FINAL_D

CHAPTER 1: AN OVERVIEW

1.1 INTRODUCTION “He who has health has hope, and he who has hope has everything.”

- Arab Proverb 1 Health care has always remained an important issue of concern from the olden days.

Herophilus once said: “When health is absent, wisdom cannot reveal itself, art cannot manifest, strength cannot fight, wealth becomes useless, and intelligence cannot be applied.” 2 2 1

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Plate1: Ancient Greek system of medicine, http://www.hospitalinfonet.com/Modules/Content /User/ShowNews

Plate 2, 3, and 4: Indian systems of medicine, www.traveliteindia.com/healing_05. jpg

Different civilisations have developed indigenous and unique healing therapies which have now come a long way in establishing an identity of their own globally. In India, the only form of health care a few centuries back was the indigenous and ingenious form of medication namely – Ayurveda, Yoga, Unani, Siddha, and Homeopathy. Then came in the western culture, with the advent of which the social

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and psychological perception to the traditional health care methods gradually changed so much so that it was almost forgotten and the western system of health care was adopted, unfortunately it could be availed by the rich, elite only. This led to differences in the health of people within the society.

This inequality in health care service was noticed much later when the World Health Organisation (W.H.O.) intervened for the welfare of the people. As stated by the Alma Ata Declaration on 12th September, 1978: “Health is a state of complete physical, mental and social well being, and not merely the absence of disease or infirmity, it is a fundamental human right and that the attainment of the highest possible level of health is the most important world - wide social goal whose realisation requires the action of many other social and economic sectors in addition to the health sector”. 3 As a result there was a revolution in health care with extensive use of a democratic and decentralised model of Health care as opposed to the centralised and elite oriented health care in the pre independence era so that more people can avail necessary health care and the goal of ‘ Health for all ’ can be effectively materialised. The idea of a health care institution also had a paradigm shift after the Alma Ata Declaration. Regionalisation of Health care was sought for as a more practical solution in a country which had a number of villages and whose village panchayats could take care of the needs of the villagers. Kleczkowski defines in his words: “Regionalisation is a complex system of technical and administrative decentralization and establishment of levels of care, which range from Primary health centre at the community level to the general/district hospital and specialized polyclinics at the intermediate level and culminate in national medical centres where the practice of all specialities is well developed and teaching and scientific research constitute a major concern alongside treatment functions. These different levels of care taken together constitute the regional medical care system, which should be an integral part of the national health system.”4

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Figure 1: Theoretical pattern of regionalization, B.M.Kleczkowski & R.Piboulea, ‘From the view point of the Architect’, Approaches to Planning and Design of Health Care facilities in Developing Areas Vol.2, Published by WHO, Geneva, (1977), (30)

Consequently, a democratic model of health was approved of where the first check point is a Primary Health Care (P.H.C.) as defined by W.H.O.: “Primary health care has to be scientifically sound and socially acceptable and must be geared to peoples needs as well as to the concerns of health professions. It is based on the application of bio-medical, behavioural and health services research and on public health experience.”5 This Centre will refer the patients other health centres for higher treatment which have greater infrastructure and expertise. The following diagram explains the hierarchy of health care:

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Figure 2: Present Health Care system, http://www.srishtisoft.com/iphealthcare.html

Gradually over the years, with the independent growth of the Private, and Public Sectors in healthcare delivery there were many hospitals that developed as profit oriented institutions that provided service at a high rate inaccessible for the poor. For which there were also simultaneous philanthropic or charitable institutions (N.G.O’s) that had a social motive rather than the former. Over time these private institutions gave way to corporate hospitals which developed autonomously with in its corporate sector contributing significantly to the socio-economic profile of the country. These hospitals developed their infrastructure and expertise and proved their mettle internationally gaining repute from accredited hospitals in UK an US. Often these countries outsourced their services to such corporate hospitals who gained revenue by treating these international patients.

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This started off a new movement which saw a collaboration of Health Service Providers and the Tourism Industry to cater to a large palette of end users. Medical tourism an upcoming phenomenon in the country does the same. In this there is a lucrative package offered for the clients which combines health and travel, such that the country can earn profits in foreign exchange.

“The health care sector in India has witnessed an enormous growth in infrastructure in the private and voluntary sector. The private sector, which was very modest in the early stages, has now become a flourishing industry equipped with the most modern state-of-the-art technology at its disposal. It is estimated that 75-80 per cent of health care services and investment in India are now provided sector. India will with no doubt become the global health destination.”6 “Indian health care industry is worth Rs 73,000 crore today or roughly four per cent of the country’s Gross Domestic Product (GDP). In view of the economic liberalisation, there is likelihood of a boom in corporate hospitals and other associated activities in the economy which will result in increased competition among corporate hospitals.” 7 The Indian Systems of medicines which were forgotten in the pre independence era are now in a revivalist mode and there are attempts to allure medical tourists by these systems which appeal to them as exotic healthcare therapies.

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6

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Plate5, 6, and7: Medical Tourism,www.thailongstay-tlm.com, www.packageindia.com/images/trichy.jpg respectively.

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A holistic approach could be adopted so that all the various systems of medicine in the country could also come to the forefront and revived and various systems can thus co-exist. As stated by I.C.S.S.R. in their book: “At the health care delivery level synthesis has to be a well-planned process with a singularly efficient monitoring and evaluation system. Both the units make use of the same diagnostic facilities. Similar units may be started at as many places as possible. Initially, hospitals, preferably those attached to medical colleges, should have alternative outpatients and inpatients departments. In course of time, medical graduates from any medical college would be able to provide such multi-system care.�8

AYURVEDA

ALOPATHY

DIAGNOSTIC SIDDHA

UNANI

HOMEOPATHY

Figure 3: Use of common Diagnostics, Author

In fact, a network system could be devised in order to connect primary, secondary and tertiary health care facilities by means of joint venture (J.V.) financial operations between public and private Institutions that will then promote the Indian Systems of Medicines (I.S.M.) with the help of Modern Diagnostic Services.The study has a broad purview as it is not only socially or economically related to the country it also has architectural implications as now it is the architect who is faced with certain challenges to cope with the current situation.

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1.2 NEED IDENTIFICATION: India today has a major boost in the economic status; one can say that this is owing to the fact that there is an upsurge of a number of health institutions whose standards are much at par with the hospitals abroad. This acts as strength for these hospitals in attracting patients from foreign countries, both developed and developing, who find cost effective quality health care service. They also develop their resource to act as hubs that nourish medical tourism.

The Architect is now posed with queries of what a hub consists of what planning strategy must be adopted so as to derive a model that generates revenue for the welfare of the health scenario of the country and how this revenue can be channelised so that the poor could also benefit from it. An Architect thus weighs the responsibility of developing a hub.

The dissertation introduces the new concept of hubs of health care which is much relevant in the present scene in India in the consequence of growing Medical Tourism and the fact that a number of plans are afloat for the country to grow as a Medical Hub from a global perspective. It is important to understand why it’s vital to create hubs .The dissertation understands a medical hub, the various aspects influencing the establishment of a hub, the role of an architect in this milieu. Analysis is important in this field as any change in the socio-economic condition of the country in the long run affects the patient-loads on the hospitals and hence the architectural planning of these spaces.

