Hybrid Primary Care Clinic_Malawi Research Project by Thabang Nyondo

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THE HYBRID PRIMARY CARE CLINIC

THABANG NYONDO

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Table of Contents 4 | Introduction to Malawi

8 | Literature Review

12 | Project Spotlight

14 | Problem and Framework

16 | Claim 1: Environmental Response

17 | Claim 2: Population Response

18 | Claim 3: Operations and Space Planning Response

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Executive Summary Malawi is one of the world’s least developed countries, ranking 170 out of 188 on the Human Development Index. Over 70 per cent of the population live below the income poverty line and approximately 63 per cent of children live in multidimensional poverty. Malawi’s pre-term birth rate is the highest in the world at 13 per cent with most people dying of infectious diseases such as tuberculosis, cholera and malaria. The spread of communicable diseases is a big issue in rural African nations causing a mass number of deaths and forcing the clinical environment which harbors many people in concentrated places to be ruled off as unsafe for many reasons. Close quarters with infected people, overcrowded waiting areas, cross contamination through bad air circulation and improper separation of clinical and public activities creates an unsafe environment and implements pathogenic principles which only look to cure and care, not promote health-ease and wellbeing. The healthcare environment plays a vital role in reducing the spread of communicable diseases and ensuring the health and safety of its community (Guenther, Vitori 2007.) Primary care clinics comprise a large sector of the most visited health facility in rural Malawi, thus creating overcrowded spaces that are inflexible, static, and unaccommodating to the diverse needs of the population. Preventive measures and primary health care are integral to achieving positive health outcomes and improved economic development. A distributed model of small clinics with flexible waiting and family spaces is an effective temporary intervention to reduce the spread of communicable diseases.

The aim of this study was to understand the problems associated with the spread of communicable diseases in a rural low income country and see what strategies could be implemented within the built environment to prevent some of the top causes of high mortality rates in impoverished regions. Malawi is no special circumstance, but it does provide an understanding of context and the existing reasons for barriers to care that are not uncommon to many similar regions. The facility framework is used as an organizing tool to apply research throughout the architectural process to see the direct relationship between design solutions and intended outcomes. My proposal after investigating the main causes of death and the insufficient infrastructure of primary health care clinics is that the overarching outcome should be to improve community and public health, with architecture as a vessel to accommodate those efforts. The solutions provide the ‘how’ when considering ways to attain the design intention pulled from case studies that have addressed similar matters and seen considerable improvements in the overall surrounding community’s health outcomes. The proposal begins with a brief introduction into the current state of the Malawian health system and a snapshot of common diseases and the typical transmission between victims, then considerations of barriers to care are outlined before a dive into the framework for the design objectives, strategies and solutions to improving community and public health.

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Introduction to Malawi The problem this paper will focus on is the issue of the epidemiological crisis that faces the country of overcrowding in tertiary hospitals when the primary care clinic is underutilized and cannot currently accommodate the capacity of patients that is required. Malawi faces an epidemiological crisis within its healthcare settings that requires an immediate and effective response that is sustainable and appropriate to its context. Through the use of more preventable methods to achieve public health, the Hospital environment could benefit from implementing salutogenic methods. Malawi a Glance has a population of 18,622,104 (2017), and per capita income: $1,180, Life expectancy at birth: F 66/M 61 years and Infant mortality rate: 42/1,000 live births. Morbidity and mortality due to acute but treatable conditions remain high in the developing world, as many significant barriers exist to providing emergency medical care

4 TERTIARY HOSPITALS 70% of services offered at

the tertiary level are for conditions that should be treated at primary care or district hospitals

26 DISTRICT HOSPITALS

(OFFER OUTPATIENT & INPATIENT SERVICES) OFTEN RURAL AND USED AS REFERRAL CENTERS

10,000 PEOPLE SERVED BY PRIMARY CARE LEVEL FACILITIES

(INCLUDES HEALTH CENTERS, CLINICS, DISPENSARIES AND VILLAGE CLINICS)

