using
available at any time.
the drug listed
Check the bin/stock
The HP uses bin card/stock card
cards updated

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BASIC HEALTH POST REFORM IMPLEMENTATION GUIDELINE 21
Chapter 3
INFECTION PREVENTION AND CONTROL (IPC) AND
CLEAN AND SAFE HEALTH FACILITIES (CASH)
OPERATIONAL STANDARDS FOR IPC/CASH

1. Hand hygiene is practiced by all healthcare providers before and after contact with a
patient/client regardless of their health status.

2. Safe injection practices and safety box use are implemented to minimize risk.

3. The Health Post ensures housekeeping activities and green areas.

4. The Health Post ensures the availability of adequate and functional toilets, and showers.

5. All Health Post staff are trained using standard infection-prevention and patient-safety
training materials.

6. The health post ensures availability basic amenities

IMPLEMENTATION GUIDE

IPC-CASH plan

The IPC/CASH plan should outline all of the activities to be included in the health post’s program.
At a minimum the plan should address the health post’s guidelines and procedures for:

Ø Standard precautions; healthcare waste management, hand hygiene, instrument

reprocessing….
• Transmission based precautions
• Equipment and supplies for IPC/CASH activities, including personal protective equipment
• Monitoring and evaluation of IPC/CASH activities
• IPC/CASH training

Standard Precautions

Standard precautions are a set of recommendations to minimize the spread of infections in a

health care setting. Healthcare workers should apply the principles of standard precautions with
each encounter with a patient and consider every person, patient or staff, as potentially infectious
or susceptible to infection.

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Most HCAIs can be prevented through readily available and relatively inexpensive strategies. The
elements of standard precautions include implementation of recommended practices regarding:

• Hand hygiene
• Use of personal protective equipment
• Safe work practices (such as safe injection practice, safe practice in the procedure room)
• Safe house keeping
• Health care waste management
• Processing of instruments and linens

Hand Hygiene: Hand hygiene is one of the most important measures for infection prevention. Hand
hygiene generally refers to hand washing, hand antisepsis, alcohol-based hand rub and surgical
hand scrub. Hand hygiene should be practiced by all healthcare providers before and after contact
with a patient/client regardless of their health status. The steps of hand hygiene should be posted.
To achieve the greatest compliance in hand hygiene, all staff should be trained or correctly oriented
on proper hand hygiene techniques as part of an infection prevention training program. Hand
hygiene facilities, such as functioning sinks, soap, and water should be in place in all patient care
areas. The HP should provide a consistent supply of clean water for all patient care areas. This can
be achieved by the short-term provision of water using containers with improvised sinks (faucets
fixed to buckets) and/or temporary storage tankers or the long-term provision of water from a
reliable supply designed for the HP.

Personal Protective Equipment: Personal protective equipment (PPE) can be defined as “specialized
clothing or equipment worn by an employee for protection against infectious materials.”1 PPE
protects the healthcare worker by creating a barrier between the person and any potentially
infectious substance. Personal protective equipment includes: gloves, gowns, aprons, masks/
respirators, protective eyewear (face shield, goggles), caps, protective shoes. Synthetic long sleeve
aprons, goggles and masks should be provided to all staff involved with conducting invasive
procedures. Each personal protective equipment has a different use and application. Table 1 outlines
the different types of personal protective equipment that are commonly used in a health post
setting. Table 2 presents a summary of the types of PPE, when each should be worn and by whom.
Synthetic long sleeve aprons, goggles and masks should be consistently used when splashes are
anticipated.

1 CDC, Guidance for the selection and use of personal protective equipment in healthcare settings.

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BASIC HEALTH POST REFORM IMPLEMENTATION GUIDELINE 23
Table 4. Personal Protective Equipment; type

Personal Protective Equipment Type

Heavy duty gloves

Gloves Surgical gloves
Examination gloves (latex or nitrile)
Goggle
Protective Eyewear
Visors
Dust mask
Masks Surgical
Respirators
Plastic apron
Aprons
Protective gown
Boots
Protective shoes
Nurse shoes
Caps
Face shield

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Table 5. Personal Protective Equipment: Uses

What is
Type of PPE When PPE should be worn
Protected?

Gloves
Surgical (normal and When there is direct contact with exposed wounds, blood, body
elbow length) fluids, or any type of lesion.
When drawing blood or handling medical instruments involved with
Examination Hands invasive procedures (catheters, IV insertion, probes, etc.).
Nitrile During surgical procedures
Latex When handling waste items or other contaminated surface
When cleaning patient areas.
Heavy duty

When splattering of blood or body fluids to the face is possible,

Protective eyewear Eyes When handling bio-hazardous, soiled linens,

When performing waste collection for hazardous or non-hazardous
waste.

Masks Mouth, To protect mucous membranes of mouth and nose when splatter-
Surgical mask nose ing of blood, body fluids, secretions or excretions is possible

Mouth and
Particulate respirators When entering the room of airborne infectious agents such as TB
nose

Face,
mouth, To protect mucous membranes of eyes when splattering of blood,
Face shields
nose and body fluids, secretions or excretions is likely
eyes

Plastic aprons Skin, To protect skin and clothing when splattering of blood, body fluids,
Gowns clothes secretions or excretions is likely

To protect feet when there is the likelihood of the splattering of

Protective shoes Foot, shoes blood, body fluids, secretions or excretions
To protect from sharps injury

To protect hair when there is the likelihood of the splattering of

blood, body fluids, secretions or excretions
Caps Hair
To reduce spread of microorganisms from healthcare personnel to
patient or food

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ENVIRONMENTAL HYGIENE
Waste Management

Improper disposal of special health care wastes including open dumping and uncontrolled burning
increases the risk of spreading infections and of exposure to toxic emissions from incomplete
combustion. Proper management of health care wastes through an integrated, effective waste
management system can minimize the risks both within and outside healthcare facilities.

Waste Management Procedures

Waste management is a multi-step process involving:

• Waste Minimization
• Segregation
• Handling
• Collection
• Storage - Not applicable at heath post level
• Transportation
• Treatment and Disposal

Waste Minimization

In a proper HCW management system, the first step is waste reduction or minimization. It helps to
ensure good sanitation of the health facility and the safety of workers and communities by
reducing the quantity of wastes generated.