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1.3 OBJECTIVES: i) To briefly learn the developments in the health care system in India over a time line beginning with newly independent India to the present day where an all new precept of Medical tourism and Information Technology have gained a firm ground. ii) To clarify my understanding of a Medical Hub, and how it can help the country develop its health infrastructure by catering both to the poor and the rich. iii) To understand the role of an architect in the modus – operandi of a hub and ultimately be able to come up with a design brief for the Medical Hub.

1.4 SCOPE: I. Medical Architecture in itself is a vast topic therefore the current study focuses on a few planning strategies only, which includes, analysis of overall planning, rough estimates.

II. It would have been too taxing to get in to the details of the design considerations of the various components of a hospital and their respective area requirements. Hence the study only mentions the internal areas under broad categories without giving the exact figures.

III. The study also focuses on, Firstly, the Indian context, Secondly, to a particular zone or city as it requires more time to study the health status of every region. As a result the study suggests a model that can be universally applied where only certain factors keep changing from place to place.

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1.5 LIMITATIONS: 1. There has been the constraint of time that has led to lesser time being devoted to the study that has to be done along with other academic requirements.

2. Since the subject of my study is current, gathering in depth information, in terms of exact figures and data relating to ongoing projects, for my case studies, was not possible due to company policies that stated them as confidential and did not wish to share it.

3. My interpretations are based on the articles, data and information gathered by meeting a few people in the field of medical care and medical architecture and planning hence the definitions and generalisations made might not be totally accurate as I relied on limited sources that had limited view points on the subject that is relatively new.

4. Due to the constraint of limited pages and the topic referring to the Indian context, foreign examples have only been mentioned and not illustrated and described for understanding the size and scale.

1.6 RESEARCH METHODOLOGY: I. Collection of all written data relevant to the subject this includes: a) Published Data i.e. Books, Articles, Magazines. b) Unpublished Data in the form of Dissertations. c) The world wide web/internet.

This was followed by a rigorous selection and analysis of information that was of utmost use for further study.

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II. Interaction with people active in the field of medical care and medical architecture and planning. For this there was a necessity of preparing a questionnaire.

The interactive session was recorded and thoroughly analysed and a feedback was written so that the interaction could be used in the study.

III. The study has been supplemented with case studies of on-going proposals for similar projects being undertaken in India. The analysis is in terms of site selection, number of facilities provided, costs incurred and general area requirements so that it helps the study in ways of planning and design of such a space.

IV. After stage-wise selecting the important studies and analysis, the research ends with appropriate conclusions and recommendations by systematically enumerating all inferences and laying down ways of arriving at a design brief for a medical hub that completes the dissertation in a holistic manner.

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REFERENCES: 1. Dr.T.A.Lambo, Deputy Director-General of WHO, Expert Committee on the Role of Hospitals at the First Referral Level, Hospitals and the health care revolution, L.H.W.Paine and F.Seim Tjam, Published by W.H.O., Geneva,1988, (iv).

2. http://www.quotegarden.com/health.html 3. Dr.T.A.Lambo, Deputy Director-General of WHO, Expert Committee on the Role of Hospitals at the First Referral Level, ‘Hospitals and the health care revolution’, L.H.W.Paine and F.Seim Tjam, Published by W.H.O., Geneva,1988, (iv ).

4. B.M.Kleczkowski & R.Piboulea, ‘Regional Planning of Health facilities’, Approaches to Planning and Design of Health Care facilities in Developing Areas Vol.2, Published by WHO, Geneva,(1977), (14) 5. S.L.Goel & R.Kumar, ’Role of Hospitals in Primary Health Care’, Hospital Administration and Management Vol.3, Published by Deep and Deep Publications, New Delhi, (1989), (38) 6. www.medical-tourist.org 7. Strategic service visions for corporate hospitals in a competitive environment, http://www.expresshealthcaremgmt.com/20010915/cover2.html 8. The Indian Council of Social Science Research and The Indian Council of Medical Research, ‘The Alternative Model: General Principles’, Health for All An Alternative Strategy, Published by Indian Institute of Education, Pune, (1981), (99)

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CHAPTER 2: CHANGING FACETS OF INDIAN HEALTH CARE

2.1 NASCENT INDIA: While adopting the Constitution on January 26, 1950, we, the people of India, dedicated us to the creation of a new social order based on equality, freedom, justice and the dignity of the individual and, to that end, decided to eliminate poverty, ignorance and ill-health. 1 Therefore to meet these goals and aims we had to set clear policies to achieve a healthy country for ourselves but the existing health system was created long back by the British administrators, as per their norms which fell short in achieving our goals in many ways than one. The existing model of health care services has evolved over the last 150 years and some of its major features were rooted in the circumstances of its origin and growth: (1) These services were first organized by the British administrators who ignored the indigenous beliefs, life-styles and practices. Instead, they decided to make an abrupt and total change by introducing the Western system of medicine in toto. This created a wide gulf between the culture and traditions of the people and the health services.

(2) The existing services began with provision of health care to overseas personnel located in India, mostly in towns and cities. Later on, these services were extended to the upper and middle classes of the Indian society who acted as intermediaries and interpreters between the rulers and the ruled. It was believed that the improvement in the health status of the people at the top layers of society would naturally trickle down to the lower layers in due course. This urban-biased, eliteoriented approach of the British continued to dominate the health services even after independence.

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(3) The British administrators began with the provision of curative services; through hospitals and dispensaries and the training of doctors, nurses and other personnel needed for them. Later on, programmes for improving environmental sanitation in towns and cities and of immunization against communicable diseases (promotive and preventive services) were also developed.

(4) The system was essentially based on urban hospitals. A typical urban hospital was a large complex offering multiple services and many specialities and expending vast amounts for the maintenance of its facilities and staff. It offered specialist services which would not perhaps be available in smaller units. The system is also highly centralized and bureaucratized.

(5) The system depended too much on doctors who were unwilling to go to rural areas and also highly medicalised like its counterpart in the West. The cultural alienation of the medical profession has led to over-sophistication. The system continued with the over-emphasis on urban, Western-oriented, curative health services at the cost of the more important promotive, preventive and simple curative aspects of community health.

(6) There is no involvement of the community.

Addressing the Rural Population of the country was the prime concern and to this provision of rural health services through Rural Health Centres was recommended

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by the European Conference on Rural Hygiene of Geneva, in 1931 under the Health Organisation of League of Nations. It defines the Rural Health Centres as: “An Institution for the promotion of the health and welfare of the people in a given (rural) area, which seeks to achieve its purpose by grouping under one roof or coordinating in some other manner, under the direction of a health officer, all the health work of that area, together with such welfare and relief organisations as may be related to the general public health work�.2 Following this our country had several Health policies being laid for the betterment of the health status of the country and one such policy was laid in the Bhore Committee (1946) that recommended that a Primary Health Centre should be set up to serve as the focal point for providing comprehensive, curative and preventive health services in the rural areas. The report in this long term programme recommended a primary health unit for a population of 20, 000, a secondary unit for population of 6, 00,000 and a district headquarters organisation for a population of three million. The committee in its short term programme recommended a primary unit for a population of 40,000, a secondary unit for a population of one and half million and a district headquarters organisation for a population of three million

2.2 POST INDEPENDENCE: As said by Dr.Lambo in an expert committee on the role of hospitals:

To increase the momentum of Health for All, to improve interaction between hospitals and other services in the community and to reorient hospitals to local health system based on primary health care, questions should be asked on how the functions of the first referral level can be better performed by local hospitals, whether they are small rural institutes or mammoth general hospitals in urban areas. Having recognized the limitations of the medical technology approach to Health for All we should move to identify new ways in which hospitals can contribute more effectively towards the social goals for health. We should avoid falling into the trap of

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“medicalization” of primary health care and bring our collective experience and wisdom to bear on clarifying the issues concerning hospitals at the first referral level.3 As a result, the world community recognized that the alternative approach of primary health care involving the totality of all potential resources and based on equity and justice, individual and community self-reliance and intersectoral cooperation, including community involvement, would promote and achieve faster and more efficiently the goals of Health for All.4 Apart from starting a community approach for a prolific health care there was also enough stress on decentralising the earlier centralised system of health care. As a consequence of the Alma Ata declaration, 1978, that gave rise to a revolution in health care with much emphasis given to Democratic and Decentralised model of Health care in a Developing Country like ours so that responsibilities of health are shared and not centralised.