84% OF MALAWIâ&#x20AC;&#x2122;S POPULATION IS RURAL

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Designing a Flexible, Green, Community Centered Healthcare Clinic For Rural Malawi •

Introduction The problems facing the country currently are rowing and continue to evolve. The problem this paper will focus on is the issue of the epidemiological crisis that faces the country of overcrowding in tertiary hospitals when the primary care clinic is underutilized and cannot currently accommodate the capacity of patients that is required. Malawi faces an epidemiological crisis within its healthcare settings that requires an immediate and effective response that is sustainable and appropriate to its context. Through the use of more preventable methods to achieve public health, the Hospital environment could benefit from implementing salutogenic methods.

Problems Facing the Country • Total expenditure on health in Malawi is at an all time high. Total population (2016) Gross national income per capita (PPP international $, 2013) Life expectancy at birth m/f (years, 2016) Total expenditure on health per capita (Intl $, 2014) Total expenditure on health as % of GDP (2014)

18,092,000 750 61/67 93 11.4

The spread of communicable diseases threatens the public health of communities While the major burden of disease due to HIV infection and TB falls on adults, malaria remains the greatest threat to survival for young African children. Of the 500 million cases of malaria and 2.5 million deaths each year in the world, 90% occur in sub-Saharan Africa. Institutions such as UNAIDS, and World Health Organization (WHO) initiatives such as “Roll Back Malaria” and “STOP-TB” seek to reduce this huge burden of illness.

•

Healthcare environments are crucial to the improvement of population health The Malawi/World Bank survey found that only 31% of communities have access to a health clinic. Almost half of all facilities are short of drugs, have inadequate means of communication and inadequate transport and there is a lack of emergency drugs in zonal warehouses and the cholera preparedness system is weak.

Makwero M. T. (2018). Birmeta K, Dibaba Y, Woldeyohannes D. (2013) ³ Atkinson, Jo-An & Vallely, Andrew & Fitzgerald, Lisa & Whittaker, Maxine & Tanner, Marcel. (2011). 1 2

ARCH 6850| Nyondo | Fall 2019. Definitions Access - “Especially in low-income and middle-income countries. Poor rural residents generally experience barriers to accessing primary healthcare, and these problems are further exacerbated for people with disabilities.” Community/ Public Health - “The science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals” Salutogenesis - “An approach to human health that examines the factors contributing to the promotion and maintenance of physical and mental well-being rather than disease with particular emphasis on the coping mechanisms of individuals which help preserve health despite stressful conditions” Restorative Environments - “The organized provision of medical care to individuals or a community”

Malaria Transmission Malaria is a life-threatening disease caused by parasites that are transmitted to people through the bites of infected female Anopheles mosquitoes. It is preventable and curable. The WHO African Region carries a disproportionately high share of the global malaria burden. In 2017, the region was home to 92% of malaria cases and 93% of malaria deaths. Total funding for malaria control and elimination reached an estimated US$ 3.1 billion in 2017. Existing Health Care Model Tertiary Care - The tertiary care hospital accommodates one major care activities Primary Care - The tertiary care hospital accommodates one major care activities Hybrid Primary Care Flexible Facility - The tertiary care hospital accommodates one major care activities.

Epidemiological Profile Main Causes of Death; HIV/AIDS, Neonatal disorders, Lower respiratory infections, Tuberculosis, Diarrheal diseases, Malaria, ischemic heart disease, Stroke, Congenital defects, Diabetes Tuberculosis Transmission TB bacteria are spread through the air from one person to another. The TB bacteria are put into the air when a person with TB disease of the lungs or throat coughs, speaks, or sings. People nearby may breathe in these bacteria and become infected. TB is NOT spread by: Shaking someone’s hand, Sharing food or drink, Touching bed linens or toilet seats, Sharing toothbrushes, Kissing. When a person breathes in TB bacteria, the bacteria can settle in the lungs and begin to grow. From there, they can move through the blood to other parts of the body, such as the kidney, spine, and brain.