Segregation

Segregation denotes the separation of waste into a range of classes according to its character.
Waste separation reduces the quantity of waste that requires specialized treatment and care.
Generally, health facility waste is classified into 3 categories of waste: non-infectious, sharps
waste and infectious waste.

Non-infectious waste is waste that is non-hazardous and under normal circumstances poses no
health risk. It includes paper, packaging, left-over foods, boxes, glass, plastic, etc.

Sharps waste includes sharp materials and equipment that are disposed after being used. For
example, used syringes, needles, lancets, blades, scalpels, broken glass, etc.

Infectious waste is a waste material that has, in part or in whole, been in contact with blood and/
or body fluids. Due to the presence of blood and body fluids, such wastes are regarded to be
infectious waste and can potentially transmit microorganisms to susceptible people. It includes
contaminated gauze, dressings, used gloves, placenta, tissues and the like.

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Segregation must:

• Take place immediately and at the source where the waste is generated; waste must never be
re-sorted.
• Ensure that proper segregation techniques are used and that infectious HCW is not mixed with
non-infectious waste.

Table 6 The 3 categories of HCW shall be segregated into colour coded containers as follows:

Segregation Category Color-coded container Non-color coded bins

Non-infectious waste/ Bins should be labelled

Black bin
General waste non-risk waste

Bins should be labelled

Infectious waste Yellow bin
infectious waste

The box should be labelled

Sharp waste Yellow safety box
biohazard waste.

Note that in the absence of colour coded bins, it is possible to place waste segregation system
using labelled waste bins with an infectious and non-infectious symbol or text on the side of the
bins. However, such bins should not be used for liquid waste.

To maximize efficiency and safety, these three waste categories must be handled and disposed of
separately throughout the main steps of: segregation, collection, handling, storage, transport,
treatment, and disposal.

Location of segregation containers

• Safety boxes
Ø A safety box should always be located within arm’s reach of any place where an injection is
given.
Ø Don’t place containers on the floor or anywhere where they could be knocked over or easily
reached by children.
• Infectious waste bins.
Ø Yellow infectious waste bins should be located in all rooms where infectious waste is
generated.
Ø Infectious waste bins should not be located in public areas.
• Non-infectious waste garbage bins
Ø Black garbage bins should be located in all sits where waste may be generated and in all
pubic area.

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 Figure 1. Segregation of health care waste by waste type

Source: Path, 2005.

Handling

When handling waste, waste management staff should wear protective clothing at all times.
Wearing PPE reduces risk from sharps and protects against exposure to blood and other bodily
fluids, and splashes from chemicals. PPE that is recommended to be worn when handling waste
includes:

• Dust mask
• Face shield
• Heavy duty, gloves
• Plastic apron
• Clothes that cover the body
• Head cover
• Goggle

NB: Check box 4A for illustration

Handling sharps

• Place the syringe in a safety box immediately after use

• Do not recap, bend, or remove needles from syringe.

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Handling safety boxes

• Safety boxes must be fully and properly assembled before use.

• Safety boxes must be sealed and collected when they are ¾ full.
• Safety boxes must never be emptied or opened.
• Put sharps containers as close to the point of use as possible and practical, ideally within arm’s
reach.
• Mark or label safety boxes so that people will not unknowingly use them as a garbage container
or for discarding other items.
• Don’t shake a safety box to settle its contents and make room for more sharps.

Handling infectious waste bins

• Infectious waste bins should be covered before collection,

• Bins should be cleaned and disinfected by using 0.5% chlorine solution for 10 minutes after
emptying.

COLLECTION

Schedule

• At a minimum, the infectious waste bins should be collected each day.

• Safety boxes should be collected when ¾ full or daily.
• Garbage bins should be collected each day.
• No infectious bag or bin should be collected unless it is labelled with its point of production and
content.

Transport

• A trolley, bin, or wheel barrow may be used for transporting safety boxes and bins
• Containers should be covered with lids during storage and transport
• Carts should be used for transporting bags of infectious waste within the facility

Disposal

OPTIONS LISTED IN DECREASING ORDER OF PREFERENCE.

• Sharps waste:
Ø Incineration using either properly built brick incinerator or another incinerator
Ø On-site burial

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BASIC HEALTH POST REFORM IMPLEMENTATION GUIDELINE 29
• Infectious waste:
Ø On-site burial
Ø On site incineration provided that the incinerator is standard incinerator and capable of
destroying such wastes
• Non-risk waste:
Ø Collection by municipal truck for landfill disposal
Ø On-site secured burning

Incineration

All incinerators should be inspected and maintained by an environmental health professional on a

regular basis, and report of the inspection should be provided to health post management.

The staff must wear protective equipment when loading and operating the incinerator. Proper
equipment includes heavy duty gloves, boots, apron, and goggles. Protective equipment should be
made of materials that do not easily burn or melt.

Burial of infectious waste

Burial pits must be properly constructed and protected. Pits must be above the water table (the
bottom of the pit should at least be 1.5 meter away from the ground water table) and fenced to
prevent access by animals and the community. Non-risk waste must not be dumped into
infectious waste burial pits.

Waste Spills

Despite the implementation of preventive measures, waste spills can occur. Outlined below are
procedures to manage waste spills according to type.

All those managing waste spills should wear personal protective equipment such as protective
gloves, goggles and masks.

A) Infectious Waste Spills

A bleach (Sodium Hypochlorite) solution should be poured over waste and be allowed to stand for
15 minutes. After the allotted time has passed, using a dustpan and broom, the waste should be
carefully brushed off the ground and into an infectious waste bag or bin. Ensure no waste remains
in the broom. After waste has been removed, cover the area with bleach solution.

B) Sharps Waste Spills

A bleach (Sodium Hypochlorite) solution should be poured over waste and allowed to stand for 15
minutes. After the allotted time has passed, using a dustpan and broom, the waste should be
carefully brushed off the ground and into a puncture proof container. Do not allow hands to contact
sharps. Ensure no sharps fragments remain in the broom. After waste has been removed, cover the
area with bleach solution.

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 C) Managing spills of broken thermometer and blood pressure equipment

Those handling spills of broken thermometer and blood pressure equipment should wear
examination gloves on both hands. All droplets of mercury should be collected with a spoon (or
similar utensil), and placed in a small, closed container for disposal or reuse. Wash or clean the area
with a bleach (chlorine) solution. When process is complete, examination gloves that were used
should be removed carefully and hands washed properly.