Each programme should be regionalised and decentralized in its implementation ands have clear, precise technical rules, to enhance the comprehensive care of the population. It is useful for promoting the integration of preventive and curative activities that the head of the clinical department of the hospital should at the same time be chief of or at least advice on the community programme in the same speciality.5 As defined by Kleczkowski Decentralisation is: ‘The national health system, within whose structure the services required to deliver care to the urban , sub-urban and rural family nucleus must be organised, is a mechanism of such administrative complexity that it cannot possibly be run on a centralised basis.

A consequence of this will be the need to provide administrative facilities at the regional level. An important factor supplementing the mechanisms of decentralisation should be the participation of the community and of health professionals in the administration of the regional and local services.’6 Now, healthcare in India follows a regimented hierarchy. The government health care delivery can be divided into two levels: Central level and State level.

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The official organs of health system at the national level constitute of: (i) Union ministry of health and family welfare (ii) Directorate General Health services (iii) Central Council of Health (iv) State Health ministry (v) State Health directorate

Figure 4: Hierarchy of Health care centres, www.indiamedicine.com

Agencies involved in Health care delivery: I. Government sector II. Voluntary sector III. Private corporate sector a) Profit based organisations b) Trust owned institutes

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Hierarchy of health care delivery: I. Apex-super speciality institute, with facilities of teaching and research II. Tertiary level III. Secondary level IV. Primary level a) CHC b) PHC c) Sub centre7 The various levels at which the new model was organised: 1. The village/neighbourhood level health services for a unit of 1000 population; 2. Health services at the sub-centre level for a population of 5000; 3. A P.H.C. for a population of 50,000; 4. The Community Health Centre at the 100,000 population; 5. The District Health Centre for a population of 1,000,000; 6. The Specialist Centres for a population of 5,000,000; 7. Training Institutions, Special Institutions for Research and Training and State and Central Health Administration. According to W.H.O.: “The hospital is an integral part of a social and medical organization, the function of which is to provide for the population complete health care, both curative and preventive, and whose out-patient services reach out to the family and its home environment; the hospital is also a centre for the training of health workers and for bio-social research.�8

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Figure 5: Relationship between health centre, community and higher level facilities, B.M.Kleczkowski & R.Piboulea, ‘From the view point of the Architect’, Approaches to Planning and Design of Health Care facilities in Developing Areas Vol.2, Published by W.H.O., Geneva, (1977), (131), Edited by Author.

The country has built a massive indigenous infrastructure and is continuously striving to develop its manpower in the quest of human resource development and to improve the physical quality of life index. The statistics of the number of Primary health centres, sub-centres, community health centres established over the first 9 Five year Plans as obtained from Ministry of Health and Family Welfare (MOHFW) are as follows:

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Table 1: number of Primary health centres, sub-centres, community health centres established over the first 9 Five year Plans, Rural Health Statistics Bulletin, Dec. 1999.

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2.3 INDIA STEPS INTO THE MILLENIUM:

Table 2: Health Status Indicators, http://millenniumindicators.un.org/unsd, UNICEF [29998], July 2003, http://millenniumindicators.un.org/unsd, WHO [29983], July 2003

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Year

1961

1966

1971

1976

1981

1986

1988 1991 1996 1998

Hospitals

0.7

0.81

0.7

0.72

0.99

1.02

1.27

1.32

1.6

1.6

52.28 60.75

63.6

72.79 73.64 77.79 78.19 78.7

95

92.5

Dispensaries

2.14

1.92

2.22

2.7

2.3

Allopathy Doctors

*

*

27.57 34.14 39.22 41.76

*

47.19 50.8

52.6

Nurses

8.1

*

14.71

18.4

21.95 27.13

*

36.88 60.2

69.1

PHCs

0.75

1.27

1.17

1.11

1.06

2.45

3.55

3.2

3.3

Sub Centres

—

—

6.36

7.87

9.74

17.18 18.77 20.9 19.3

19.4

Beds

1.9

2.45

3.38

3.67

2.81

3.25

Table 3: Health Care Services Per 1 Lakh Population, Health Information of India, Central Bureau of Health Intelligence (CBHI), Ministry of Health and Family Welfare (MOHFW), Government of India (GOI), respective years.

Beds = Beds in hospitals and dispensaries. Nurses = Nurses and Midwives. PHCs = Primary Health Centres. * = Not available; — = Not applicable.

2.3 INDIA STEPS IN TO THE MILLENIUM: Major socioeconomic changes in the world reflect the spirit of the times and the features that seem to have affected healthcare over recent years are not the development of space-age technology but the rise of what might be called ‘internationalism’, and the ‘march of medicine’.

The technology of an age that has put men on the moon and satellites into space has made many marks on modern society, but none more obvious than the developments that have taken place in transportation and communications.

Journeys that only forty years ago took weeks can now be completed in hours.

Events taking place in one country today can be seen and heard in the homes of inhabitants on the opposite side of the world while they are actually happening.

“We are living in what is-to use a popular phrase- a shrinking world, and one in which it is now virtually impossible for any nation to remain isolated from the changes taking place around it. The world is becoming more genuinely “international” than ever before, a trend much influenced and hastened by the existence of the United Nations Organization.”9

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Medical or Health tourism has become a common form of vacationing, and covers a broad spectrum of medical services. It mixes leisure, fun and relaxation together with wellness and healthcare. 10 Medical tourism can be broadly defined as provision of 'cost effective' private medical care in collaboration with the tourism industry for patients needing surgical and other forms of specialized treatment. This process is being facilitated by the corporate sector involved in medical care as well as the tourism industry - both private and public. 11 This movement has hit off with quite an impressive start that it has enough prospects of bringing in more revenue for the country’s economy as a result its gained quite a lot of attention from other profit oriented entrepreneurs for the undoubted fact of earning profits. Health and medical tourism is perceived as one of the fastest growing segments in marketing ‘Destination India’ today.

While this area has so far been relatively unexplored, we now find that not only the ministry of tourism, government of India, but also the various state tourism boards and even the private sector consisting of travel agents, tour operators, hotel companies and other accommodation providers are all eying health and medical tourism as a segment with tremendous potential for future growth.

The health care sector in India has witnessed an enormous growth in infrastructure in the private and voluntary sector. The private sector, which was very modest in the early stages, has now become a flourishing industry equipped with the most modern state-of-the-art technology at its disposal.