Figure 1: Referral Process in Malawi (using maternal care example)

*Bisika T (2008) The effectiveness of the TBA programme in reducing maternal mortality and morbidity in Malawi. East Afr J Public Health 5: 103-110 **Ministry of Health (2011). Malawi: health sector strategic plan 2011-2016 Draft III. Lilongwe. Malawi; Government of Malawi.

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Barriers to Care

Inadequate space to accommodate patients and visitors creates overcrowding

Non-availability of means of transportation Challenges with geographic access at individual or household levels were reported by several studies as lack of transport/difficulty organizing transportation or lack of money for the costs associated with transportation. Kyei-Nimakoh, M., Carolan-Olah, M., & McCann, T. V. (2017).

Shortages of medicines and health workers, insufficient health facilities and equipment, overcrowding, poor access to emergency services, long distance and transportation difficulties, poor attitude of health workers, and hence perceived poor quality of care - fall under the theme of shortcomings in public health service provision. Abiiro, G. A., Mbera, G. B., & De Allegri, M. (2014).

Access

Trust/

Knowledge

Lack of information on health care services/provider Extra efforts need to make services known to users, especially, through mass media like radio and television, the most significant barriers were long waiting times at health facilities that gave people a bad experience. Birmeta K, Dibaba Y, Woldeyohannes D. (2013)

Space Building trust in the community

Primary Care Provider

Community engagement and participation has played a critical role in successful disease control and elimination campaigns in many countries. Despite this, its benefits for malaria control and elimination are yet to be fully realized. Atkinson, Jo-An & Vallely, Andrew & Fitzgerald, Lisa & Whittaker, Maxine & Tanner, Marcel. (2011).

Kyei-Nimakoh, M., Carolan-Olah, M., & McCann, T. V. (2017). Access barriers to obstetric care at health facilities in sub-Saharan Africa-a systematic review. Systematic reviews, 6(1), 110. doi:10.1186/s13643-017-0503-x Abiiro, G. A., Mbera, G. B., & De Allegri, M. (2014). Gaps in universal health coverage in Malawi: A qualitative study in rural communities. BMC Health Services Research, 14, 234. https://doi.org/10.1186/1472-6963-14-234 Birmeta K, Dibaba Y, Woldeyohannes D. Determinants of maternal health care utilization in Holeta town, central Ethiopia. BMC

Health Serv Res. 2013;13:256. Atkinson, Jo-An & Vallely, Andrew & Fitzgerald, Lisa & Whittaker, Maxine & Tanner, Marcel. (2011). The architecture and effect of participation: A systematic review of community participation for communicable disease control and elimination. Implications for malaria elimination. Malaria journal. 10. 225. 10.1186/1475-2875-10-225.

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Definitions & Literature Review Community/Public Health

Salutogensis

“The science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals”

“An approach to human health that examines the factors contributing to the promotion and maintenance of physical and mental well-being rather than disease with particular emphasis on the coping mechanisms of individuals which help preserve health despite stressful conditions”

“Architecture can enrich the environment with complexity, order, and aesthetic considerations offering perceptual cues to assist and avoid confusion.” Connellan, K., Gaardboe, M., Riggs, D., Due, C., Reinschmidt, A., & Mustillo, L. (2013). “Building design has the potential to cause stress and eventually affect human health.” Evans, G. W., & McCoy, J. M. (1998). “There is evidence, then, that contact with the natural world— with animals, plants, landscapes, and wilderness—may offer health benefits...Taking seriously our affiliation with the natural world—may be an effective way to enhance health, not to mention cheaper and freer of side effects than medications.” Frumkin, H. (2001).

Golembiewski, J. A. (2017). Salutogenic architecture in healthcare settings. In The handbook of salutogenesis (pp. 267276). Springer, Cham. Connellan, K., Gaardboe, M., Riggs, D., Due, C., Reinschmidt, A., & Mustillo, L. (2013). Stressed spaces: mental health and architecture. HERD: Health Environments Research & Design Journal, 6(4), 127-168.Evans, G. W., & McCoy, J. M.

