world bank document...facilities, wlhich was held for the sadc region in harare in may 1996, and may...

pie UOSH!lItIUH IODUOIEl t 9 0O91

S31111113Vi 13A31 UlNSOS ONV 191111 10

SIOIIIHOHV ONV SHINNV1J 1101 10100 V

u m.~-- _-. 4

_V . _~% -, *. -

* A_ ¢

XX -- , ~~- . -I *f v

$ @ ''' " ' ' * 1 * | ' $' .. ji, = ' s t~~~~~~~~~~~~~

' ^' , ths ~~~~s''*5 > * " As '' s '"1 "'* '' ' ^~~~~~~

t ' - , . s . 9 ,,,,8.r j * ,_ s~~,;+-s 5 :- * , t , * ;

;. 'I VI HI VI N- IDNIO1IDU, =,j , _ . ,s ,_ r_ -' ___r *

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

BUILDING FOR HEALTH CARE

A GUIDE FOR PLANNERS AND ARCHITECTS

OF FIRST AND SECOND LEVEL FACILITIES

Michael Hopkinsonand

Kees Kostermans

Publication in relation to the Regional Workshop on Civil Works

for Health Care Facilities, Harare, MaY 1996

WORLD BANKEastern and Soutlherni Africa

Human Developmenit Gr-oup1996

AcknowledgmentsThe authors, Michael Hopkinson (health planner, architect, Initiatives consultant to the World Bank)

and Kees Kostermans (public health specialist, World Bank, Eastern and Southern Africa, HumanDevelopment Group) thank all participants at the Regional Workshop on Civil Works for Health CareFacilities (held for the SADC region in Harare in May 1996) for their many inputs to this publication.The Annex lists all participants. We are especially grateful to Evelyn Serima (MOHCW, Zimbabwe),Basileo Mandlhate and Thierry Rivol (MOH, Mozambique) for their valuable help in preparing theworkshop documents. We thank Eppie Ushewokunze and the staff of the Bank's Resident Mission inHarare, especially Gillian Williams, for their assistance with the logistics of the workshop.

=The drawings showing health centres in chapter 5 are based on standard drawings in use in

Mozambique, South Africa and Zimbabwe. All other designs are based on sketch designs produced by zMichael Hopkinson.

The publication was edited by Leo Demesmaker (consultant) and made ready for publication byTomoko Hirata (World Bank, General Services Department). The photographs for the title illustrationshave been provided by the authors and Keith Hansen (cover).

The task was managed by Kees Kostermans (AFTHI1). -

We, the participants to the workshop and the authors, express our thanks to the Government ofDenmark which made funds available for the workshop and for this publication.

The document will be available on the following WWW address:http://wx\w.vworldbank.org/html/afr/healthb z

-_You may wish to send your reactions or questions to the authors' e-mail addresses:for Hopkinson: <[email protected] >for Kostermans: < [email protected]@internet >

Reproduction is permitted for non-commercial purposes. Reference should be made to thispublication, the authors and the World Bank.

T he findings, interpretations, opinions and conclusions expressed in this book are entirelv thoseof the author(s) or of the participants in the Regional WVorkshop on Civil Works for Health CareFacilities, wlhich was held for the SADC region in Harare in May 1996, and may not be attributedin any manner to the World Bank, its affiliated organizations, or to members of its Board ofExecutive Directors or the countries they represent, or to the Governments of the workshopparticipants. The preceding disclaimer applies with equal force to the illustrations and figures.

FOREWORDThe planning for infrastructure for health carc seldom receives the attention it deserves. Ministries of Health

tend to spend large proportions of invcstment budgets for the construction of tacilities. These investments havelarge implications for the recurrent budget of these Ministries for many years after the original expenditure. Forthis and other reasons, careful planning of appropriate facilities is extremely/ important for the general ftitureavailability of fuinds in the sector.