India benefits from a large staff of world class experts and the ultra-competitive cost advantage it offers. India could earn more than $1 billion annually and create 40 million new jobs by sub-contracting work from the British National Health Service; the head of India's largest chain of private hospitals. Acording to

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CII, India has the potential to attract 1 million tourists per annum, which could contribute up to, US$ 5 billion to the economy. Medical tourism can contribute Rs 5,000-10,000 crore additional revenue for up market tertiary hospitals by 2012, as per Confederation of Indian Industry (CII)-McKinsey joint study.

With prices at a fraction (sometimes only 1/10th!) of those in the US or

Nature of Treatment

Approximate Cost in India ($)

4,500

Cost in other Major Healthcare Destination ($) > 18,000

Approximate Waiting Periods in USA / UK (in months) 9 - 11

Open heart Surgery Crania-facial Surgery and skull base Neuron-surgery with Hypothermia Complex spine surgery with implants Simple Spine surgery Simple Brain Tumour - Biopsy - Surgery Parkinson’s - Lesion - DBS Hip Replacement

4,300

> 13,000

6-8

6,500

> 21,000

12 - 14

4,300

> 13,000

9 - 11

2,100

> 6,500

9 - 11

1,000 4,300

> 4,300 > 10,000

2,100 17,000 4,300

> 6,500 > 26,000 > 13,000

6-8

9 - 11 9 - 11

Table 4: Comparison of prices of India v/s other countries, www.mti.gov.sg

EU, the concept has broad consumer appeal – if people can overcome their prejudices about health care in developing countries. The reality is that Indian private facilities offer advanced technology and high-quality procedures on par with hospitals in developed nations. India is the leading country promoting medical tourism in the world. Medical tourism to India is growing by 30% a year

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and the Indian education system is churning out an estimated 20,000 to 30,000 doctors and nurses each year.

Complementary and Alternative Medicine or Traditional Medicine is rapidly growing worldwide. In India also, there is resurgence of interest in Indian Systems of Medicine. People are becoming concerned about the adverse effects of chemical based drugs and the escalating costs of conventional health care. Longer life expectancy and life style related problems have brought with them an increased risk of developing chronic, debilitating diseases such as heart disease, cancer, diabetes and mental disorders. Although new treatments and technologies for dealing with them are plentiful, nonetheless more and more patients are now looking for simpler, gentler therapies for improving the quality of life and avoiding problems.

India has 1.5 beds per 1,000 people while China, Brazil and Thailand have an average of 4.3 beds. The study projects that changing demographic and disease profiles and rising treatment costs will result in healthcare spending more than doubling over the next 10 years. In addition, public spending could double from Rs 1,700 crore if the government reaches its target spending level of 2 per cent of the GDP, up from 0.9 per cent today.

With the expected increase in the pharmaceutical market, the total healthcare market here could rise from Rs 10,300 crore currently (5.2 per cent of GDP) to Rs 23,200 crore -Rs 32,000 crore (6.2 per cent - 8.5 per cent of GDP) by 2012, according to CII-McKinsey estimates. 12

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Another important and positive development taking place in the Indian healthcare sector is the use of Information Technology for purposes such as computerization of medical records, networking of various departments in a hospital, and providing of tele-medicine services. In ICRA's (Information and Credits Rating Agency) experience, computerization helps in the obtaining of real-time information on hospital management indices and the handling of medical records, especially in high-volume settings where manual recordkeeping may be inefficient. For instance, online reporting of laboratory and radio-diagnostic results over a local area network (LAN).

Telemedicine is the use of information communication technology platform for the delivery of health services. It has enormous potential for increasing the access to medical services by increasing the reach. As the transaction costs are coming down telemedicine is likely to become widely acceptable. Information Communication Technology (ICT) has changed almost every aspect of social and economic activity, within the last two decades. ICT can provide a powerful platform that could benefit the poorer citizens of developing countries. By enhancing access to education and health care through distance learning and telemedicine, ICT can improve the quality of life for poor rural communities who do not have access to these facilities.

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Plate8: Schematic Diagram Showing Process of Telemedicine, http://planningcommission.nic.in/reports/sereport/ser/stdy_ict/13_apollo.pdf

The most critical requirement of telemedicine is a reliable high-speed network.

Telemedicine has the potential to revolutionize the whole of the health care industry. Telemedicine has three generic applications, namely: · clinical applications · administrative applications and · Educational applications.

Telemedicine has a number of benefits namely: •

reducing the cost of service delivery

•

easy and quick access to the specialist

•

cost effective post treatment consultation

•

travel time reduction and

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•

enhanced quality and efficiency of medical care, hence increased care Turnaround 13

Now, we see how India has very good prospects of magnetizing health care facilities in the global scenario and assuming the role of a health hub of Asia.

Plate 9: Inflow of patients from rest of the world to India, Author.

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REFERENCES:

1. The Indian Council of Social Science Research and The Indian Council of Medical Research, ‘Wanted : An Alternative National Health Policy’, Health for All An Alternative Strategy, Published by Indian Institute of Education, Pune, (1981), (3) 2. S.L.Goel & R.Kumar, ’Administration of Rural Hospitals’, Hospital Administration and Management Vol.3, Published by Deep and Deep Publications, New Delhi, (1989), (9,10) 3. Dr.T.A.Lambo, Deputy Director-General of WHO, Expert Committee on the Role of Hospitals at the First Referral Level, ‘Hospitals and the health care revolution’, L.H.W.Paine and F.Seim Tjam,Pg11,1988.

4. L.H.W.Paine & F.Seim Tjam, ‘The Health Care Revolution’, Hospitals and the Health Care Revolution, Published by WHO, Geneva, (1988), (17) 5. B.M.Kleczkowski & R.Piboulea, ‘Regional Planning of Health facilities’, Approaches to Planning and Design of Health Care facilities in Developing Areas Vol.2, Published by WHO, Geneva,(1977), (13) 6. ibid.

7. M.Aggarwal, ‘Health Structure in the Country’, Dissertation on Functional Planning For Secondary Level Health Care Facility, Published by School of Planning and Architecture,(1991), (15,16,17,18,19,20) 8. WHO Expert Committee on Organization of Medical Care (1957)Role of hospitals in Community health Protection, Geneva, R.Lewelyn-Davies & H.M.C Macaulay,’ The hospital in the regional health service’, Hospital Planning and Administration, Published by WHO, Geneva,(1966),(9) 9. L.H.W.Paine & F.Seim Tjam, ‘Origins’, Hospitals and the Health Care Revolution, Published by WHO, Geneva, (1988), (25)

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10. www.traveliteindia.com 11. ibid.

12. ‘Medical tourism, the next big wave: CII’, www.indiatimes.com 13. http://planningcommission.nic.in/reports/sereport/ser/stdy_ic /13_apollo.pdf

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CHAPTER 3: UNDERSTANDING A MEDICAL HUB

3.1 FINDING A DEFINITION: A HUB is a centre or node of a certain activity we have hubs for entertainment, business, cultural interaction .So what possibly could a Medical Hub be? Well, literally the word suggests that it is a hub that serves the medical/health needs of a community/area. But to elaborate on it one sees it is quite a broad concept for e.g. A community has a civic centre, an educational centre similarly it has a health centre ,This health centre acts as a Health HUB for this community .Now a group of communities together forms a sector which has a health centre this certifies to be a HUB for the sector now as we move from Part to Whole we observe the size and scale of the tasks carried out by this Health Hub also increases such that higher we go up the ladder the larger the hub grows.