“Substantial evidence shows aesthetic design changes in healthcare settings can improve health outcomes for patients. Architecture provides a narrative context that affects a person’s behavior, neural and endocrine systems, and through its influence on the brain and the body, architecture can directly influence health.” Golembiewski, J. A. (2017). “This theoretical framework could be considered as a theoretical framework for health promotion. The salutogenic perspective focuses on three aspects. First, the focus is on problem solving/ finding solutions. Second, it identifies General Resistance Resources that help people to move in the direction of positive health. Third, it identifies a global and pervasive sense in individuals, groups, populations or systems that serves as the overall mechanism or capacity for this process.” Lindström, B., & Eriksson, M. (2006).

(1998). When buildings don’t work: The role of architecture in human health. Journal of Environmental psychology, 18(1), 85-94. Ouellette, P., Kaplan, R., & Kaplan, S. (2005). The monastery as a restorative environment. Journal of Environmental Psychology, 25(2), 175-188.

ARCH 6850| Nyondo | Fall 2019. Restorative Environments

Courtyards

“A restorative environment: Has access to positive distractions, Enables a sense of control with respect to the surroundings, Has access to social contact, Creates an ambiance that enables clearing of the head, recovery of directed attention, achieving cognitive quiet, and reflection” (Betrabet, 1996)

“An open space enclosed wholly or partly by buildings or circumscribed by a single building”

A spiritual perspective may make it possible to re-frame the situation and set aside the struggle. People in restorative environments may develop insights about their lives, leading to the discovery of new spiritual dimensions. They may find reassurance in the belief that there are powerful forces in the world that are beyond one’s understanding, that one is not alone, Ouellette, P., Kaplan, R., & Kaplan, S. (2005).

Evidence of reduced pain in patients, reduction in depression (likely, especially if garden fosters exercise), and higher reported quality of life for chronic and terminally-ill, patients (likely, especially if garden fosters exercise.) Marcus, C. C. (2007) An evidence-based overview of healing gardens and therapeutic landscapes from planning to post-occupancy evaluation. It provides general guidelines for designers and other stakeholders in a variety of projects, as well as patient-specific guideline Marcus, C. C., & Sachs, N. A. (2013)

Laboratory and field experiments have repeatedly found that natural environments better interrupt the stress process than predominantly built settings, even over brief periods. Although restoration may proceed for only a brief period with a visit to a healing garden, substantial benefits might accrue, reckoned over people and time. Hartig, T., & Marcus, C. C. (2006). Essay: Healing gardens— places for nature in health care. The Lancet, 368, S36-S37.

Therapeutic landscapes: An evidence-based approach to designing healing gardens and restorative outdoor spaces. John Wiley & Sons.) an evidence-based overview of healing gardens and therapeutic landscapes Marcus, C. C., & Sachs, N. A. (2013)

Frumkin, H. (2001). Beyond toxicity: human health and the natural environment. American journal of preventive medicine, 20(3), 234-240 Lindström, B., & Eriksson, M. (2006). Contextualizing salute genesis and Antonovsky in public health development. Health promotion international, 21(3), 238-244.

Marcus, C. C., & Sachs, N. A. (2013). Therapeutic landscapes: An evidence-based approach to designing healing gardens and restorative outdoor spaces. John Wiley & Sons.) (Marcus, C. C. (2007). Healing gardens in hospitals. Interdisciplinary Design and Research e-Journal, 1(1), 1-27.)

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OUTCOME HEALTH PROMOTION SALUTOGENESIS

DISEASE ILLNESS SICKNESS

PATHOGENESIS

HEALTH-EASE WELLBEING FUNCTIONING

“A salutogenic orientation, as the basis for health promotion, directs both research and action efforts”

DISEASE PREVENTION, CURE AND CARE Figure 2: Salutogenic Principle

Problem

of women and children, and its need for a more efficient primary health care model to support its existing clinics (Makwero, 2018).