Planning of facilities also deserves a lot of attentioni since the facilities formi the premier wNorkingenvironment for most health workers. Onlv in a well-planned facility can the services be delivered efficicntly. Forpatients it can make an enormous positive differcnce if the facility has a spacious waiting area or wvell ventilatedwards.

The planning of infrastructurc has many possibilitics for conflict sinic various parties are involved in theplanning process. Construction of health facilities may have a high profile for politicians. Conistructioni offacilities often involves at least twvo Ministries: the Ministry of Constructioln and the Ministry of Health, eachwithl its owvn expertise. The population at large, doctors, ntirses, patients, politicians, architects, each havc theiroxwn intercsts; the health planner wvill have to wveigh the arguments of all parties when making a decision.

We hope that this book wvill be used as a guide for professionals involved in the planning of newconstructioni or the rehabilitation of first anid second-level health tfacilities, and that it mav serve to improve thedelivery of thosc services in the SADC regioni and far beyond.

Ruth KagiaTechnical Manager

WVorld BankEastern and Southcrn AfricaHLumani Development Grotip

CONTENTS1 INTRODUCTION I

The Southern Africa RegionThe Harare WVorkshopThis Publication

2 PROJECT INCEPTION 3Health Policies: Goals and OptionsHealth Infrastructure: Buildings, Installations and EquipmentOverview of What is Available

= Assessmcnt of Needs,,, Capital Investment Policies and Recurrent Costs Implications

Perceived Causes and Goals- Possible Impacts of Civil Works Activitiesz Improvement in Quality and Efficiency

Increased Running Costs

Ca 3 PROJECT ORGANISATION 8The Client OrganisationThe Consulting Architects and Engineers OrganisationThe Contractor's OrganisationProject Management and Site SupervisionThe Planning, Design and Construction ProcessThe Division of Responsibilities During Each PhaseParticipation of Users During the Design ProcessCommunity-based Projects

4 THE PROJECT BRIEF 17The Contents of a Project BriefAims of the ProjectResults of Planning StudiesSite and Site FactorsEngineering InformationInformationi onl Existing EquipmentMasterplansNorms and StandardsOutline Schedule of Accommodation and CostsDepartmental Planning PoliciesContents of an Operational Policy StatemenltDetailed Schedule of RoomsRequirements for Individual RoomsOutline Equipment and Component SchedulesBuilding ConstructionBudget Costs PlanActivity Schedule and Time PlanFormulatinig a Design Brief for Consultants

5 PROJECT DESIGN 46A Hospital is Not a BuildingDesign Layout for Site Layout PlansDesign Principles for DepartmentsThe Use of Standard Room SizesStandard Plans

Outpatients DepartmentPharmacy / Dispensary eEmergency / Minor TheatreMother and Child ClinicDiagnostic X-rav Department =Operating Theatre Department _Rchabilitation DcpartmentLabour Ward / Delivery m

Standard Acute Care Ward zKitchenLaundryCentral Stores and W orkshopsAdminiistrationMortuarvCentral Staff Change

Health Centr^e DesignUse of Existing Departments

6 ENGINEERING 65High-technology AutoclavesNledical Gas ReticulationisAir-conditioning SystemsAppropriate MaintenanceFire Fighting and Fire Protectioni Systems

7 COSTS MANAGEMENT DURING CONSTRUCTION 70Cash-flow ReportCosts ReportPayments CertiticatcsVariation OrdersMonitoring Costs Report by the Client

8 PLANNING OF HEALTH EQUIPMENT 72Three Steps in PlanningThe Status of Health EquipmcntTasks of a Health Care Technical Service

9 COMMISSIONING 76Functional Content of the ProjectManagement of a Commissioning ProgramimeOperational PlanningEquipment and SuppliesPersonnel ManagcmentInformationPre-hand-over ActivitiesCommissioning of Engineering ServicesHand-ovcrThe Tasks Immediately after Take-overIImplications of the Defects Liability Period