So if every health centre can be termed as Hub then which one do we appropriately term as a true Medical Hub? Just as every cell has a nucleus we would consider the highest in the hierarchy as the true hub merely for the size, scale and variety of responsibilities it holds. There is also the strategy of Hub – Spoke Planning of healthcare facilities. According to this theory there is a main hub that houses all specialities and there are a number of spokes that provide only certain kinds of specialised treatment. While we term the largest facility as our medical hub the rest of Hubs could be termed as mini medical hubs or more appropriately spokes that are connected either physically ( corridor, roads etc..)

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or virtually, (networking, telemedicine etc…)So how is a Medical Hub different from the other mini hubs? Why is it larger than the other hubs, what greater responsibilities does it hold?

Figure 6: Nucleus, Atom and Molecule, Author

Figure 7: Formation of Health care Hubs, R.Lewelyn-Davies & H.M.C Macaulay,’ The hospital in the regional health service’, Hospital Planning and Administration, Published by WHO, Geneva, (1966), (15), Edited, Author.

Since this medical hub is the largest it must rightly be the superior most in size, quality, facilities, and expertise. It would not only provide super specialty health treatment but would also have facilities for accommodation, food etc...It could quite easily be classified as a super specialty or a corporate hospital but they too fall out to an extent in fulfilling the criteria of a true Medical hub as a Medical Hub is nearly complete with out the much required facilities for knowledge and high end research institute.

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‘A hospital system should include provision for training the staff needed to man all health services of a country, both curative and preventive. Every hospital, whatever its size and whether or not it is designated as a teaching hospital, it should be regarded as a potential centre for teaching and research. In larger hospitals, special facilities must be provided to encourage these functions.

Medical education can conveniently be divided into undergraduate and postgraduate levels.’1 A teaching hospital tends to be somewhat selective in the types of patients it admits, often giving preference to those who are suffering from rare conditions or who are suitable subjects for research. Additional accommodation will be needed to provide in selected district hospitals–lecture and demonstration rooms, studies, cloak-rooms and so on.

In addition there should also be consideration given to establishment of limited number of training schools for radiology and physiotherapy, which would entail some augmentation of the relevant departments in a few selected hospitals. The training of laboratory technicians should also be undertaken.2

So does this mean a Teaching Hospital within the city premises is to be termed a hub? If so then what are this topical issues called – Medicities, Medical Parks and Medical Malls? Why is there a sudden splurge of healthcare facilities with a variety of names? Why are there so many Hubs being planned and many discussions and seminars held on this subject? What is this new concept and what role do they play in our socio-economic environment? I clear my idea about a Medical hub/city/park/Mall by interacting with a few experts in the field of Medical Care/ Medical Architecture/Planning in order to be able to formulate my own definition of a Medical Hub.

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3.2 INTERACTIVE REVIEWS / CASE STUDIES: I begin the questionnaire session with Dr.Praneet Kumar, Head Medical Planning, Fortis Healthcare: 1. Why do we create Hubs?

All centres of excellence cannot be at one place so to optimize resource pooling for maximum benefit of the community, which comprises of the users, service providers, staff, in order to have better opportunities to contribute to the professional enrichment.

2. What all facilities should a hub house within itself?

A Medical Hub is a confluence of all major facilities, and if it takes the form of a medicity then it’s like a township within the city and therefore has to be self-sufficient with its own facilities for travel, communication, entertainment etc‌ 3. How can such a Hub be connected to its spokes or any other healthcare institution?

Through Telemedicine, Faculty Exchange Programmes also help in enriching these hubs in terms of knowledge and skill.

4. Can one formulate a standard in developing a hub/city/park in terms of area requirement, investments to be incurred?

Well the area required will depend upon the types of facilities a hub would house depending on which the area details can be calculated and the investment incurred is an automatic outcome depending upon the value of the plot/land.

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5. What is the Fortis Medical Hub project about?

It’s a medical and nursing college in Gurgaon along with a research laboratory, called Fortis International Institute of Medical and Biosciences (FIIMBS), on 11.5 acres of land in Gurgaon, NCR. The doctors and nurses these colleges churn out will be absorbed in Fortis's new and existing facilities. The company is also planning to start a central reference laboratory to expand its diagnostic businesses.

6. Why has Gurgaon been chosen?

Firstly, Land is easily available, second due to its strategic location from the Indira Gandhi International Airport, the domestic airport, 3 main Roadways namely – National Highway 8, Old Delhi-Jaipur Highway, Mehrauli-Gurgaon Road and proximity to Delhi, main Haryana and Rajasthan.

Plate 10: The National Capital Region, Source: www.noidaonline.com

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The model that Fortis has adopted for growth is a hub-and-spoke one. It is developing Multi-speciality tertiary care centres with superspecialised nodal centres -- for instance, cardiology

in

Mohali and orthopedic

and

neurosurgery in Noida. The spokes will have multi-specialty features covering practically all critical diseases. In Punjab, while Mohali serves as a hub, our hospital in Amritsar serves as a spoke and two more spokes are being planned in Ludhiana and Jallandhar.3

AMRITSAR

JALANDAR

MOHALI

LUDHIANA

Plate 11: Punjab State Map, www.mapsofindia.com

A similar project is underway, Escorts Heart Institute is planning a Rs 1,000 Crore "Medical City" In Gurgaon and it is being described as the first project of its kind in Asia, Naresh Trehan, the well-known cardiologist and executive director of Escorts Heart Institute and Research Centre (EHIRC), said it will be called the Asian Institute of Medical Sciences and will be on the same lines as the Johns Hopkins Hospital in the US as recorded by Confederation of Indian Industry’s (CII’s) Annual National Conference, 2004. The proposed hospital will specialise in various therapeutic segments and not just in the cardiovascular area,

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for which EHIRC is renowned. To be spread over 50 acres, the complex will house •

a 2,000-bed multi-specialty hospital,

•

a hotel,

•

service apartments,

•

a research and development centre,

•

a medical college and

•

a residential colony.

The proposed project will cater to well-heeled Indians as well as foreigners who would be drawn by the comparatively lower price of treatment in the new trend called "medical tourism." 4 My next interaction was with Ar.Shashidhar, Managing Director, Architect, Archimedes with the background of designing Apollo Chain of Hospitals, and was also involved in designing for an upcoming Medical Mall: 1. What is this new concept of Medical hubs also at times referred to as Medical parks etc..?

Medical Hub sounds different but I feel in reality it’s a mere jargon to rouse interest among people. Because, this idea of creating hierarchy in medical care has long been adopted. Of course, now it is given more importance due to the emergence of a number of private, corporate and insurance institutions who are

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in a way encouraging this growth. For instance the Medical Mall is where there are a host of facilities provided for the user but these exist independently almost like the variety of showrooms in a shopping mall.

ALPHA Medical Services Pvt Ltd has launched a one-stop healthcare shop for all healthcare needs. Set up at an investment of Rs 4.5 crore, the Alpha Family Health Mall is a four-storied centre that has a polyclinic, a diagnostic centre offering basic pathological tests and a healthcare store. A medical equipment division under the same roof allows healthcare institutions to source their hospital furniture and surgical equipment from there. Dr Vijay Kejriwal, Medical Director of Alpha Family Health Mall, said the diagnostic centre has X-ray facilities, portable USG, computerized ECG and facilities for microsurgery, and so on. There is a 15-bed day care centre, an operation theatre, an intensive therapy unit, and a neo-natal intensive care unit, among others.