The current space allocated for triaging and patient waiting rooms is a breading pen for the spread of diseases. The insufficient con- Thesis trol of air flow and patient flow creates a dangerous environment that promotes the spread of diseases. Due to long waiting hours Preventive measures and primary health care are integral to and staffing bottlenecks, it is necessary to propose an intervention achieving positive health outcomes and improved economic deto change the experience and treatment of the patients as they velopment. A distributed model of small clinics with flexible waiting enter into clinics. Poor ventilation and lack of air conditioning in and family spaces is an effective temporary intervention to reduce primary health care clinics, where duration of waiting time may be the spread of communicable diseases. as long as several hours, pose a possible threat to patients seeking primary health care (Wright, 2016). Framework Significance In the southern African region climate models predict increases in ambient temperature twice that of the global average temperature increase (Hondula, 2015). Increased temperatures affect human health and vulnerable groups including infants, children, the elderly and people with pre-existing diseases. Malawi is an appropriate location for this study because of its high at-risk population

Design Objectives The main objectives are to introduce ideas that fall under the theoretical principles of the salutogenic model. The objectives represent attainable and measurable goals that are reachable through the programming and design of a facility (Battisto, and Franqui, 2013.) The themes chosen below are the main categories of domains that need to be addressed to achieve the overall outcome of improving community and public health.

Golembiewski, J. A. (2017). Salutogenic architecture in healthcare settings. In The handbook of salutogenesis (pp. 267-276). Springer, Cham. Battisto, Dina, and Deborah Franqui. “A Standardized Case Study Framework and Methodology to Identify “Best Practices”.” In ARCC Conference Repository. 2013.

ARCH 6850| Nyondo | Fall 2019. Sub Problem – The current health care clinic is insufficient to providing for the needs of the community (Verderber 2015.) The current clinical environment is unsafe due to lack of guidance and supervision. Many of the staff are ill-trained and cannot accommodate the capacity of patients entering the clinics (McCue 1990.) • • • •

Improve Operational Efficiency Reduce Environmental Impact of Health facility Improve the Space Layout Primary Care clinics Enhance Population Health

Design Strategies These are the statements claiming what the design can do to achieve the expected outcome through the specific design objectives (Battisto, and Franqui, 2020.) There is some overlap in what the design should do and how to achieve it through the objective because the strategy is just an example recommendation of how to achieve multiple outcomes. Sub Problem – A focused approach is necessary to achieving even incremental improvement in rural healthcare systems. The overall outcome of achieving community and public health is important, but through many avenues and strategies, targeting the population, places, and practices in rural healthcare will ensure sustainable and achievable solutions. (Shahtahmasebi, Said. 2006.) Listed below are the core strategies highlighted to achieve community and public health; • Improve education and health awareness • Increase access to medical services • Increase the use of renewable resources

• • • • •

Accommodate a diverse range of health issues/ medical needs Improve the image of health facilities Decrease the spread of infection and diseases Improve education and health awareness Increase efficiency and workflow

Design Solutions The solutions are created in response to the directive from the design strategies. Design solutions are broken down into built environment factors and then measured empirically, there are an interpretation of a design strategy in a physical project (case study examples) help define a concept of how to achieve a conceptual strategy (Battisto and Franqui, 2020.) Sub Problem – The existing primary care clinical environment does not promote salutogenic principles which are essential in creating a space that promotes health and wellness for staff, patients and visitors (WHO, 1986.) The architectural environment is the vessel that accommodates and encourages better health practices through space planning, co-location of services and the patient care process (Capolongo S 2014.) The items listed below are examples from case studies of ideas on how to implement the strategies. • • • • • • •

Fully passive building with community/family areas Dedicated spaces for play Wards facing courtyard with seating sparsely spaced Air circulation vents in all wards with operable windows Naturally illuminated spaces Abundant greenery Flexible facility for time of surge and epidemics

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Case Studies Project: The Butaro District Hospital

The Butaro District Hospital Butaro Sector, Rwanda

Location: Butaro Sector, Rwanda Architects: MASS Design Group Year Completed: 2011 Size: 64,500 square feet Program: Outpatient and Inpatient Services

In 2007, Burera was one of the last two districts in Rwanda without a tertiary care hospital, leaving a population of 340,000 without access to a single doctor. A districtwide plan to increase access to care was developed, it began with the creation of a new district hospital in Butaro.