_ Introduciing the New ServicesOpening CeremoniesReview of the Commissioning Process

10 PROJECT EVALUATION 80- The Need for Feed-back

How to Organise and Evaluate

CD11 EPILOGUE 82

CD Mistakes-and How to Avoid Thcm

APPENDICES 89A List of Participants at the Harare Workshop

B Example of a Standard Building Specification

C Key Activities to be Undertaken by Health and Construction Ministries

D A Preliminary Brief Prepared bv a Ministry of Health

E Use of Non-technical Solutions

F Calculating the Need for In-patient Beds

G Example of Facility Use and Capacity Figures

H Setting Priorities

J The Re-use of Existing Buildings

IK Checklist for Approving Design Proposals for Hospital Projects

L A Practical Masterplani

M Other Sources of Information

0~

1. INTRODUCTION -- -

Expenditurc on health services takes Up a significant proportion of the annual budgets of govcrnnments of =developed and developing countries. Good health has a high priority w'itlh all populations wvhosc carecxpectations are expanding in parallel with their improved understandinig of what health services with thesupport of moderni science cani achicvc. The demands made in quality and quantity of services rcquired from thecpublic sector are becoming increasingly; difficult to satisfy: most counltries are studying how bcst to use thelimited health serviccs resources available.

These pressures have led to a reappraisal ofthe type of service xvhich wxill most economically giv e thc bestresults to improve and sustain the good hcalth of the populationi. In recent years this has influcnced thereorientation of health services from curative to preventive activitics and shifted the emphasis to commrinunity-based rather than institution-based care. In many counltries, however, the existing health infrastructure has not ocasilyN facilitated these newv emphases.

Because of this, most hcalth sector btidgets and investment projects have had substantial rcsources allocatedto realigning hcalth facilities to the new, strategies for providing health care. Many primarv level facilities havebeen constructcd to provide improved access to care with increascd efficicncv; at the samc timc, servicesprovided at rural, district and central hospitals have bcen reappraiscd to provide the rcquired support andsupervision to the ncw and morc appropriate referral systems.

THE SOUTHERN AFRICAN REGION

In each southern Africa country, extensive hcalth sector projects have becn establishcd by governmrcnts oftenwith financial and technical suLpport fromii donors. T he projects have usually becn promoted around thcmes suchas equity, accessibility, emplhasis on promotionl and prevention activities, cost-effectivCeness, comm0 unityinvolvement, integration of programmes, and co-ordinationl of separate health activities. This approach generallyimplics chaniges of the alignmcnt of health carc and parallel cfforts to avoid carlier mistakes.

The projects tace many problemiis: setting clear prioritics; lack of technical expcrtise; problems incommuniication between the differcnt disciplines involvcd in planning and constructing healtlh buildings, and lackof continuitv from project to project. As a rcsult, achievements being madc throtIgh the newv health programmesare often compromised and the anticipatcd bencfits have not always been ftilly achieved. In some typical instances:

MNIany patients by-pass primary level for secondary and tcrtiary,-lcvel facilities, and many health centresand healthl posts are tinder-Lutilised;

* New or improved health buildings often require recurrent expeniditure wlhich is not available in thegovernmlaenit's budgets. Buildinlgs are often completed but staff, equipment and consuLmlables are oftenyears later in appearing;

* Facilities provided at nlCw institutions are often extensive and reqLuire more staff than is available;

* Mistakes in design make it difficult to achieve required standards of fiunctionial qLiality and efficiency;facilities are too difficult for available expertise and resources to maintain;

* Buildings do not offer coimfortable and safe places of work for healtlh staff

= Many of these problemils are caused by mistakes whiclh could be avoided if dialogue betweeni professionalsworking with building projects in all countries in the region could be improved.