Housekeeping: Maintaining a clean environment is essential to provide quality care for patients.
Proper cleaning will reduce the number of microorganisms in patient care areas and will help to
minimize the risk of exposure to infectious agents to patients, families, caregivers, visitors and
health post staff

Work plan: The health post should develop operating procedures or work plan on the cleaning
process and schedule for each rooms.

Supplies: The health post should have a regular supply of all necessary cleaning materials. At a
minimum, each health post should provide the following:

• Disinfectants and detergents, bleach, powder detergents e.g. Omo

• Mops, cloths for dusting, brooms, soaps , buckets
• Personal protective equipment for cleaning staff and alcohol for hand rub preparation.

The head of the department should plan for and request supplies to meet monthly consumption
needs.

Procedures: Administrative and office areas with no patient contact require normal domestic
cleaning including sweeping, dusting, washing floors and windows with detergent.

All patient care areas should be cleaned by wet mopping, scrubbing or dusting and\or scrubbing
using disinfectant cleaning solutions. The cleaning solution should be prepared according to the
guidance outlined in the Infection prevention and patient safety reference manual for health care
providers and health care managers in Ethiopia. Staff should be trained /oriented on how to prepare
cleaning solutions and procedures for preparing the solution should be posted in an area visible to
the cleaning staff.

Safety: The staff should wear appropriate personal protective equipment appropriate for the work.
For example, during cleaning, staff should wear plastic aprons, heavy duty gloves, masks and
protective shoes. Staff likely to be exposed to substances that may splash or splatter should wear
goggles. Other protective equipment should be provided as necessary.

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BASIC HEALTH POST REFORM IMPLEMENTATION GUIDELINE 31
Box 1: Below provides a graphic of representation of what should be worn during cleaning.

Wearing PPE reduces risk from sharp, germs,

exposure to blood and other bodily fluids, and
splashes from chemicals.
Staff handling waste should wear the following:
• Dust mask
• Face shield
• Heavy duty, gloves
• Plastic apron
• Clothes that cover the body
• Head cover
Other cleaning staff should wear PPE as appropriate
to their exposure.

Fig 2. Personal protective equipment during cleaning

Instrument processing

There are four main steps in instrument processing as outlined in Figure 2 below:
decontamination, cleaning, sterilization or high-level disinfection and storage.

Figure 3: Instrument processing steps

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Point of use Cleaning/cleaning: Physical removing and mechanical reduction of the number of
microorganisms, of infectious agents, especially endospores and other organic matters should be
done during cleaning. Cleaning though use of detergent or soaps and brushing must be done for
effective sterilization and high level disinfection. Use liquid soap is good for effective cleaning.
Cleaned instruments should be dried, packed or wrapped if necessary, and labeled before go to
sterilization.

Sterilization: The hospital should have functioning autoclaves and dry heat ovens for sterilization
of medical equipment. There should also be a supply of 2-4% glutaraldehyde or 8% formaldehyde for
chemical sterilization of plastic items. Proper packing should be applied before following the
procedure. In case of chemical sterilization removing of objects from the solution with sterile forceps,
rinsing all surfaces three times with sterile water, and air-drying must be done. Mechanical, chemical
and biological indicators can be used to control the well-functioning of the process. Mechanical
indicators are most commonly used. This would include checking adherence to recommended time,
temperature and pressure. Chemical indicators are often used as supplement to mechanical
indicators.

High level disinfection: HLD can only be used when there is No sterilization system. Steamer pans
and boilers should be in place for high level disinfection purposes. Steaming, Boiling and chemical
HLD can be applied. Instructions how to perform HLD should be posted in the procedure rooms and
staff instructed to follow the outlined procedures.

Storage of sterilized equipment: All sterile items should be stored in an area and manner to protect
the packs or containers from contaminants such as dust, dirt, moisture, animals, and insects. The
storage area of sterile items for the hospital is best located next to or connected to the place where
sterilization occurs. The space should be in an area separate, enclosed, with limited access and
should be used only to store sterile and patient care supplies. Sterilized instruments should be re-
sterilized again if anything happen on the package before 30 days.

Soaking of instruments in disinfectant prior to cleaning

According to the WHO and PHAO, soaking of instruments in 0.5% chlorine solution or any other
disinfectant prior to cleaning is not recommended for the following reasons

ü It may damage/corrode the instruments

ü The disinfectant may be inactivated by blood and body fluids, which could become a source
of microbial contamination and formation of biofilm

ü Transportation of contaminated items soaked in chemical disinfectant to the

decontamination area may pose a risk to health care workers and result in inappropriate
handling and accidental damage May contribute to the development of antimicrobial
resistance to disinfectants.

Worker safety

In addition to the procedures outlined above, the health post should ensure that mechanisms are
in place to identify and address occupational health and safety risks to staff. The health post
should also ensure that staff can access services in the event that they are exposed to infectious
agents.

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BASIC HEALTH POST REFORM IMPLEMENTATION GUIDELINE 33
Injection safety

The use of injection materials in the health post setting exposes healthcare personnel to needle
stick injuries and potentially to infectious materials.

The injection safety should include the following areas:

• Needle and syringe usage and disposal:

Ø Every injection is given using a single sterile syringe and needle combination
Ø Syringes are not reused
Ø No recapping, manual detaching or manipulation of used needles
Ø After each use, the needle and syringe are safely disposed of in a puncture proof container
• Needle stick injuries:
Ø There is a reporting and tracking mechanism for needle stick injuries
Ø HIV Post exposure prophylaxis plan (see below)

HIV Post exposure prophylaxis

The risk of HIV infection after a needle stick injury or other exposure to HIV-infected blood is
estimated to be 0.3% (3 in 1000 or 1 in 300). However, several cases of seroconversion among
healthcare workers exposed to HIV via mucous membrane or non-intact skin have been documented.
Implementation of standard precautions will significantly reduce occupational exposure of health
post staff (both healthcare workers and support staff) to HIV and other blood borne pathogens. In
the event that healthcare personnel (HCP) are exposed, health posts staff should immediately
contact the nearby health centre to identify and assess staff need for PEP and provide care and
treatment.

