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Women and children in many parts of the world are thwarted from leading productive lives due, not only, to lack of education but also basic healthcare. The design of a new prototype healthcare facility to serve

as a template for the delivery of medical services in Afghanistan would meet that country’s dire need and help improve its social progress.

With a per capita income amongst the lowest of all developing countries, Afghanistan is second to last on the United Nation’s human development index, with a life expectancy of 43 years for women, and one of the highest maternal mortality rates in the world, according to UNICEF. The long war-torn country’s child mortality rate is second

only to Sierra Leone as a result of measles, malaria, malnutrition and more. Access to quality healthcare for pregnant women and their children before, during and after childbirth would eliminate most of these deaths and immensely improve the education and productivity picture for the Afghan society overall. Based on World Health data, Afghanistan was selected as one of four sites to be part of a project by the International Organization for Migration and USAID (U.S. Agency for International Development) to create a template for delivery of basic medical services. Public health services would provide disconnected rural communities with a way to bridge the gap to move upward in cultural development.

A PROTOTYPE IN AFGHANISTAN THE STORY OF THE DEVELOPMENT AND CONSTRUCTION OF A PROTOTYPE HEALTHCARE FACILITY TO HELP TRANSFORM CULTURE

By: Deborah A. Sheehan, Principal and Health Market Leader, Cannon Design, Chicago, USA

Courtyards between the inpatient bed units allow for light and ventilation and add a social and religious component to the plan. The geometry of each courtyard is oriented towards Mecca. Courtyards between the inpatient units provide views of nature from the beds. Gender

segregated circulation pathways flow around the perimeter of the courtyard, offering patients dignity and privacy in accessing their care. Images © Cannon Design (unless where noted)

FEATURE PLANNING

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SIMPLE, FLEXIBLE DESIGNWhat would be the ideal building block to make this progress possible? Architects answered with plans for a simple, flexible, transferable community hospital that could demonstrate a permanent commitment, yet be small enough to be placed in rural villages. The basic 100-bed model requires a minimal investment, yet is capable of bringing a leap in the quality-of-life to thousands. The solution distinguishes itself in that it invites participation and investment of the local people. The plan uses universal techniques to adapt to the cultural and medical needs of the visitors.

The size for the hospital prototype is especially supportive of sustainability. Because water, power and waste removal are assumed unavailable, the hospital must be small enough to operate off the grid, yet large enough to achieve an economy of scale in water and power production. Depending on the size, power generation and sterile processing are either in the building or supported by mobile resources. Several architectural features support low energy consumption. Roof overhangs, for example, protect the south façade from direct sunlight during the hottest part of the day. Air is brought in through low windows while operable clerestory and openings in the ceiling allow warm air to escape. Basic fans facilitate air movement. In the winter, a lower sun angle allows direct sunlight and heat gain deep into patient rooms. Baseboard units provide radiant heat, while fans bring in tempered fresh air and circulate it throughout the building.

The plan’s flexibility emphasises changes in size, according to a community’s needs. Three smaller modules can be created based on the 100-bed prototype: a 50-bed women’s hospital, a 20-bed day hospital and a clinic. Because the modules are flexible and expandable, a hospital can be reconfigured as needs change. By selecting the necessary module for a particular location, construction and operational costs are kept low. Modules can be built with any common material, including walls of brick, adobe, concrete or sandbags. Construction of the modules requires that utilities be secured and protected on the site. Water is extracted from a well by deep boreholes and pumped through a treatment facility. A water tower provides a two-day reserve in case of power failure. Fuel tanks for the generator are sized for a three-month reserve. Wastewater generated from food production is collected and treated in separate tanks, as required by Islamic law. The tanks then discharge into a sand filter bed.

ADAPTED TO SPECIALITIESA key difference between this and other solutions typically implemented on a semi permanent basis is the clinical model. This prototype can provide all the basic services needed for community

Bed configurations can adapt to future change in patient acuity to support elevated care at bedside

Flexible Nursing Models flex staff to patient census over time of day

IN SHORT

The design of a new prototype healthcare facility to serve as a template for the delivery of medical services in Afghanistan would meet the country’s dire need and help improve its social progress

Mortality, education and productivity could all be improved in Afghanistan by providing a new system for the delivery of basic medical services

The size for the hospital prototype is especially supportive of sustainability because water, power and waste removal are assumed unavailable

health and education, with enough space to house a couple of key specialities. In Afghanistan, the need for training midwives and female caregivers is essential to lowering infant mortality rates. Orthopaedic services are also in high demand due to land mine injuries. The 100-bed module provides enough space for basic medical-surgical services, as well as an emphasis on obstetrics and orthopaedics. One of the flexible planning innovations proposed is a six-bed unit that can be operated as a three-bed unit when staff levels permit. By dividing the units into gender specific wards of 24, then into rooms of six, then into groups of three, there is tremendous adaptability of use over time of day, shift, or season. Depending on evolving care delivery model, clinical service line,

Illustration shows financial investment in ratio comparison to healthcare efficacy measured by mortality rate. Reprinted with permission © World Bank Group

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staff resources, and cultural preference, the units can be managed in many configurations without renovation. Because of their adaptability, these health centres also function as social centres for education, security and employment, positively impacting the community as a whole.