The thrust would be on women, childcare and day care. 5 Next is my interaction with Ar.Sumit Kalra, of Sumit Kalra Consultants, who is currently handling the renovation and Medicity project of Moolchand Hospital 1. What is this Moolchand Medicity project as I happened to notice while passing the flyover?

We are renovating and refurbishing the Moolchand hospital complex.

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2. But why create a hub in such a busy locality?

The idea is to address the catchment area viz. the South Delhi Population covering Defence Colony, South extension, Lajpat nagar, Andrews Ganj Extension etc… as ultimately we cater to the end users so it’s important to clearly establish who all are going to access this facility.

Also easy accessibility was a strong criterion, and finally visualizing the fact that after its built people will also relate to it as a wellness centre with having just a look at it as it’s going to be conspicuous along the ring road.

MOOLCHAND HOSPITAL SOUTH EXTSN. PRT II

LAJPAT NAGAR RINGROAD HUDCO PLACE

Plate 12: Eicher plan of Moolchand hospital and surroundings, Author 3. What is the kind of investment that went into this project?

Well the exact figure is confidential but the cost of construction around Rs. 3500 – 4000 /sq.ft. And this figure will depend from project to project

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considering what type of internal planning and facilities are provided within the hub as there are in the market a range of options apart from the ones prescribed by BIS right from the room sizes to the materials that hence affect the cost.

4. Will this hub cater to the poorer section of the society also?

Its definitely catering only to the upper classes or anybody who is promoted by Insurance companies and MNC’s as they tie up with the hospital to decide financial schemes / discounts so this will definitely give no room for the poor and its always such that the poorer people go to any healthcare centre mostly a PHC only for curing illness but this hub is much more than that , that is the reason why it’s a wellness centre they come to this place for general well being because the atmosphere or ambience is healing and refreshing. May be after a few years if the mindset of people changes and the economic condition improves the hub will be catering to more people its like only a few people visit Gyms to stay fit not every body in the society does .

I had a brief talk regarding my topic to Ar.Hussain Varawalla, architect and planner of HOSMAC health care, to gather his views on a Medical Hub at which he had to say: It’s an interesting idea, what is important that this idea must be checked for the financial viability and with detailed analysis of social and economic conditions it

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has to be then embedded in an architectural context to truly give it a meaningful angle for an architect to take this idea further in to reality.

I also gathered Dr.Vivek Desai’s, Managing Director, HOSMAC Health care, opinion on this topic: The future of healthcare industry in India will see a continued strong demand for construction of health care facilities, including completely new or replacement facilities and projects involving major additions and modernization. The annual value of healthcare construction projects will see a up trend in the immediate years ahead owing to various factors like opening up of the insurance sector, privatization initiatives etc. Therefore planning and design will continue to merit prime emphasis among several responsibilities of hospital officials. Because of the changing character of facilities and continuing increase in their complexity, planning and design will assume greater importance than ever before. Thus planners, architects, builders, hospital executives, board members, medical staff representatives, and others who possess responsibility for undertaking hospital construction projects should have basic understanding of planning process and of appropriate concepts of hospital and related healthcare facility design objectives.6 Another new development that promises the best of care and technology on wheels even to the remotest of areas is the recently introduced concept (in India) of mobile, modular and autonomous hospitals that can operate within no time.

The high-tech system integrated in modular containers enables mobile intensive

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care to the same medical standards as an infrastructure hospital that assures compatibility with all modes of transport road, rail, sea and air .

The modularity concept permits the size and functions of the hospital to be adapted to the specific requirements of each operational deployment for eg : use of international ISO 20ft containers. It can be constructed in aluminum, stainless steel, or fiberglass and is fully insulated. Its length ranges from 6 to 12 meters. It can be transported on a semi trailer (adapted to the terrain). Extending covered gangways at the ends of each module permit easy movement of personnel between all the medical and surgical modules and tented wards. The utility module provides a 24-hour supply of power, gas and fluids before replenishment. In India after the Bhuj Earthquake more attention has been drawn towards this new aspect of healthcare. Typical Mobile Units (Trailers, Containers, and Self-Propelled) include: •

Mobile hospitals - single and multiple units

•

Mobile emergency disaster and surgical / trauma

•

Mobile health exam and X-ray

•

Mobile blood collection and labs

•

Mobile Magnetic Resonance Imaging (MRI) and lithotripsy

•

Electronics and computer instrumentation trailers

•

Mobile kitchens

•

Mobile training and classroom units

•

Mobile car / truck X-ray inspection systems

•

Networking and telecommunications

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Plate 13: Integrated Biological Detection System (IBDS) used by the British Army, www.army-technology.com

Plate 14: ISO 20ft expandable container shelter with rigid panels, ibid.

Plate 15: French Army mobile hospital deployment in Bosnia, ibid

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The shelters can be easily transported and handled and can be brought into operation very quickly with minimal on-site work due to their expandable nature.

Plate 16: Euro Shelter’s French Army mobile kitchen using expandable shelters, ibid.

This concept of mobile hospitals lends high flexibilty to the healthcare framework of a country where reaching remote areas has always been a problem. Furthermore, it proves extremely useful at times of disaster as a portable, well -equipped hospital that could be set up as per requirements of the site and for immunization programmes and helath camps.

3.3 FOUNDING A DEFINITION: After having seen and heard a number of views and studies I perform the next task of assimilating all that I have learned into formulating the definition of a Medical Hub. So I come back to the questions I raised in the beginning to resume the link. I have had the opportunity to interact with people of diverse fields, Medical Architecture, Planning and Medical Care.

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This has exposed me to the ways in which people of different professions think about the idea of Medical Hub. Every individual had a different version to speak of, for a doctor the main concern was to get the infrastructure laid as soon as possible as the urgency lay with treating a number of people who were not privileged enough to get basic treatment.

A planner thought that if creating a hub was to create a mini-city then it should have its arteries planned first before any other body of the team could perform, for instance it is important to decide and plan the roads, sewage, zoning the area and then get down to the architectural nitty gritties. So maximum stress was now for overall planning in terms of socio – economic viability and planning, and infrastructural planning.

For an architect what is of utmost importance is a design brief the first thing to rationalize was the decision of what all requirements are to be provided in the hub and then the architect also lends his help in to working out the expenditure and at times points where savings can happen a minor portion of Value Engineering is performed by the Architect. In formulating an image of a Hub all these varied views matter.

A hub is as said earlier an enclosure of a large number of facilities to treat the ill. A hub is to a spoke as a hospital is to a clinic. But it’s been long since there was a paradigm shift in the way a hospital or healthcare centre is perceived as I read it somewhere:

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What has changed in recent times is the very definition of the word “healing”, moving away from medical interventions to embrace a more holistic meaning, the focus moving away from treating “illness” to creating “wellness”. 7 So now a medical hub houses every possible facility it could be a medical mall with independent facilities co existing under one roof or a medi city that encompasses vast areas of land with ample space to plan facilities such as university, laboratory for research and future innovations or smaller units that function independently in the form of modular mobile clinics. A Medical Hub is no rigid entity, the very flexibility of choices makes it a viable option for future, and depending on one’s requirement and decision this hub can be fabricated. The following figure shows a few possible choices:

Figure 8: Types of Medical Hubs, Author

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Another criterion is that a hub must be able to cater to foreign patients as well in terms of quality of care and spaces designed with in the hub that encourage the new found phenomena of Medical Tourism because ultimately it is this idea that brings in more revenue that can be either channelised to improve the medical establishment or put to use in to research or dedicated for the economically weaker sections for their health care in the welfare interest.