NB: The following guidelines only address the management of occupational exposure among
healthcare workers. In addition to PEP for occupational exposures, health posts should link clients
to the nearby health centre which provides PEP services for non-occupational exposure to HIV, such
as sexual assault. The recommendations provided in this section are based on the national PEP
protocol.

PEP Procedures

If an occupational exposure occurs, the following procedures for PEP should be followed:

Step 1 Treat exposure:

• Use soap and water to wash areas exposed to potentially infectious fluids as soon as possible
• Flush exposed mucous membranes with water
• Flush exposed eyes with water or saline solution

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Step 2 Report exposures:

Report and document the exposure. The incident should be reported to the healthcare personnel’s
immediate supervisor and nearby health centre.

Personal Protective Equipment, Commodities and Supplies

The health post staff should ensure availability of :

• Personal protective equipment and cleaning supplies such as gloves, soap, towels, linens,
alcohol, etc
• Functionality of sinks and toilets
• Functionality of incinerator and other waste disposal equipment
• Water supply

Educating patients, caregivers, and other visitors regarding IPC/CASH guidelines

Family members/caregivers are integral in the health delivery process, as they may assist in the
care of the patient. Therefore, it is critical that family members and other caregivers are informed
and educated on IP&PS guidelines.

Educate patients and visitors on IPC/CASH guidelines using illustrative pamphlets. The health post
staff is responsible for educating patients and visitors about IPC/CASH practices within the health
post.

The staff can educate patients and visitors in either a group or an individual basis. The health post
should have pamphlets and/ or brochures that highlight the IPC/CASH practices and that the
patients, caregivers and visitors are expected to abide by. For example, educational pamphlets
should address hand hygiene procedures. Brochures, pamphlets, or other educational materials
should be illustrative in nature. This enables all visitors and patients — regardless of education or
literacy level—to quickly grasp the concepts of IPC/CASH guidelines. Wherever possible, posters
detailing IPC/CASH practices also should be posted in patient/ clients care areas.

Health post infrastructure

There should be separate room for each service provided in the health post. The room should be in
line with respective standards set with adequate ventilation. Arrangement of service rooms need to
be considerate with regards to the flow of service provision in the health post.

Furthermore, the homes or living area of professionals working in the health post or any other
kebele personnel should be away from the health post service areas.

Electricity

There should be a reliable source of electricity for every health post. If the source is either
generator or solar panel, there should be a dedicated personnel overlooking the maintenance and
function of these appliances through arrangements with respective woreda/health center.

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Water supply

All health posts should have access to a safe and reliable water supply. Water in health post must
be:

• Free of disease-causing organisms and any other hazardous substances,

• Clear, colourless, odourless, and tasteless,
• Not too highly concentrated with calcium, magnesium, manganese, iron, or carbonates,
• Without any corrosive substances, and
• At a relatively low temperature.

A backup water supply such as water tanks, a reservoir or dedicated well should be available in case
the main supply is interrupted. Water tanks should hold sufficient water to supply the health post
for at least three days. Backup supplies should be cleaned regularly and water checked to ensure
the quality and safety of the water being brought to the health post. A mesh filter can be used to
prevent large debris from entering the water supply. Filters must be cleaned on a regular basis, as
they tend to get clogged with dirt or mud.

Pest and rodent control

Rodents and insects can spread disease and cause damage to buildings and equipments. The
presence of pests and rodents can be minimized by keeping the facility clean and free from waste
materials.

Inspections should be performed on a quarterly bases to detect the presence of rats, rodents or
other pests, paying particular attention to store rooms. Proper extermination methods should be
undertaken when pests are suspected. Extermination techniques should be performed in accordance
with local rules. Patients and staff should be temporarily removed from areas if there is a risk of
exposure to toxic chemicals or substances.

Health Post Security and safety

Security for the staff, patients, property, and information located within the health post is essential.
Security personnel play a vital role in ensuring that the health post is welcoming and accessible but
also a safe environment for patients, visitors and staff. Security personnel need a thorough
knowledge of the premises in order to protect buildings and valuable equipment.

The health post should have a policy to control access to the health post addressing all relevant
areas. Access to the health post should be limited to staff, patients, caregivers and visitors with
legitimate access. Health post staff need to dress badge always while in the health post.

IPC/CASH standard and Verification Checklist

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Table 7: IPC/CASH standard and Verification Checklist

Implementation Yes (√) Met = 1

SN Verification criteria
standards No (x) Not Met = 0
Check the presence of hand washing
facilities (at minimum with soap, water at
Hand hygiene is service delivery points
practiced by all
healthcare Check availability of continuous water supply
providers before
1
and after contact
Check whether hand washing posters are
with a patient/
posted at a visible location
client regardless of
their health status.
Randomly spot-check staff regarding hand
washing practices (Knowledge)

Safe injection Check that safety boxes are available in the

practices and safety right area
2 box use are
implemented to Verify through spot checks or interviews
minimize risk. whether recapping of used syringes is
practiced
Check/observe the Health Post compound
The Health Post cleanliness
ensures
3 housekeeping Check/observe that service areas are visibly
activities and green clean
areas.
The health post is properly fenced

Verify that there are functional showers in

The Health Post
the Health Post (if applicable)
ensures the
availability of
4 Verify presence of toilets with hand washing
adequate and
facility
functional toilets,
and showers. Verify cleanliness of toilets (inside and
outside)
All Health Post staff
are trained using
Verify by checking staff training database
standard infection-
5 from the respective HC or check if
prevention and
certificate/letter of participation is issued
patient-safety
training materials.

The health post Check presence of water supply

6 ensures availability Check presence of electric supply (solar or
basic amenities main grid)

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Chapter 4
COMMUNITY ENGAGEMENT
OPERATIONAL STANDARDS

1. The kebele has functional community health volunteers (women’s group, men’s group,
village health leaders, youth groups, and other local social structures).