THE PROTOTYPESThe 100-bed hospital includes bedded care, outpatient clinic, diagnostic and treatment, emergency department surgery, x-ray, dental, support space, education and administration, and an ambulance port. The 15-metre clear span, single story, single slope roof accommodates many types of space. The hospital can provide all the basic services needed for community health and education, as well as allow enough space to house key specialities. An emphasis on obstetrics and orthopaedics can be accommodated, along with basic medical-surgical services. Flexible bed units allow that a six-bed unit can be operated as a three-bed unit when staff levels permit. Gender-specific wards of 24 are possible and can be further divided into rooms of six or three, for many configurations without renovation.

The 50-bed hospital, supported by mobile surgery, accommodates the separation of the sexes, an important cultural consideration, and multi-patient wards. From the main entry, men

and women can reach inpatient services along separate routes. A main courtyard creates a secure public space for visiting family members, between wings and oriented towards Mecca. 50-bed women’s hospitals target prenatal care to blunt Afghanistan’s momentum of high infant mortality. By designating the entire facility for women, cultural boundaries in education and access are removed. Education facilities in the hospital can be expanded to train speciality caregivers, increasing the employment of women in the community.

The 20-bed day hospital, also supported by mobile surgery, can rotate as an outpatient day hospital or overnight inpatient care. Inpatient exam rooms can receive day visitors, and then be quickly converted to overnight recovery as needed for the last surgery cases of the day. Classroom space can double for public health screenings and inoculations. This smaller hospital can grow to the 50-bed and 100-bed size by building shell treatment spaces and using the space for interim support, reserving places for expanded bedded care, reusing public health spaces for new healthcare worker programmes, and leveraging staff and resources across long distances with mobile modality trailers and trucks. As the number of highly trained personnel increase for inpatient services, so will the need to recruit and train staff from the immediate community. On-site housing that was built to house construction

A strong connection to place makes these permanent, scalable hospitals a part of the communities in which they are built. Universally understood building-organising principals like courtyards are combined with local influences in colour and materials. Knowing that mechanical ventilation would not be maintained or was unavailable, the naturally ventilated architecture responds to both summer and winter conditions

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workers can be converted to a dedicated dormitory. Combined with the 20-bed hospital’s education and administration spaces, a complete school of nursing is possible for the community, further contributing to productivity.

The no-bed clinic is the prototype’s most basic building block. This module is adaptable to support major care surges during catastrophic events. Primary and routine surgery care is conducted during normal periods, with a triage centre during mass casualty. Divided into high and low acuity, the building is further divided into public and support functions. Every side of the building specialises in a group of functions, based on access and privacy. The plan creates a hub for future expansion or addition of mobile units. The ‘hub’ clinic serves as the docking platform for mobile medical units, which can carry medical resources throughout large remote areas, reaching people without access to healthcare of any kind.

THE HUB CLINICAs an outpost in a developing nation’s health network, the hub clinic is the ideal docking platform for mobile medical units. These units may reside at other facilities, or in storage, but would be installed here to respond to a temporary or overwhelming need. The mobile units can also serve as an interim step prior to a permanent addition. These mobile units provide developing governments the ability to leverage

their resources across much larger areas, and react to catastrophe. They also allow outside organisations an opportunity to contribute with a proprietary platform and controllable logistics. This means that imaging equipment companies, for example, could access markets that are not currently available. Services that are highly technical, such as cardiac cath, can be brought to many new patients. Services that are too specialised for wide use, such as lithotripsy and cataract surgery, can be brought to rural areas. The hub clinic provides an interface for the local and international community to interact, via technology and expertise. In Afghanistan, it is the beginning of new expectations for both the patient and the care industry. Higher expectations are that suffering is no longer acceptable and that medicine is not just available for those in urban centres or for only the wealthy who can travel to access healthcare.

CONCLUSIONMortality, education and productivity, all of these can improve in Afghanistan by providing a new system for delivery of basic medical services. A flexible, transferable hospital plan makes a commitment to communities that urgently need not only healthcare, but also learning, jobs and a better way of living. Women and children will be the most dramatic winners, and will be far better able to contribute to the positive transformation of their ravaged nation.

The main courtyard is situated just east of the main public entrance and provides a central gathering space for communal events. This courtyard creates a secure, public space for worship and education events. This central feature also orients visitors to the campus’ key services