The following figure explains the dual responsibility of a medical hub:

Figure 9: Dual roles of a Medical hub, Author

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REFERENCES: 1. R.Lewelyn-Davies & H.M.C Macaulay,’ Some Special Roles of the Hospital’, Hospital Planning and Administration, Published by WHO, Geneva,(1966),(46) 2. ibid.

3. http://www.thehindubusinessline.com/2005/10/06/stories/2005100602131900. htm 4. http://www.gurgaonscoop.com/story/2004/8/5/131710/1808 5. http://www.telegraphindia.com/1050708/asp/calcutta/story_4962590.asp 6. www.hospitalinfotainment.com/knowledge/hospital management.

7. ibid.

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CHAPTER 4: ROLE OF AN ARCHITECT IN THIS MILIEU

4.1 ROLE OF AN ARCHITECT: An architect in general, adopts many roles and morphs into different

characters

throughout the design process and execution, from a visionary during the early stages, to translator, designer and critic during the creation of the architecture, to a consultant during deployment of the architecture. Throughout, the architect is also playing a vital leadership role in choosing the technology to confirm that the choices are viable.

Figure 10: Roles of an Architect, http://www.designcorps.org/role.html

Knowledge is the only strength for an architect to rule the team with his awareness of the different technical and available alternatives that drive the project towards success.

Healthcare architecture differs from that of other building types in the complexity of the functional relationships between the various parts of the hospital. In the

48

residential and commercial building types the design brief is relatively easy to understand and cater to. Healthcare architecture, however, requires specialized knowledge on the part of the architect and the supporting engineering team. The lack of such trained professionals results in many of the hospitals in India today being ill conceived and costing their promoters much more in construction and in inefficient operation than they need to. Eventually it is the patient who bears the brunt of this incompetence through lack of quality in the medical care provided physical and mental discomfort and increased cost of hospitalization. We have Florence Nightingale saying: “The very first consideration to be sought in planning a building is that it shall be fit for its purpose. And the very first architectural law is that fitness is the foundation of beauty. The hospital architect may feel reassured that, only when he has planned a building that will afford the best chance of speedy recovery to sick and maimed people, will his architecture and the economy he seeks be realized.” 1

When most of us think about the future of medicine, architecture is not the first thing that comes to mind. We think of advances in technology, enabling better imaging techniques, robotic surgery, and advances in medical research, enabling genetic engineering etc… It is only recently that healthcare architecture has been given its due recognition owing to the depth of knowledge, expertise and awareness towards development in the field of medicine that is required on the part of an architect to provide the expected facilities in a medical establishment. A health care architect will be active during the entire lifespan of the building and will serve as caregivers, members of the patient-care team. With the burgeoning use of high – technology in medicine and change in the economic sector by virtue of increased private

49

ownership of healthcare facilities, healthcare architecture too sees an equivalent growth and change in the forms and models of facilities provided. Roles of healthcare architects are revolutionized in this radically changing future.

The need of the hour is to have fewer hospitals and more ambulatory facilities, including freestanding clinics, medical office buildings, and specialized freestanding diagnostic centers. In addition, an increased demand for healthcare facilities on the retail model – medical malls, possibly in landscaped settings, specialty hospital facilities on the retail model and strategically placed regional complexes: very large, very comprehensive hospitals in which specialized facilities and specialized practitioners are concentrated. Remote monitoring telemetry, and sophisticated data transmission that will link the local specialty hospital to the more distant comprehensive facility. There may also be new opportunities in healthcare resorts and healthcare communities. Healthcare resorts would be places for convalescence and supervised care – a hybrid cross between hotel, spa and hospital. Healthcare communities are another likely direction, where there are planned communities focused on wellness, and providing various levels of assisted living may largely take the place of hospitals, skilled nursing facilities and retirement villages.

4.2 HEALTHCARE ARCHITECT, LEADER OF THE PLANNING TEAM: To create any kind of facility an architect talks out clearly with the client regarding the functional requirements of the facility and then further develops an area reference for each of the facilities. This is the first and foremost part of the design process the preparation of a Design Brief. Design brief sets out a framework for an

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architect within which he/she can modulate and modify the design by figuring out the functional analogy of the activities mentioned in it. It is the primary guideline that an architect sticks to and tries to improvise by adding his inputs to make a better design.

So is the task for a Healthcare Architect who in collaboration with Medical Planners, Experts in the field of Medicine and other related consultants for associated services decides the design brief for the healthcare facility. It is through this session of discussion that a healthcare architect is aware of the extent and number of facilities and input required to build the whole infrastructure. As a healthcare architect apart from catering to the needs of the medical practioners and the patients he/ she also takes care of related issues such as aesthetics and form, circulation pattern, structural stability, climatological response, environmental sustainability, cost effectiveness etc‌ for it is only a healthcare architect who can decide the spatial and volumetric disposition of the built facility and nobody else is balanced with the right amount of know-how in the various fields involved.

So when it comes to project execution a Healthcare architect plays an essential and indispensable role in leading the team for only an architect can take judicious decisions which can be taken for an unbiased one. Since the architect also plays a very good role in mediating between the various parties involved in the project he/she is the best judge and leader in healthcare architecture who is supported by the planners, doctors and management body as there will be no room for favoritism or injustice. If a healthcare architect holds such great importance in the field of healthcare then it’s inevitable for me to include the role of an architect in deciding the design brief of a Medical Hub.

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4.3 CREATING A MEDICAL HUB: An architect must think in terms of modular planning that supports the various constants and variables for healthcare for instance it is an architects job to work out the sizes and functions to be incorporated within any unit be it a diagnostic, ward or OT unit. It needs the forevision to be planned flexibly for future changes.The decision of hubs of various facilities is that of an architect as it is his/her judgement that accounts for the choice from the various options discussed earlier. The architect through out the planning process keeps in mind two main driving ideas – one to provide services to as many patients as possible keeping in view the efficiency and second idea of mobilising and networking of the facilities by creating modular design that automatically induces flexibility in design.

Creation of small hubs that are interlinked via wireless modes of communication – telemedicine not only save time and money on travel within a state or country they also reduce loads on local infrastructure including the city or town hospitals as a result here also an architect lends his skill and ideas to network the whole system of hubs so as to maximise healthcare and optimize infrastructural facilities.From part to whole one observes that at a global level too we see that if the goal of a well networked healthcare system is achieved then the country grows as a successful healthcare hub. Since similar proposals are beig carried out in other countries for instance the major helath destinations planned in dubai and south east asia could all be further linked with the Indian system and a similar idea would then be applicable where traveling is minimsed and overseas facilities made available through telemedicine or any such technological prowess that will make provision of

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healthcare independent of local infrastructure of the respective countries in terms of roads, airlines, accomodation facilities etc….

4.4 DESIGN BRIEF OF A MEDICAL HUB: A Medical hub is something that is very plastic, in the sense of adapting to suit the local conditions and something that can not be generalized but to make matters easy an architect with the help of software developers and planners can develop software that sets out the various components of a hub under two classifications – constants and variables.