2. The Health Post staff closely work with other sectors to strengthen community
engagement strategies

3. The health post staff establish regular forums with community health volunteers at kebele
and gote levels

4. The health post implements school health packages in all schools in the kebele.

5. The in collaboration with the supervising HC, the health post staff organize community
forums on regular basis

6. The kebele regularly implement community score card (CSC) jointly with the supervising
HC

IMPLEMENTATION GUIDES

Enhance community engagement strategies: Comprehensive community engagement strategies

will be implemented in all kebeles. This requires the active engagement of health sectors and
mobilization of local administration and other sectors. The community engagement strategies
identified for implementation at the kebele and community levels include:

• Introducing Village Health Leaders (VHLs) to link Women’s Development Groups/ Armies (WDG/
As) and communities with the HEP;
• Optimizing the WDG/A strategy;
• Appending men and youth engagement strategies;
• Using existing treasured and trusted social platforms;
• Designing and implementing tailored motivation mechanisms.

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Figure 4: Community engagement strategies and their relationships

Building the capacity of community health volunteers: Once all required community-based
structures are established and deployed, building the knowledge and skills of those recruited
community volunteer health cadres is essential to reaching every individual, family, and community
and improving health and health system literacy. The HP staff in the HC are responsible for building
the capacities of these community health cadres. Key activities include but are not limited to:

• In collaboration with kebele administration and the HC, recruit active community health
volunteers;
• Provide capacity-building training for recruited community volunteers;
• Set up regular performance review and learning platforms at the kebele and sub-kebele/gote
level as per the national guideline;
• Provide community-level mentorship/coaching to community volunteers in their catchment
areas;
• In collaboration with the local administration and the HC, implement motivation mechanisms
for volunteer community health cadres.

Engage other sectors: Working relationship with kebele and sub-kebele structures is essential to

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BASIC HEALTH POST REFORM IMPLEMENTATION GUIDELINE 39
fostering local political ownership and ensuring multi-sectoral engagement to improve the
community engagement strategies and promote health. As health sector is a member of the kebele
cabinet, there is an opportunity to advocate and share the performance of community engagement
in health in the regular meetings. The major activities to strengthen community engagements in
health include but are not limited to:

• Actively working with other sectors, such as Education, Water, Women, Youth and Children’s
Affairs, Agriculture, and others to recruit, train, deploy, and monitor community health volunteers;
• Regularly discussing successes and bottlenecks with kebele leadership and other key
stakeholders to implement local solutions;
• Working with community representatives to ensure accountability and ownership of community
and primary health care systems by implementing a community scorecard.

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COMMUNITY ENGAGEMENT STANDARDS AND VERIFICATION CHECKLIST
Table 8: Community engagement implementation checklist

Yes (√) Met = 1

Implementation
SN Verification criteria Remarks
standards Not Met
No (x)
=0
Number and gender
Village-level Health Leaders are
mix from list of
recruited, trained, and deployed in
VHLs at HP from the
the kebele as per the guideline
report
At least 80% of Village- Health
Leaders attend meetings and Observe VHL
trainings and supervise other registers and
community groups at least once in meeting attendance
on quarterly basis
At least 80% of Women’s
Development Groups/Armies report
to and attend meetings and Observe WDG/A
trainings with Village Health registers
The kebele has Leaders/Health Extension Workers
functional quarterly
community
health volunteers At least 80% of men’s groups are
(women’s group, actively participating in health
1 men’s group, activities (e.g., they report to and Observe register,
village health attend meetings and trainings with reports, and minute
leaders, youth Village-level Health Leaders/Health book
groups, and other Extension Workers at least
local social quarterly)
structures). Youth groups are actively participate
in health activities (e.g., they report
Observe register,
to and attend meetings and
reports, and minute
trainings with Village Health
book
Leaders/Health Extension Workers
at least quarterly)
Other local social structures (e.g.,
idir, clan leaders) are identified and
actively participating in health
Observe register,
activities (e.g., they report to and
reports, and minute
attend meetings and trainings with
book
Village Health Leaders/Health
Extension Workers at least
quarterly)

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 There is a joint annual plan on which
Observe a joint plan
key sectors have agreed to
signed by all
The Health Post strengthen the community
stakeholders
staff work closely engagement strategies
with other The performances of community
sectors to engagement has been reviewed on Observe HP reports
2 strengthen a regular basis (at least quarterly) in and meeting
community the presence of kebele leaders and minutes
engagement other sectors
strategies in Observe the action
health. Joint action points have prepared
points included in
and implemented based on reviews
the quarterly/
findings
monthly plan
HP staff have schedules/plan to
The Health Post train and regularly review the
Observe schedules
staff establish performance of volunteer
regular forums community health groups
with community The HP staff provide training and/or
3
health volunteers review performance of Village-level
at the kebele and Health Leaders, Women’s Observe minute
gote levels every Development Armies, men’s groups, book and reports
quarter. and youth groups on at least a
quarterly basis

A school health work plan is

The Health Post prepared included in their annual, Observe work plan
implements monthly, and weekly work plan
school health
4
packages in all
School health packages are
schools in the Observe school
implemented in all schools in the
kebele. health reports
kebele

The Health Post Community forums are conducted Observe minute

staff organize on quarterly basis book
5 community Action points have been prepared
forums every Observe an action
and implemented based on
quarter. plan
feedback from the community
Community scorecard
Observe guideline
implementation guide is available
The kebele
A community scorecard committee Observe list of CSC
regularly
has been established in the kebele committee
6 implements a
community The community scorecard
scorecard system. committee implements the Observe minute
community scorecard in the kebele book and reports
on a quarterly basis

42 HEALTH EXTENSION PROGRAM OPTIMIZATION:

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Chapter 5
HEALTH INFORMATION SYSTEM AND
PERFORMANCE MONITORING
OPERATIONAL STANDARDS
1. All the health post staff have prepared their annual, quarterly and monthly plan

2. The health post should have implemented CHIS/family folder system

3. The health post needs to implement data quality audit on selected priority problems

4. The health post should have updated display charts

5. The health post has functional electronic CHIS

IMPLEMENTATION GUIDE
Health Information System

Community Health Information System (CHIS): The Community Health Information System uses the
Family Folder, which is a tool or package designed for data collection and documentation to meet
the necessary information needs for providing family-focused promotive, preventive, and
environmental health services at the community level. Complementing the Family Folder is a simple
HIS record-keeping and reporting procedure that feeds community-level health information.

