The hospitals we are delivering in Ghana, Côte d’Ivoire, Zimbabwe, Kenya, Zambia, and Gambia, are being built in response to the demand for quality, accessible healthcare in sub-Saharan Africa. A World Health Organization report, published in 2007, estimated that between 550,000 and 650,000 extra beds were needed across sub-Saharan Africa to meet the expected ‘healthcare gap’. This needs to be addressed. Thanks to increasingly buoyant economies, African governments feel empowered to tackle the issue head on with hospital building programmes. However, such activity takes time; time to organise and time to deliver.
In Ghana, spending on healthcare in rural areas is only now starting to close a gap which has existed between the existing healthcare estate and the needs of the population, nearly three quarters (70%) of whom live in communities that are over five kilometres from the nearest healthcare facility. There is also a recognition that good healthcare facilities could boost tourism. A current hospital project in Zimbabwe has been driven by this. Some of the airline companies will not commit to scheduling flights into an airport unless there is a hospital of reasonable size and facilities within a nearby radius.
Impact on life expectancy
This distance to the nearest healthcare provision, exacerbated by lack of access to transport, has had a dramatic impact on the health and life expectancy of rural communities in recent years. The region also suffers a high mortality rate among children. A report by the Ghanaian Ministry of Health in 2001 reported that child mortality in areas remote from healthcare was 40% higher than in communities within five kilometres of it, while infant mortality in rural areas was 60% higher than that in urban areas.
Tackling this has become a priority for the authorities. Historically, healthcare in Ghana has been concentrated in the main urban centres, where the more affluent population tends to live, and benefits disproportionately from public sector healthcare – particularly secondary and tertiary care, as well as private healthcare provision.
Among the country’s rural population, which is often poor, the informal and charitable sector has been an important provider, with patients also paying for their care at the point of delivery. The Ghanaian Ministry of Health’s District Hospital programme, which we worked on, has aimed to counterbalance these trends, creating high-quality secondary care within communities across the country. However, building a large hospital in the middle of a remote rural area is one thing; it is another to do so in a way that is mindful of the needs of patients and their families, many of whom travel – often on foot – not inconsiderable distances to be seen by a doctor, and it is vital that any new facility works within its surroundings.
First African hospital project
Our first African hospital project was the Shai-Osudoku District Hospital in the Greater Accra region of Ghana, which was delivered in 2015. The core model for the hospital was for a 120-bed scheme featuring two operating theatres and other departments – including diagnostics, accident and emergency, dental, traditional medicine, and outpatients. When it came to developing the project, from the outset we had to completely re-think the concept of a hospital. We had to re-consider several aspects of how hospital care works in Africa, versus our experience of the UK model, not least around the expectations of patients when they come in.
For example, in rural African hospitals there isn’t an appointment system; if someone has a heart condition and they need to see a doctor they will know that Cardiology day is, say, a Tuesday. They will attend a clinic or a hospital on that day, often with several members of their family in tow, and they will wait to be seen, often for long periods of time.
Understanding this and other dynamics around African healthcare informed the design process. We created large waiting areas for patients and their families, often including outdoor spaces so that people could be in the fresh air, along with awnings to offer protection from the sun.
Need for cooking areas
We saw that cooking areas would be needed, again outside, since families tend to cook both for their sick relative and themselves while they are at the hospital. The same consideration was given to those people coming to the hospital to collect the body of a relative; we created a large, covered area outside the mortuary in response to local customs. When a body is retrieved for burial, it is a cause for coming together and celebration of a life, and so space needs to be created for a large number of people who will gather in order to take part.
Addressing the local climate, a flow of fresh air is beneficial to patients, visitors, and hospital staff alike. We aim for our hospitals in rural areas to be ‘shallow plan’; that is to say they are usually single-storey in construction, relying less on electricity and air-conditioning for ventilation and light, and more on fresh air and natural light. Where possible everything is naturally ventilated, with deep overhanging blinds shading the windows, walls and external walkways, which give patients and visitors further outside space – and are cheaper to build.
Sustainable power sources
With intermittent power, natural ventilation and light come into their own. Obviously, some aspects of a hospital will always rely on electricity – lighting in operating theatres, refrigeration in the mortuary, for example – but elsewhere in the building we can depend on more sustainable sources. Staying on the subject of sustainability, a key aspect of the design and delivery of these hospitals is a ‘kit of parts’ concept, where components and building materials are adaptable to different terrains, different budgets, and different requirements on the ground.
For a hospital we designed in Côte d’Ivoire we used steel frame for the walls sitting on a concrete base. The steel frame was made on site using 3D cutting and folding technology, and simply bolted together, the walls then being filled with insulation and clad in concrete sheets. The machine used for folding and cutting the steel frames was based on site for the construction period, and then moved to the next site.