Project: Kachumbala Maternity Unit Location: Kachumbala, Uganda Architects: HKS Year Completed: 2017 Size: 2,960 square feet Program: Maternity Unit

Project: Centre of Excellence In Pediatric Surgery Location: Entebbe, Uganda Architects: Renzo Piano Building Workshop & Tamassociati Year Completed: 2020 (expected) Size: 96,800 square feet Program: Pediatric Surgery

https://massdesigngroup.org/work/design/butaro-district-hospital https://www.hksinc.com/what-we-do/case-studies/kachumbala-maternity-unit/ https://www.emergencyusa.org/project/uganda/centre-of-excellence-in-paediatric-surgery/

Figure 3: Entrance to Hospital

Design Solutions â&#x20AC;&#x153;The 150-bed Butaro District Hospital was developed to provide both inpatient and outpatient services, with a particular emphasis on maternal services. A laboratory, neonatal intensive care unit, and operating rooms were core programs to provide referral care and critical care services. Centered around an umuvumu tree, the hospital is a landscaped campus of buildings on the terraced hillside. It is designed to mitigate and reduce the transmission of airborne disease through various systems, including overall layout, patient and staff flows, and natural cross-ventilation.â&#x20AC;?

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Kachumbala Maternity Unit

Centre of Excellence

The region’s existing maternity ward was part of an existing health facility built in the 1950s. Two cramped, windowless rooms served as a place to give birth and receive pre- and post-natal care and it also doubled as an office where health care providers did their paperwork & medical records.

The mortality rate for children under the age of 5 is approx 69 deaths per 1,000 live births. Despite significant improvements in recent years, a continued effort remains essential in to achieving sustainable development. Ensuring high standards in pediatric surgery is therefore a priority.

Kachumbala, Uganda

Entebbe, Uganda

Figure 3: Mother looking to courtyard

Figure 4: Conceptual rendering

Design Solutions

“The passively-designed unit houses two delivery suites and a seven-bed postnatal ward to accommodate a minimum of six births per day, with the flexibility to support future expansion. The lowcost facility was built with the help of a locally-sourced workforce – about 40 people – and 95 percent of the building materials were locally produced. Sustainable, passive features are design musts in locations where the power supply isn’t reliable and natural resources are scarce.

“The center will embody a number of core principles. Chief among these is a concern for environmental sustainability. The center will make use of innovative technologies to minimize its environmental impact and maximize sustainability.

The predominant building material, interlocking soil-stabilized blocks were handmade on-site, using locally arising murrum mixed with cement in a brick press, reducing both costs and the need for power tools.”

Consideration for the holistic health and well-being of patients is at the heart of the center’s design. Dedicated to medical education, the hospital strives to not only provide excellent pediatric care but will also become a regional training center for health professionals.”

ARCH 6850| Nyondo | Fall 2019. Enhance flexible opportunities Increase efficiency and workflow

Sub Problem: The built environment uses unhealthy and unsustainable building practices that threaten the environment and negatively impact the health outcomes of it’s users

Improve Operational Efficiency

“Poor health infrastructure will continue to expose society to threats of epidemic and social injustice” - Rwanda Hospital Design Standards.” MASS Design Group, 2014.

Improve Community and Public Health

“Better design and construction processes will produce not only better health outcomes, but economic, educational, environmental, and emotional impacts to the community” - Rwanda Hospital Design Standards.” MASS Design Group, 2014.