Family Folder: This is a family-centered tool designed for the HEW to manage and monitor her work
in educating households and delivering an integrated package of promotive, preventive, and basic
curative health service to families. The Family Folder is a pouch provided to each family. Information
on household identification, data on family members and household characteristics in terms of
environmental sanitation (latrine, handwashing facilities, waste disposal, and drinking water source)
and malaria prevention (LLITN) is recorded on the cover side of the Family Folder.

Figure 5: Sample Family Folder

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These standardized Family Folder or CHIS recording forms are developed according to international
standards through consultation with technical programs and care providers. Below is the list of
basic forms/instruments used in the record-keeping process at the HP/community level: A) kebele
profiling forms; B) family/household health information recording instruments; C) tallies, and D)
reporting forms.

Kebele profiling forms: Kebele profiling forms serve as tools for collecting data on the kebele
population, health resources available within the kebele, the status of environmental health, and
basic health indicators. This information serves to help plan health activities and as baseline data to
calculate coverage indicators and assess changes in the health status of the population. The kebele
profiling forms are:

Kebele demographic profile: This form is for compiling the demographic data of the kebele. Once
the household registration is complete and the cover pages of the Family Folders have been filled
out, the following data are compiled from these cover pages. The information is updated annually
based on the updated data from the Family Folders.

Table 9: Kebele demographic information

Kebele resource mapping: This is a form for compiling data on potential resources within the kebele
that can be useful in promoting health-related activities: e.g., schools, religious institutions, teachers,
agriculture department agents, trained traditional birth attendants, and community health workers
(or graduate model households) within the kebele. Data on slaughterhouses and marketplaces are
also compiled to target health-promotion activities.

N.B. The data for kebele resource mapping are collected from the office of the kebele administration
and updated yearly. This information is also used to draw the map of the kebele with its main key
descriptions, like HPs, mediation places, market areas, main roads, and rivers.

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Table 10: Kebele resource mapping

Kebele household environmental sanitation profile: This is for compiling data on the household-
level environmental sanitation profile of the kebele. Once the household registration is complete
and the cover pages of the Family Folders have been filled out, the following data are compiled from
these cover pages. The information is updated annually based on the updated data from the Family
Folders.

Table 11. Kebele environmental sanitation information compilation form

N.B. The initial kebele profiling will be done at the time of household registration, when all the
households in each gote (sub-kebele) of the kebele are numbered and the families are issued Family
Folders. Subsequently, the kebele profile will be updated annually based on updated data recorded
in the Family Folders.

Family Folder: The Family Folder is a pouch issued to every household in the kebele. It contains
information about the household that will help the HEW identify the health (preventive, promotive,

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BASIC HEALTH POST REFORM IMPLEMENTATION GUIDELINE 45
and environmental) service needs of the family or household and provide the service or counsel
them accordingly. During the initial household registration, every household in a gote is issued a
unique identifier number consisting of a 2-digit gote code followed by 3-digit household number
(XX.XXX). The HEW, in consultation with the kebele administration, will assign the gote code to each
gote in the catchment kebele. Subsequently, when a new household is created in a gote, the last
available serial number for the Gote will be assigned to that new household.

The Family Folder pouch has five basic parts:

• Identification;
• Household description;
• Household characteristics;
• HEP package training status;
• Household implementation status of the HEW packages.

Tickler boxes/reminder file system: The tickler/reminder file system comprises 12 boxes arranged
serially, with each box representing a month of the year that helps identify the clients who should
have received follow-up services in a certain month but have defaulted. Figure 5 provides more
details.

Figure 6: Tickler/reminder file system

Health card: The health card comes in two colors, with identical content to identify the sex of the
household member. Blue is assigned to male members and yellow for female members. Every
household member older than five years has his/her own health card, and every child under five
years of age has a health card associated with his/her mother’s yellow card. When the child reaches
five years old, he/she is issued a new health card based on his or her sex. A child who has lost his/
her mother or whose mother for some reason does not have a yellow health card, uses his/her own
health card based on his or her sex. The health card has ten parts:

1. Identification;
2. Earlier health history;
3. Disease information;
4. Referral information;
5. HIV/AIDS:

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 a. ART follow-up;
b. Home-based care and support for PLWHA;
6. Tuberculosis;
7. Family planning;
8. History of Immunization;
9. Height and weight status;
10. Orphan support.
Integrated Maternal and Child Care Card: Every woman in a household who is pregnant and delivers
a baby has her own integrated maternal and childcare card. The card is a folded, yellow, A4-sized
card with the front used for recoding pre-pregnancy status and pregnancy follow-up information.
The inside is used to recode delivery, postnatal care, immunization, and a growth monitoring chart
for boys. The back side contains growth charts for girls. The content of the integrated maternal and
childcare card contains:

• Identification;
• General condition;
• Obstetric history;
• Current pregnancy;
• Pregnancy follow-up.

Master family index (MFI): The MFI is an index to record the name, father’s name, and grandfather’s
name for each household in alphabetic order by gote. For every letter, use one or more pages, as
necessary, and start a new page for the next letter. Separate lists are maintained for each gote. For
recording household information, use one row for each household’s record. In the first column write
the name of the head of the household. In the next columns, write the household head’s father’s
and grandfather’s names. Put the household number in the last column.

Table 12: Master Family Index (MFI)

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Field Book: The Field Book has five columns. For every client served for whom the Family Folder is
not available to the HEW, enter the date of the visit, name of the client, and the service provided.
Services are recorded in the third column. For recording the service, note the specific service
provided. For example, for Family Planning services, record the type of commodity or service
provided; for disease, write the diagnosis. In the fourth column, note the name of the household
head or the household number, if available, and in the fifth column note the name of the gote to
which the client belongs.

Table 13: Field book

Tallies and reporting forms: Tally sheets are tools used to count service items provided to individuals
or any observation units. There are four kinds of tally sheets: service delivery, disease information,
tracer drug availability, and family-planning method dispensed.

The HIS reporting forms collect and transfer the data required to calculate the indicators used in
performance monitoring. The data are gathered from family/household health information records,
using tally sheets, and entered into the reporting forms both manually and electronically. The
quarterly and annual reporting forms for each level, along with the definition for each data item
reported, and the registered items and tally source for each data item are included in the updated
HIS/CHIS manual.

Figure 7: HMIS/M&E reporting flow

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Reports flow into and out of the Health Extension Program through the head of the HP, who
disseminates the information compiled to the responsible officers. These officers review and may
provide feedback or additional processing.

