INTRODUCTION

Globally, an unprecedented health crisis has been experienced since January 20, 2020, when the WHO (World Health Organization) declared it had gone from epidemic to pandemic and was called COVID-1 No country was prepared to deal with such a situation except China, because of its background, a country that, since 2003, had already visualized a contingency plan¹. The coronavirus family can cause from a common cold to pathologies of greater complexity, such as that observed in severe acute respiratory syndrome (SARS) or Middle Eastern respiratory syndrome (MERS). The new coronavirus (COVID-19) is a strain that is transmitted from person to person through small water-based droplets or particles that remain in the environment when sneezing or coughing. This means that infection can occur without maintaining physical contact with the infected person². According to a Minsa report, as of May 27, 2020, globally 5 848 536 cases have been detected; 359,661, deceased; 2,537,939, recovered patients and 2,950,936, active cases; the lethality is 6.15%. In Peru, 1 345 905 total cases, deaths are 3983; the lethality is 2.93%. In Piura, of 6039 cases detected, 481 have died with a lethality rate of 7.96%:³for December 31, 2022, Peru, reported 4 479 771 positive cases, within its twenty-four departments. One of them, Piura, had 160,836 positive cases and the district of Castilla was one of the most affected⁴.

This situation, in turn, brought into evidence deficiencies in the health system, especially in the infrastructure and equipment of health facilities. In the proper design of their physical spaces and in the humanization of users or patients; likewise, there is the lack of attention of the competent authorities to provide timely responses in the face of the pandemic, as is the case of the district of Castilla, which is the context of this research.

The study site is the Cayetano Heredia Hospital (HCH), located in the department of Piura, whose construction began in 1972 in the district of Castilla, between the avenues Guillermo Irazola and Independencia, was inaugurated on October 2, 1974 in the government of General Velasco Alvarado. Consequently, the old Hospital de Belen, also located in Castilla, which was created in the early years of the colony, was closed. During the first stage of Alan Garcia's government, the hospitals of the Ministry of Health were integrated with those of the Social Security, and since then, it has been under the administration of the IPSS (Peruvian Institute of Social Security), which later changed its name to EsSalud by law 27056 of January 28, 1999.⁵.

The Hospital III Cayetano Heredia is the institution of the highest complexity of the Health Network of the Piura departmental Management and the Grau Region, a level III hospital, of regional reference; offers basic and specialized care services, in the areas of outpatient consultation, hospitalization, ICU, surgical center and emergency.⁶.

In a 2020 study on quality of work life, 60% of their healthcare providers rate QWL as fair, as institutional support is rated very poor (70%). 81.7% refer to a lack of job stability. It was concluded that the QWL found is regular and deficient. The lowest levels of satisfaction were in institutional support and job security⁶.

It has been observed, especially in Peru, that in hospitals the infrastructure and its equipment do not meet the minimum normative standard, they are not flexible to adapt to change; nor do they have sufficient human and material resources or contingency plans to deal with a health disaster such as COVID 19⁷. Therefore, they had serious constraints to cope with the demand of COVID-19 and any other similar; it is thus that this pandemic was tasked to bare the current care in the health services and show all the restrictions that exist in the establishments to provide adequate health care to the people and much more in a pandemic context.

The major existing problem is the antiquity and physical and functional obsolescence of hospitals, mainly of MINSA⁸. Peru nationally has 181 hospitals, only 16% of the Ministry of Health hospitals are less than 25 years old, 37% have an age of 25 to 50 years, 36% are more than 50 years old⁹. This means that the hospitals are very old with obsolete infrastructure, inadequate medical oxygen system, lack of oxygen generation plants, insufficient and deficient oxygen supply, and inadequate air control system in ICU environments.⁷, this situation determined the increase in COVID cases and deaths, both in Peru and in Piura and Castilla.