Modular aspect of design
Where there is demand and available land, the modular aspect of the design, and its standardisation, mean extra units can be added as and when required. We also looked to generate sustainable and renewable energy, not least through photovoltaic panels, and generating power on site by delivering factory-built plant and oxygen-generating rooms.
As one might expect, connection with the community is important, which includes employment for both hospital staff and those who maintain it. As much as possible the fabric of these hospitals is designed to be locally maintained. Materials and finishes are chosen on the basis that they can be repaired by a local team of builders – for example, installing a floor made from local terrazzo that can have chips and damage repaired on site, rather than using sheet flooring that would have to be sourced from further afield, or even overseas, if it needed replacing.
Five-year review
The client recently carried out a fiveyear review of the building and its fabric. Departments within the hospital had moved and changed, and the buildings had adapted. What was clear was that the buildings were subject to forces from the elements and from daily use. In our ongoing projects we have learnt from this by deepening roof overhangs to give even greater protection from sun and torrential rain. Internal walls are often on the receiving end of things like trolleys and other equipment, and thus benefit from wall protection. Budgets for these hospitals are constantly tested to provide the greatest number of facilities, but this needs to be balanced against the capital costs of creating truly robust and longlasting environments.
Another selling point of our design is the hospitals’ ‘pandemic adaptability’ – the shallow plan and courtyard form is naturally adaptable to adaptation for use when a pandemic occurs. The singlestorey building form features a number of possible entrances, all of which can be sectioned off and operated independently. We have also discussed the provision of designated pandemic hospital zones, which feature a hardstanding area, complete with a dedicated service building. This area can be used to build ward marquees and support services.
Making all welcome
We want to make the hospitals we design environments where everyone – patients, visiting friends, and families – feel welcome. Making the hospital feel this way can go a long way towards aiding the recovery of patients. It’s part of a salutogenic approach to hospital care; one which focuses on the health and wellbeing of patients, rather than merely on the ailment that brought them there
Creating a well-designed hospital environment also benefits staff. African hospitals often bear the brunt of a drain of talent, as local health professionals seek opportunities overseas. By helping communities build well-equipped, wellresourced hospitals that staff can see are responsive to the needs of the local community, workers can be encouraged to remain, doing what they do best. This can be enhanced by offering them good quality living accommodation on site – an important benefit for those working in hospitals located in remote rural areas.
In addition to the eight hospitals we have already delivered across the continent, tp bennett is currently involved with the delivery of 14 hospitals in Côte d’Ivoire and Gambia.
‘Zero tolerance’ for maternity mortality
The impact of these new hospitals on local healthcare outcomes has been considerable. In the case of the ShaiOsudoku District Hospital, Medical director, Dr Kennedy Brightson, initiated a ‘zero-tolerance policy’ for maternity mortality, and within five years the incidence in the area has been reduced to zero, compared with 2,000 annual cases before the policy came in. The hospital’s authorities attributed this to what they called ‘good infrastructure, the commitment of staff, and quality healthcare’, a point echoed by the country’s health minister, Kwaku Agyeman Manu, who pointed to what he called ‘a well-motivated workforce’.
Word of the hospital’s success has spread. It has been identified by the World Health Organization as a possible benchmark for other health facilities across Africa, due to its infrastructure and the delivery of its services. We are proud of the achievements of both our team and those working on the ground across sub-Saharan Africa to bring about radical and beneficial change for those requiring hospital treatment.
Looking ahead, we have considered how we might change our delivery approach. We are working with NMS Infrastructure to develop standardised departments within the relevant construction teams, and expand the ‘kit of parts’ concept of creating the components for a hospital. As well as shortening the design time, it could reduce the potential for delays during a procurement period, since materials and equipment could be ordered in packs
We are also developing the design model so that it will be easier to expand a hospital in the future, creating additional wards or new clinical areas, making them easier to build, more adaptable, and cheaper to run
Communities across sub-Saharan Africa deserve the highest standards of healthcare. There are numerous reasons why in some parts of the continent this is not the case. However, the hospitals we are designing, along with the dedication of those on the ground who build and then work in them, delivering the care people need, are playing their part in addressing the healthcare gap to the point that hopefully, one day, it no longer exists.
Polly Barker
Polly Barker is the Healthcare lead at tp bennett, and has extensive design and project management experience. After gaining experience in the retail, commercial, and residential sectors, she started to specialise in health and education, and now has over 20 years of specialism in this field, both in the UK and internationally. She currently acts as the practice’s Construction Design and Management (CDM) manager, offering advice, and coordinating policy and procedure, regarding health and safety in design and construction. She is also an active member of the Sustainability Group, responsible for promotion of sustainable design