Accommodate diverse range of needs Create site appropriate sustainable design Use locally sourced materials

Reduce Environmental Impact of Health Facility

Sub Problem: The existing primary care clinical environment is a breading pen for the spread of diseases. It needs to be modified to make the clinical visit safe for both staff and visitors

Build and sustain local capacity

Reduce use of artificial lighting Incorporate energies that are self sufficient Improve education and health awareness Co-locate healing and public spaces

Improve Population Health Outcomes

Aid patient recovery process Increase access to medical services Create more inviting and welcoming facility

ARCH 6850| Nyondo | Fall 2019. Outdoor triaging to streamline patient care 1 process Integrate silos of care

Courtyards as waiting spaces to avoid overcrowding in close quarters

Clear separation of clinical and public activities

Offer a multitude of services in central location for easy access and convenience

Rammed earth and indigenous construction materials

Fully passive building, created with vernacular construction methods

Air circulation vents in all wards With operable windows

Drainage of rainfall managed to Reduce pooling of water

Low-cost facility was built with the help of a 10 locally-sourced workforce Devoted spaces for play

Cool area with shade that promote gathering and socialization

Small scale spaces that provide respite and retreat from lives stresses

Patient rooms in close proximity to natural 14 environments

Open Corridor Studio, SACHIBONDU HOSPITAL NW Province, Zambia

MASS, BUTARO HOSPITAL Uganda

6 Studio, SACHIBONDU HOSPITAL NW Province, Zambia

Pediatric Surgery Center of Entebbe Uganda

Studio, SACHIBONDU HOSPITAL NW Province, Zambia

Image sources : https://massdesigngroup.org/work/design/butaro-district-hospital https://www.hksinc.com/what-we-do/case-studies/kachumbala-maternity-unit/ https://www.emergencyusa.org/project/uganda/centre-of-excellence-in-paediatric-surgery/

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Claim 1:

Outdoor fast track triaging will help streamline the patient care process which will decrease the spread of diseases and possibilities of cross contamination , improving the operational efficiency and preventing the spread of communicable diseases.

Design Objective Improve operational efficiency

Design Strategy Increase efficiency and workflow and decrease errors related to cross contamination through spatial planning. Design Solution Outdoor triaging area for streamlined patient care process and positive patient experience.

Blurring the lines between medical and public facility functions by allowing for family visitors to play/wait outside in a more welcoming and common environment.

Evidence “Many studies have shown that natural environments foster recovery from stress better than built settings because natural environments support well-being, health, and restoration from stress and attentional fatigue” (Hartig, et al. , 2003 ; Kaplan, 1 995 ; Korpela, 20 1 3 ; McCuskeyShepley and Mc-Cormick, 2003) Findings from literature reviews show that “arriving at the facility may not lead to the immediate commencement of treatment. Shortages of qualified staff, essential drugs and supplies, coupled with administrative delays and clinical mismanagement, become documentable contributors to maternal deaths” (Thaddeus, Maine, 1994)

Outdoor waiting and triaging that separates the ill and allows physicians to isolate high risk patients who could possibly spread diseases in an open and well ventilated space.

Cervinka, Renate, Kathrin Röderer, and Isabella Hämmerle. 2014. “Evaluation Of Hospital Gardens And Implications For Design: Benefits From Environmental Psychology For Architecture And Landscape Planning.” Journal of Architectural and Planning Research 31 (1): 43–56. T haddeus, Sereen, and Deborah Maine. 1994. “Too Far to Walk: Maternal Mortality in Context.” Social Science & Medicine 38 (8): 1091–1110. https://doi.org/10.1016/0277-9536(94)90226-7.

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Claim 2:

Use of indigenous low cost materials creates a site appropriate sustainable design which aids in reducing the degradation of the site and the negative impact of the health facility on the natural environment ensuring the preservation of local land and resources.