It is necessary to unveil the idea of ​​quality, associated with words such as: good, excellent, brilliant and expensive, qualifiers that do not guarantee quality. A very expensive hospital building does not necessarily mean it is of good quality; it may have many undesirable characteristics, such as the inadequate functioning of proximity relations between departments¹⁰. And it is that today there is much discussion about the supremacy of the aspects of design, humanization, and spatial perception of hospital environments over technological aspects, specifically medical, and many investigations have been carried out that confirm the therapeutic effects that the physical environment has in the recovery process of patients^11,12,13,14. Likewise, health risks to hospital personnel resulting from inadequate designs of the physical infrastructure have been studied^15,16.

Humanization, on the other hand, synthesizes all the actions, measures and behaviors that must be generated to guarantee the safeguard and dignity of every human being as a user of a health facility. This means that the user is at the center of every design decision, not only as a producer of functional requirements, but as an expression of the human values ​​to be considered¹⁷. For the design of the physical environment, organizational system and behavioral models of a health facility, it is necessary to begin by establishing the cultural and physical context of the user. In order to favor a humanized perception of the facility and promote a process of identification of the user with the symbols, messages and meanings that the appearance of the building can communicate.¹⁷.

This research aims to analyze the relationship between health infrastructure, for which three aspects have been considered: equipment and supplies, built environments, humanization of care in the face of COVID-19 in the district of Castilla - Piura in the year 2022; therefore, their results may contribute to a better knowledge of other realities and thus contribute to subsequent research.

METHODOLOGY

The research design is non-experimental, explanatory-level, with a mixed approach; therefore, quantitative methods such as survey and qualitative such as in-depth expert interview are applied, within the hermeneutic paradigm, for which several sources of information such as the Pan American Health Organization (PAHO), World Health Organization (WHO), Ministry of Health (MINSA). vulnerability, health infrastructure, COVID-19, equipment and supplies, built environments, humanization.

According to the 2017 Census of INEI, the population of the district of Castilla is 160, 201 inhabitants: because of a large population, the statistical selection criterion, of proportional attachment, was considered to determine the sample.

The questionnaire, as well as the guide of the in-depth interviews were validated by expert judgment, for which referred instruments were sent to two doctors in architecture and a methodologist; once validated, he proceeded to apply them in different areas of the district of Castilla. The results of the survey, with 21 questions, were processed with the IBM Statistic SPSS 27.

RESULTS

After having applied, reviewed and analyzed the results of the surveys to the local inhabitants of the district of Castilla and the interviews to the health experts, the following is observed in terms of the aspects: health infrastructure, equipment and supplies, controlled environments and humanization of care:

DISCUSSION

The commendable work of health professionals and the mission they had in the context of the pandemic must be recognized. However, it cannot be denied that the situation was aggravated by the conditions in which they worked, with inadequate infrastructure, equipment, and physical sanitary spaces, not at all appropriate to attend to health emergencies, a situation that is beyond their control. However, it is noteworthy the criterion of the humanization of the space that implies the reception, the affable treatment of the patient, the empathy as important factors that were evident in all the health establishments of the North.

At the Cayetano Heredia Hospital in the Castilla-Piura district, 81.7% of health personnel report that there is no job security¹⁸. The WHO, in 2017, specifies that, in several countries of the world, more than 50% of collaborators work in an unorganized sector, which does not provide them with social protection, to access a health service and, many times, they do not have elements for the application of occupational health and safety regulations.⁵Despite the fact that health personnel have the necessary training and resources to avoid risks and comply with self-care practices in the biopsychosocial field of the human being; however, a number of problems have been found, such as the increase in pathologies: discs, anxiety and depression⁶.

When the response from other health centers in the interior of the country is analysed, it does not differ much, but when compared with the responses from other countries, the difference is overwhelming. Many lives are lost due to deficient health equipment, due to the lack of flexible and adaptable physical capacity or space that can house more ICU beds and due to the lack of political will of the competent authorities to have responded efficiently and effectively and avoid deaths and an increase in cases. Added to this is the dehumanization of spaces, which did little to help improve patients affected by COVID-19.

Every hospital project or health center should have a space designated for possible expansion, cover the need to accommodate new patients and have a greater number of ICU beds. In addition, spaces or environments should be designed with the ability to adapt and be flexible to other uses during the time required by the pandemic.