Figure 8: CHIS data flow

Electronic Community Health Information System (eCHIS): This is used for electronic and
comprehensive data collection, documentation, analysis, reporting, and use of the information by
HEWs to meet the necessary information for providing family-centered health services at the
community level. There are 3 mobile applications in eCHIS system:

• [Primary] Health Extension Worker application: It supports the HEWs in Family Folder (Pouch)
management and prioritizes RMNCH service delivery and follow-up;
• Health Center referral application: It supports the HC workers to confirm referrals and provide
referral feedback to HEWs;
• Focal person application: It supports the supervisor (focal persons) in providing technical and
programmatic support to the HEWs.

Figure 9: eCHIS mobile application system

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Data Quality

Data quality is often defined as “fitness for use.” Good-quality health is dependent on the access to
and use of good quality data. It is a starting point for healthcare information, whether maintained
manually or electronically. The availability of quality data lies at the heart of functioning evidence-
based decision-making in the health sector. It is widely recognized that quality data lead to better
clinical and health administrative decisions that result in better health outcomes for the country.
Data quality is important for service users, for healthcare organizations, and for researchers.

Symptoms of data-quality problems:

• Different people supply different answers to the same question.

• Data are not collected in a standardized way or objectively measured.
• Staff suspect that the information is unreliable, but they have no way of proving this.
• There are parallel data systems to collect the same indicator.
• Data-management operational processes are not documented.
• Data-collection and reporting tools are not standardized; different groups have their own forms.
• Too many resources (money, time, and effort) are allocated to investigate and correct faults
after the fact.
• Mistakes are spotted by external stakeholders (during audits).

Possible solutions to problems of data quality: Guidelines and recording and reporting forms
should be standardized and simplified across the health system:

• Integration and institutionalization of health data;

• Build the capacity of the health work force, from data generation to information use;
• Staffing of health institutions with necessary skilled human power to support the HIS;
• Strengthen the Performance Monitoring Team (PMT) at each level of the health system;
• Enhance the culture of information use at each level of the health system.

Data quality assurance: Data quality assessments help improve data quality by uncovering hidden
problems in data collection, aggregation, and transmission of priority indicators/data. Knowing
about these problems allows health professionals and managers to develop a data-quality
improvement plan. Different techniques are used at the facility and administrative levels to
determine the level of data quality and take corrective measures.

Techniques of data quality assurance: The following methodology shall be applied to assure data
quality at the service delivery and intermediate health administration units. A desk review can be
performed of the data that have been reported to the national level, whereas the quality of the
aggregate reported data for the recommended program indicators can be examined using
standardized data-quality metrics.

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HEALTH POST ASSESSMENT
Data quality checks using the lot quality assurance sampling (LQAS) method: Other Health Post
assessments can be performed to conduct data verification and evaluate the adequacy of the
information system to produce quality data (system assessment).

Lot quality assurance sampling: LQAS is a technique useful for assessing whether the desired level
of data accuracy has been achieved by comparing data in relevant record forms (e.g., registers or
tallies) and the CHIS reports at the Health Post level.

Basic Principles of LQAS

1. A method for testing hypothesis, e.g. desired level of HMIS data quality is achieved (or not)

2. Small random sample for a lot/supervisory area is used

a. The optimal sample size is 19

b. A sample size of 12 also serves well, particularly if it is consistently used over time for
studying the same supervisory area

c. Testing only two possibilities i.e. Yes or No; Present or Absent

3. If the number of sampled items not meeting the standard exceeds a pre-determined
criterion (decision rule), then the lot is rejected or considered not achieving the desired level
of pre-set standard

4. “Decision rule” table is used for determining whether the pre-set criterion is met or not

5. Aggregating LQAS data from multiple supervisory areas can give us mathematical percentage
of the level of achievement.

6. Comparing LQAS results over time can also indicate if there is any change or not.

Information use culture: The term data/information use refers to the use of data in the decision-
making process. A decision-maker uses information if he/she is aware of the decision to be made or
question to be answered and relevant information is explicitly considered in the decision-making
process, even if the quality of the data is suboptimal.

Culture of information use: The perceived value of individuals and organizations on the role of
information for informed decision making.

Information use at the Health Post level: Facilities need information on the coverage or amount
and quality of services, resources availability including human resources, patients’ satisfaction with
the service etc. These kinds of data inform facilities in planning and managing health services,
program’s performance, and resources.

Information use at the administrative level: For this, information is needed on, e.g., service
coverage, burden of disease, disease occurrences, staff performance, and resource availability for
planning, policy formulation, performance measurement and improvement, designing interventions,
developing strategies, and formulating policies.

Major platforms and forums for information: The major platforms in the health sector for use of
information are the woreda-based annual planning, regular performance monitoring meetings, and
participatory review meetings. These platforms use information to monitor progress vis-à-vis
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performance targets set at the time of strategic planning-Health sector Transformation Plan (HSTP)
and the woreda-based annual planning. Within this performance improvement framework, results
are achieved through a process that considers the institutional context, describes the desired
performance, identifies gaps between the desired and actual performance, identifies root causes,
selects interventions to close the gaps, and measures changes in performance.

Performance Monitoring

Performance management is an ongoing process focused on reinforcing high performance or

improving substandard performance to enhance the knowledge, skills, and behaviors of all
employees to achieve organizational goals. HPs should improve the implementation of CHIS/Family
Folders through supervisions and mentorship for community and HP staff.

• Supportive supervision: This is a continuous and participatory process in which Health Post
staff share responsibility for the community to improve community performance using data
verification and support the community to obtain the best possible performance from the HPs.
• Performance Review Meeting (PRM): This is the practice of periodic review and evaluation of
the HPs’ performance with the community leaders against specified goals or expectations.

MONITORING AND EVALUATION

Planning in BSCs: A balanced scorecard (BSC) is a management system that enables organizations
to translate the vision and strategy into action. BSC also enhances and encourages accountability to
the planning system. Nationally, the BSC is used as the main planning tool in in the health system
(FMOH, health bureaus, and health facilities). HPRIG implementation should be included in BSC
planning by all staff standards should be cascaded to the Health Post staff at the individual level.
The Health Post staff should also review the performance of the implementation of the standards
regularly.