- THE HARARE WORKSHOPCD

In May 1996 aroLudi forty-five staff mnemnbers of iklinistries of Health and of Mi1nistries of ConstrUction fromAngola, Botswana, Lesotho, Malawi, Mozambique, Naniibia, Soutlh Africa, Swaziland, Zambia and Ziinbabwe

= gathered in a Regional Workshop on Civil Works for Health Care Facilities. The group consisted of healthC planniers, architects, enginieers, quantity surveyors and economists.

In the southern African regioni there is a wealth of experience atmnogst governimenits and doniors and their- consultanits on health buildinig. This experience is not alwavs well documented, and there is often too little

contact between the groups involved, particularlv those from different couLntries. The workshop was intended tobring individtials working witlh health care buildinigs together to exchange their individual experiences and in thiswa' reinforce their collective expertise.

THIS PUBLICATION

This ptLiblication captures most of the topics hanidled in the Regioinal Workshop on Civil WVorks tor Health CareFacilities, and puts the workshop materials in a systematic order. It is an anthology of materials used by theorganisers and presenters in the workshop. Tle comments of workshiop participants have been taken into account.

The publication will mainilv give guidanice for the physical plannling of facilities for the primary andsecondary level of healtlh care. Howevcr, since most of the same principles and caveats applv, the book will beuseftul for planniers of tertiary facilities.

2. PROJECT INCEPTION

HEALTH POLICIES: GOALS AND OPTIONS

Rational platnninig for health facilitics requires rational planninlg for health services, since the facilities existonly to support the delivery of these scrviccs. Manyv countries arc nowv reassessinig the adcquacy of healthserviccs and determining which services should bc publicly provided. The current extreme constraints on publicresources demand such an evaluation. T'his is normallv done in three phases. First one calculates the burden ofdisease in a countrv, by estimating which diseases as the main causes for morbidity and mortality cause the mostloss oftdisability-adjusted lifc years (DALYs). Secondly one assesses the cost-effectiveness of healtlh interventionswvhich can address these causes of loss in DAI.Ys. In a conventional cost-effectiveness analysis the econiomnic costof an intervention is divided by an cstimate oftits healtlh effects. In a third phase, the most cost-effectiveinterventions are packaged in the best wav for their efficient and effective delivery. 'The packagingog ofservicesitself has often a great impact on their costs. Normally services are packagcd in three lcvels of care. The first lcvelcovers a basic package of promotive, preventive and curative services. The second level serves as the first referralmeclhaniism and the third level deals with more sophisticated mainly curative services.

Of course, cost-effectiveness alone cannot be allowed to dictate the package of services. Government is X

responsible for enisurinig that services arc equally available to the population. Diseases which disproportionallyaffect the poor have to be addressed. Of course, the issue of affordabilityl has to hc considered. Each health =

intervention will requirc institutional and logistical support, trai ned stafftand supplies. In times oflconstraintdifficult choices must be made about which services can and which services can not be provided through thepublic sector. There is the key question of how close to the populationi can services be provided? Only whensuch decisions on services and thcir delivery syrstemns have been made, can Governments start the rationalplanning oftfacilitics.

HEALTH INFRASTRUCTURE:BUILDINGS, INSTALLATIONS AND EQUIPMENT

Althouglh the quality of staff and mainagcmiieilt and the av ailabilit of drugs and consumables are important,the physical environment in which health care activities take place also has direct influence on the quality andefficiency of service. Buildings influenicc the extenit and quality oftservices which can be providcd just as much asfixing their location. A health centrc, a rural hospital or a teachinlg hospital: the type and kind of institutioninfluences the activity wvhich can be accomplished there.

The network of health posts, hcalth centres, rural and district hospitals, and provincial and central hospitalsusually reprcsents an impressivc investmcnt in buildings, plant and equipment. But cven now in most countricsthe distribution of these different types of institution, and the level of rcsourccs which they consume, does notreflect international ptiblic health and political opinion of what is appropriate.