Likewise, Estrada M⁷considers that not only in Peru, but in all countries of the world, hospitals are sized and designed on the basis of a portfolio of services to treat certain pathologies according to the epidemiological profile of the place that demands it.

The situational state of hospital infrastructure in Peru presents certain criteria to consider such as: patient treatment and recovery, health and care of medical personnel, biosecurity and asepsis of intervened environments and constant operability and maintenance.²³.

“… In rigorously asepsis environments, such as the ICU, operating room, laboratories, among others, it is necessary to install mechanical air extraction ventilation, where the extraction grille will be installed above 30 cm from floor level.²³.

MINSA has 181 hospitals nationwide. Only 16% of MINSA hospitals are under 25 years of age. 37% are between 25 and 50 years old. 36% are over 50 years of age; the biggest problem is the age and physical and functional obsolescence of its hospitals.

Regarding the supply restrictions in hospital infrastructure and equipment in the face of COVID-19, there is: the high percentage of very old hospitals with obsolete infrastructure (oversaturated, slums. In poor physical condition, with disjointed services due to inorganic growth), inadequate state of mechanical facilities (inadequate medical oxygen system, lack of oxygen generation plants, insufficient and deficient oxygen supply, inadequate air control system in ICU environments), insufficient and inadequate endowment of equipment (outdated equipment, lack of adequate and necessary equipment in intensive care units, lack of maintenance), insufficient maintenance of infrastructure, facilities and equipment (lack of maintenance personnel, lack of a maintenance system, insufficient budget).⁷

Likewise, facing the restrictions for management, there is: the inadequate information system- lack of timely, reliable and secure information on: availability and status of ICU beds, availability and status of equipment, availability of land areas in hospitals to implement temporary contingency infrastructure and availability of urban infrastructure that serves as temporary contingency infrastructure.⁷.

In the Diagnosis of Infrastructure and Equipment Gaps in the Health Sector, which serves as the basis for the Multiannual Investment Programming (MIP) for the period 2022-2024, of the three levels of government, it states that 97% of all health establishments at the first level of care have inadequate installed capacity, expressed in the precariousness of the infrastructure, obsolete, inoperative or insufficient equipment.⁹.

The health establishments of the first level of care, which have been identified as having inadequate installed capacity, are those that have not had any comprehensive intervention with infrastructure and equipment in the last five years. Piura has 97% of first level care establishments with inadequate installed capacity out of a total of 448 ES⁹.

In the face of this reality, PAHAE proposes to address the health emergency with the immediate construction and manufacturing for different situations; the timely acquisition of finishing materials that allow achieving asepsis and biosafety in indoor environments. The inclusion of HVAC systems with filters and negative pressure control, as well as considerations for installations that contribute to hygiene and functionality²³, proposal is framed within the context and reality faced in the Castilla-Piura district and supports the need for a regional contingency plan. Furthermore, it takes into account hospital habitability as a crucial aspect that affects patients' sensitivity and addresses their basic physical and psychological requirements.⁷.

The main limitation of the research was the attitude and low availability of experts to answer in-depth interview questions, difficulties in accessing health facilities, as well as limited in-depth interviews.

CONCLUSIONS

Health experts point out that in the design of a health facility, different environments for different types of pathologies should be taken into account in order to offer a better service, as well as the zoning of areas for respiratory isolation and vector isolation, according to the reality of each region. Therefore, it is important to have a regional contingency plan, the same that allows to carry out the appropriate management of the necessary processes quickly and efficiently, since each department faces different realities and diseases; in the case of Piura: COVID-19, dengue, zika and chikungunya; the last three produced by transmission vectors such as the mosquito.

Among the main deficiencies found in this region is the lack of an effective hospital engineering and architecture, which allows guiding the adaptation, reconversion and expansion of different physical spaces that respond to the needs of patients.

The environments in which patients and healthcare workers stay must be increasingly humanized, to provide comfort, lighting and natural ventilation, i.e., domesticity in the environments, where people feel comfortable, and be treated with respect and kindness, given that medical stays will probably tend to increase in the future..