Data-quality checks using the DHIS2 application

Ensuring data quality is a key concern in building an effective CHIS. Data quality has different
dimensions, including:

• Correctness: Data should be within the normal range for data collected at that facility. There
should be no gross discrepancies when compared with data from related data elements.
• Completeness: Data for all data elements for all health facilities should have been submitted.
• Consistency: Data should be consistent with data entered during earlier months and years while
allowing for changes with, e.g., reorganization, increased workload, and consistent with similar
facilities.
• Timeliness: All data from all reporting organizational units should be submitted at the appointed
time.
• Data quality checks: Data quality checking can be done through various means, including:
Ø At the point of data entry, the software checks the data entered to see whether it falls within
the min–max ranges for that data element (based on all previous data registered);
Ø Defining various validation rules, which can be run once the user has finished data entry.

52 HEALTH EXTENSION PROGRAM OPTIMIZATION:

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 Ø The user can also check the entered data for a particular period and organizational unit(s)
against the validation rules and display the violations for these validation rules.
Ø Analysis of data sets: i.e., examining gaps in data.
Ø Data triangulation: comparing the same data or indicators from different sources.

IMPLEMENTATION CHECKLIST AND INDICATORS

Table 14: Health information system and monitoring implementation checklist

Implementation Yes (√) Met-1

SN Verification criteria Remark
standards No (×) Unmet=0

Have annual plan using BSC

All the health post
Have cascaded quarter plan Check their plan
staff have prepared
form the annual plan using BSC and weather their
1 their annual,
plan cascaded
quarterly and Have cascaded monthly plan from the HP plan
monthly plan form the annual plan using BSC
Have used a standards registry
and field book
Have used a standard tallies
and CHIS reporting tools
Have used family folders/HH
register
Have secured enough registry,
tallies and CHIS reporting tools
for three months
The health post
should have Have willow/tickler boxes
2
implemented CHIS/ Unique FF numbers are given Check samples of
family folder system to all HHs (If applicable). FF
Data registration should have
tickler box for tracing system
for EPI, ANC, FP services.

Every individual family folder

should be registered electronic
based record system.
Separate shelve for storing
medical records.

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 Self-assessments of health
post performance conducted
using LQAS (Lot Quality
The health post Assurance Sampling)
needs to implement Check completeness (content
3 data quality audit on & representative) and
selected priority timeliness (on time reporting)
problems
Major indicators selected for
follow up where the health
post has poor performance

Display plan VS performance

by using standard minimum
display charts
Plan VS performance
Map of catchment area
Catchment Population Profile
Ten Top Causes of Morbidity
(Males & Females)
The health post Top Five Causes of Morbidity In
4 should have updated < 5 Children
display charts
Functionality of WDGAs
Reproductive Health (ANC)
Immunization Monitoring For <
1 Children (Penta3, PCV,
Measles)
Sanitation profile
Malaria Monitoring Chart
Outreach Locations and
Schedule
Have functional tablets with Randomly
updated eCHIS application. sample 5
Have updated community data individual family
in electronic Community Health folders seen in
Information System (eCHIS) the previous
quarters, and
The health post has
confirm that all
5 functional electronic
data elements
CHIS
were entered in
Review the utilization of electronic CHIS
electronic CHIS (demographic
data, clinical and
administrative
data)

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Reference
1. HEP optimization Roadmap 2020

2. HEP optimization Roadmap implementation manual 2021

3. Ethiopia`s Essential Health Service Package 2019

4. Federal Ministry of Health (2010), Community Health Information System User’s Manual for
Data Recording and Reporting, October 2010

5. Federal Ministry of Health (2018), eCHIS End User Training for HEWs, November 2018

6. Federal Ministry of Health (2018), Health Data Quality Facilitator Manual July 16, 2018

7. World Health Organization. (2010). Western pacific country health information profiles:
2010 revision.2.

8. A Guide line on Referral system- 2010

9. Ethiopian IPLS

10. HCRIG

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Appendixes
APPENDIX A:
SUGGESTED CLEANING GUIDELINES FOR HEALTH POST ENVIRONMENTS

Item/Area Method Minimum Frequency

Use clean cloths and change frequently

Waiting during cleaning; disinfectant solution Daily; pay attention to chairs and tables and
area preferred (follow contact time). Wet mop other surfaces in frequent contact with hands.
floor (detergent is adequate).

Use clean clothes for each room; change

cloths frequently when doing a large
Between patients unless surfaces are covered
area; disinfectant solution preferred
Exam (then daily) or immediately when contaminated
(follow contact time). Wet mop floor
room/area with blood/body fluids. Pay attention to exam
(detergent is adequate unless
table, chairs, and tables.
contaminated with blood/body fluids
then use a disinfectant).

Hand Use disinfectant to clean sink, water tap,

washing and faucet handles. Re-supply soap, Daily
sinks clean towels.

Use dilute bleach or other disinfectant to

clean toilet, sink, water tap, faucet
Bathrooms handles, and door knobs. Wet mop floor Daily; more often as needed
with a disinfectant solution. Re-supply
soap, clean towels.

Wet mop floors; detergent/water

Corridors solution is adequate. Change bucket Daily
solution and mop head frequently.

Trash Empty daily, more often as needed.

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APPENDIX B:
REFERRAL FORM (SAMPLE)
Patient Referral Form
From (referring facility)
Address of health facility
Arrangements made Yes No Tel No Fax No Case
number
To (receiving facility) Date
Receiving health professional
Patent’s Name address Date of birth …………............ age ……... Sex M F
History

Findings

Treatment given
Reason for referral
Name of referring health professional Signature
( and telephone number) Reg. NO
On completion of management of patients, please fill in and detach the referral back slip below and send with patient
or fax or post

Tear off …………………………………………………………………………………………………………………………………

From Tel No Fax No

Reply from (name) Date
To referring person
Address of health facility
Patent’s Name
Identity No Address Age Sex M F
This patent was seen by on
Patents History

Physical Findings

Special Investigations
Diagnosis
Treatment/Operation
Medicines prescribed
Please continue with (meds, Rx, F/u, care)
on
Refer back to
Name of doctor, signature and Reg.NO

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58 HEALTH EXTENSION PROGRAM OPTIMIZATION:
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Health Extension Program Optimization:
Basic Health Post Reform Implementation Guideline