Design Objective

Reduce environmental impact of health facility Design Strategy Promote site appropriate and sustainable design methods Design Solution Use of indigenous low cost materials such as rammed earth and mud bricks. Evidence “Present interpretations of sustainability have given them (usually, earth, timber, straw, stone/rock and thatch) a new status as likely technologies for the contemporary world. Along with the others that have been re-devised, earth has of late gained acknowledgment as a suitable technology for contemporary buildings.” (Ikechukwu, Ugochukwu, 2019) “Though promotional efforts can achieve some Favorable responses, certain ideas rooted in history can hardly be shaken and it is better to consider their effect than to assume their absence. Materials chosen for development and utilization should be as close to what the people are familiar with and perceive as a progressive material as possible. ” ( Ofori, 1985)

Interlocking mud bricks with large opening not only offer ventilation but use less raw resources and still create an aesthetically pleasing exterior surface.

Rammed earth which does little to disturb the natural site reduces heating and cooling loads which reduce the overall operating costs and maintenance of the facility

Onyegiri, Ikechukwu, and Iwuagwu Ben Ugochukwu. “Traditional Building Materials as a Sustainable Resource and Material for Low Cost Housing in Nigeria: Advantages, Challenges and the Way Forward.” Ofori, George. 1985. “Indigenous Construction Materials Programmes: Lessons from Ghana’s Experience.” Habitat International 9 (1): 71–79. https://doi.org/10.1016/0197-3975(85)90034-7.

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Claim 3:

Co locating waiting space with play areas creates a more inviting and welcoming facility that accommodates a diverse range of family needs which entail improves the population health outcomes by promoting the probability of positive returns/referrals and preventative physician visits

Design Objective Improve population health outcomes Design Strategy 14

Co location of healing spaces with public functions Design Solution Integrating play area with waiting spaces within a natural environment that complement each other. Evidence “Salutogenic spatial and socio-environmental structures can support comprehensibility, meaningfulness, and manageability of life, which is steady coping with challenges, by intentionally offering specific and general resistance resources by these structures” (Golembieski, 2017) “An organizational process of coordination which seeks to achieve seamless and continuous care, tailored to the patients’ needs and based on a holistic view of the patient” (Mur-Veeman, Hardy, Steenbergen, Wsitow 2003)

Using a scale that is common to the rural environment of small unit homes creates a familiar space that encourages visits and accommodates visitors, spouses and children

Abundant greenery and naturally illuminated spaces will free patients from the anxiety of their day-to-day situations and provide dedicated play that offers respite and relaxation in an often traumatic and tense environment. Golembiewski, Jan A. “Salutogenic architecture in healthcare settings.” In The handbook of salutogenesis, pp. 267-276. Springer, Cham, 2017. Mur-Veeman, Ingrid, Brian Hardy, Marijke Steenbergen, and Gerald Wistow. “Development of integrated care in England and the Netherlands: managing across public–private boundaries.” Health policy 65, no. 3 (2003): 227-241.

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Conclusion Preventative measures and primary health care are undoubtedly of importance, the widespread provision of advanced primary medical infrastructure is integral to achieving positive health outcomes and improved economic development. The myriad of challenges facing primary care clinics requires innovative solutions that are affordable, robust and sustainable over time (Barjis, Kolfschoten, and Maritz 2013.) Furthermore, due to special characteristics of such rural areas and their inhabitants, any healthcare solution should implement proper architectural planning and design practices to prevent basic medical errors and negligence of local community needs and resources. An obsession with the search for universal solutions, rather than trying to identify appropriate strategies for the particular local context is common in most development plans for impoverished communities. In addition, a lack of empathy and developers’ inability to communicate with the supposed beneficiaries of development have sometimes led to antagonism. A positive trend in recent years has been a notable shift in the focus of rural development strategies, from the rather dictatorial ‘topdown’ approaches of the past to locally based and more democratic ‘bottom-up’ strategies (Binns, Hill, and Nel 1997). In understanding the problems of basic barriers to healthcare and positive health outcomes, the design framework helps as a tool to assist in providing appropriate solutions based on context and intended outcomes. The main objectives of improving operational efficiency, reducing the environmental impact of health facilities and improving population health outcomes are essential principles in the success of primary care clinics.

Children posing for picture at Kachumbala Maternity Unit Kachumbala, Uganda, Africa

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