CONSTANTS

VARIABLES

1. AREA REQUIREMENTS FOR CLINICAL COMPONENTS WARDS, DIAGNOSTICS, OT’S ETC...

1. COST INCURRED IN EVERY PROJECT DEPENDS UPON THE SIZE AND SCALE OF HOSPITAL AND THE VALE OF LAND

2. AREA REQUIREMNTS FOR NON – CLINICAL COMPONENTS – ACCOMODATION, STAFF QUARTERS, PATIENT HOTELS ETC…

2. CLIMATOLOGICAL, TOPOGRAPHICAL, DEMOGRAPHY CONDITIONS

3. SUPPORT SERVICES – LAUNDARY, A/C PLANT, ELECTRIC SUBSTATION ETC…

3. NO. OF BEDS REQUIRED ETC…

4. TYPE OF SPECIALITY

Table5: Constants and Variables in deciding a Design brief for a medical hub, Author

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For instance, learning from the facilities provided in the Escorts Medicity we can say that a 2,000-bed multi-specialty hospital, with a hotel, service apartments, a research and development centre, a medical college and a residential colony.

Is the standard for a hospital of that scale similarly standards or modules can be planned for different situations where data can be fed in a programme and figures can thus be obtained from the software. Thus to achieve quality healthcare there needs to be coordination of health care architect, the IT sector and technology such as telemedicine to achieve a model and hence design brief of any medical hub.

Figure 11: Architectural Solution for a Medical Hub, Author

REFERENCES: 1. www.hospitalinfotainment.com/knowledge/hospital management.

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CHAPTER 5: CONCLUSIONS AND RECOMMENDATIONS

5.1 RECAPITULATING: In recent times, in India, owing to the growth of private sector profit oriented interventions and insurance agencies there is a boom in healthcare institutions. This has encouraged ideas of creating hubs of healthcare on the lines of Hub-Spoke planning with a view of targeting a certain group of population both Indians and foreigners to earn profits. Ideas such as health tourism have also gained ground due to such profit motive institutions. Nevertheless, this new socio-economic phenomenon of Medical Tourism encourages building a hub in every state of the country ensuring maximum interaction of medical experts within the country as well as globally across different nations thus lending a dynamic nature to the hub.

This not only benefits the field of medicine but also the health infrastructure of the nation. Talking of the Indian Context one must not forget the indigenous treasure trove of knowledge ,our very own traditional systems of healing which also could find their own much deserved identity and position within this hub such that the hub gets richer with more knowledge and the traditional systems too get their due recognition.

To sum up all the studies and discussions I conclude that a HUB is a flexible module that takes the shape of its container. In India especially, where the word “diverse� is only an understatement of the wide spread conditions and environments in our country, a medical hub is completely equipped to tackle a diverse range of circumstances.

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“For, many years to the come the world will continue to harbour many different philosophies, cultures and systems; hence hospital programmes, which reflect so closely the essential features of the style of life, will have to be carefully adapted to the diverse conditions prevailing in individual regions.” 1

5.2 MEDICAL HUB IN SOCIAL AND URBAN FABRIC: After having seen the Medical Hub and its configuration it’s important for me to learn its part in the social and urban fabric of India. On an urban scale it’s necessary to learn how this medical hub subsists in its environment. Considering that there are Medicities being planned spread over large areas of about 50 acres in the NCR just indicates that apart from being a large area to manage it also bears great financial burden in terms of maintenance and operation which is ultimately shouldered upon the clients or the users. It also pressurizes the local infrastructure and resources for its day to day functioning for instance large capacity power, highly sophisticated clinical requirements, multitude of associated servicing departments etc…In my view hubs need not depend on huge amounts of resources or be made into hospitals with 1000 plus beds as growing numbers will only complicate internal management and unnecessary expansion of the hospital wings. As mentioned earlier, a hub can take a variety of forms depending upon the urban scale, the catchment area, urban restraints and many more of such variables. The hub can be modified accordingly and the problem of costly duplication could be avoided. It is the responsibility of the developer and the architect to decide the hub’s optimum potential towards a certain size and scale of its surroundings. Also as discussed earlier steady growth of the IT sector and easy wireless communication in healthcare- Telemedicine, have already done enough benefits to minimise the travel and stay aspect for treatments

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and are anticipated to make further simplifications in the system for the ease of both the service providers, clients and the architects.

Coming to the social roles of a hub I observe in a country where the majority of the population is un-insured this surge of healthcare institutions patronised by the insurance companies only discourages a large population of people who need basic health care and the same phenomena hence continues to stay where the poor or even the middle class are left with two extreme choices in health care – one, the public, sub-standard healthcare or the other, private, highly expensive healthcare. At this point we still have a long way to go in accomplishing our goal of health for all.

Ill health is an inevitable consequence of poor sanitation and public facilities and lack of education, we can take a lot of motivation from the National Health Service, Britain, where majority of healthcare is in the public interest and there are initiatives taken by the Government to ensure public health by means of constant check with the help of health volunteers who not only take care of the ill but also perform the role of educating them. India too, many years ago, started the idea of health volunteers however; it has proved to be inefficient in functioning due to lack of incentives for the volunteers to perform the way they should. A Hub which is essentially market driven can be manoeuvred to benefit the masses and hence assuming dual roles.

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5.3 RECOGNIZING AN ARCHITECT’S ROLE: In this field, the role of an architect is supreme as a mediator and a link between the planned and the achieved. In my view, only a medical architect can bridge the gulf between brilliant ideas and pragmatic establishment of the idea. A few people may think an architect cannot lead a multidisciplinary team nonetheless the role of an architect is of such significance that it can never go unnoticed especially at the time of project execution. Besides, only an architect can act as an unbiased player in the entire process of planning and designing.

5.4 KEYS TO SUCCESS: Apart from the constants and variables within a hub the biggest variable that affects the functioning of a hub is the human factor. It is the human factor that mobilizes the whole mechanism and needs to act more effectively and efficiently in terms of management for a workable system such as a hub to exhibit its full potential.

In an age where only private undertakings prove efficient in realising corporate goals, effective mergers between such profit oriented institutions and the Government such that requirements of quality healthcare at affordable rates could be availed by the general public. This is how schemes such as Joint Ventures (J.V.) and Builtoperate – Transfer (B.O.T) come into the picture in the bridging the drives of both the enterprises. An amicable deal ensures monetary and non-monetary benefits.

This is the only by which an expensive hub can exist in the urban framework and serve the public or else it would only prove to be a luxurious investment only consuming resources and returning minimum benefits to the society. The new aspect of mobile modular clinic could also be employed for the remote rural 58

population by performing basic roles of preventive and promotive services like health camps and immunization programmes.

Figure 12: Role of a Medical Hub, Author

To conclude my study on a positive note Medical Hubs have extreme potential of revolutionizing healthcare status of our country if only there is some moderation incorporated by the profit oriented institutions that can on their part perform a few charitable activities by helping the government in promoting an unfinished task of generating public awareness which will go a long way in eventually eradicating the sickness from our society and realizing the united aspiration of building a healthy nation.

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REFERENCES: 1. Bridgman, R.F., (1955), The Rural Hospital: its structure and organization, Geneva (WHO: Monograph Series, No.21), R.Lewelyn-Davies & H.M.C Macaulay,’ The hospital in the regional health service’, Hospital Planning and Administration, Published by WHO, Geneva, (1966), (14)

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