upper bound of staff counts in that they assume that all health workers would be available at the facility to attend to patients at all times.

The ratio of health care providers to inpatient beds can shed light on how human resources align with other facility capacity measures. Nurse-to-patient ratios, for example, are highly variable even in the United States, where state-level laws require different ratios for different types of care, but these ratios may vary from 1:1 to 1:6.<sup>14</sup> SDI data from Kenya, Tanzania, and Sierra Leone indicate that the number of health workers per inpatient bed ranges between one and two providers per bed across all three countries. While this metric makes the dramatic assumptions that all health care workers on staff at the facility are in the facility at the same time and are all available (and trained) to attend to an inpatient bed, this crude provider-to-bed ratio gives a sense of the bandwidth of facilities in an all-hands-on-deck scenario.

# Effective communication and coordination

Effective channels for sharing information with the community, local authorities and across various levels of health facilities are essential for coordinating care and for ensuring seamless flow of information and patients between facilities to optimize the use of limited resources. For instance, during pandemics, especially at the peak of transmission, it is important to not overwhelm emergency departments or hospitals (which may be perceived as offering enhanced services) for cases that can be managed elsewhere. Relatedly, severe cases requiring specialized care should be transferred to higher level facilities along with necessary medical history, if the first point of contact with the health system happens at a lower level facility. Likewise, outpatient services should be limited and provided in a way to reduce possible exposure and further transmission. Additionally, access to timely information from local authorities regarding evolving guidance and safety recommendations and dissemination of such information to patients and communities can also happen through the health facilities. Therefore, all facilities, regardless of their location or level of care offered, should at the minimum, have access to a functioning phone and preferably in today’s world, access to the internet.

Do health facilities in Kenya, Sierra Leone and Tanzania have access to a minimally adequate level of communication tools to coordinate clinical care and health service plans with local authorities and neighboring health facilities? The SDI surveys provide insight on the availability of a functional telephone, either a fixed or mobile phone and a functioning computer with internet access. These data indicate that only between 33% and 43% of facilities across all three countries have a functioning fixed or mobile phone. Similarly, access to a functioning internet connection is poor across all countries, with less than 30% of facilities with internet access. Across all three countries, availability of a functioning phone or internet is poorer in lower-level facilities compared to hospitals, as shown in Figure 4, and poorer in facilities in rural as opposed to urban areas. This has potential implications for care coordination between lower-level facilities and hospitals, with the risk of overcrowding in the latter or challenges in initiating appropriate linkages to care from the former.

> 14 Lippincott Nursing Education. “The Importance of the Optimal Nurse-to-Patient Ratio”. November 10, 2016. <u>http://nursingeducation.lww.com/blog.entry.html/2016/11/10/the_importance_ofth-GCAE.html</u>

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