There are too many beds in the large hospitals and they consume too large a proportion of resourccs.Despite the 1977 Alma Ata Declaration of Health for All based on primary health carc, most agencies anddonors have refused to invcst in the secondary and tertiary institutions and little attempt has been made toimprove efficiency or to realign the activities to reflect the Declaration.

Networks of primary level facilities, clinlics and health ccntres are rapidly being extcnded. Compared withz hospitals their running costs are vcry low. However, they are difficult to staff particularly wvhen situated in very

remote locations and patients often by-pass them in favour of hospitals.

- In most major health development projects, considerable rcsourccs are invested in conistruLction, as a means_ to establish a health infrastructure whichi will provide an appropriate basis for promotive, preventive and curative

intcrventions.

o OVERVIEW OF WHAT IS AVAILABLE=

Whcn discussing investmcnt programmes for upgrading and building new facilities, it is difficult forMinistries and donors to sct reasoniable priorities. They know too littlc about the extent and condition ofindividual facilities and understand too little of the effects that improved quality and changes to buildings and

- installations will have on future recurrent expcnditure.

Many health Ministrics have no detailed inventorv of the coun1try's health facilities, though they probablyhavc adequate data from which to compile one. Only relativcly simple information is required:

CD . Name of institution;* Location;* Catchmcnt population;

a- * Date of construction;+ Date of most recent refuirbishmcnt;* Number of beds, if possible in the diffcrent catcgories:

-malc; femalc; maternity; paediatric;* Number of out-patient consultation rooms;+ Numbcr of major and minor operating theatrcs;* Numbers of staff houscs in different categories;* Availability of mains electricity;* Fucl used in the kitchen.

This information provides a Iscfull basis tor discussing and setting prioritics.

When decisions arc being made concerning individual facilitics, thcsc data need to be supplemented by on-sitc-collccted observations. The cxamplc of a survey of existing conditions which is shown in Appcndix D is thercsult of a tour-hour inspcction of a provincial hospital in Zimbabxvc. Eventually all institutions in Zimbabxvewill be documented in this way. In Namibia the Ministry of Health (with a littlc support from the NVorld Bank)in a concentrated programmc carricd out a comprehensive visual rcgistration of all its health facilities inapproximately 6 months

ASSESSMENT OF NEEDS

Similarly too little seems to be known about the factors -such as the freqCuenIcy wvith whl1ichi the population

visit health ticilities, the services the' retquit-e w hen they arrive there and the capacity of individual staffmembers or itemiis of equipmcnit to satisfy their reqquirements- which should influeLnce the size and distributionof services at the various facilities. Anv discrepancy betwkeen thc services which are available and those whichshould be available should be established.

Informationi is also needed on the rate of admissionis of in-patienrts, the average length of stay of in-patielntsin the different xvards, and the acceptable bed-occupancy rate.

This inforrmationi, examples of xvhich are shown from iMozambique and Zimnbabwe in the Appenclix, is easyto gather fromii available statistics and on-site observations.

CAPITAL INVESTMENT POLICIES AND =

RECURRENT COSTS IMPLICATIONS °

As a rulc it is casier to raisc the financc to pay ior the conostruction of new heealth institutions, thani it is totpav the anniual running costs. The rule of thuLmlb used in many countries is that for every 1000 dollars spent in CZcapital investment, 200 to 3)00 dollars must be found annually to pay for recurrenit costs.

It is often1 argued that investing in high-quality building colnstructioni and finishes reduces mainitenanicecosts, but in the long term the differenices are usually not siimificant. -

In health budgets, staff is a major cost component, anid there is oftenl a direct relationislhip between the spaceprovided in a facility and the numiiber of staff employed there. In modern district hospitals, the kitchen riay be X

four times larger than those built 20 years ago for a similar hospital, and tor the same number of beds employfour times the number of kitcheni staff.

Clearly' then the recurreint cost implications of capital investments in health infrastructure are critical and one _should make every cftort to keep spacc provisions an.1 cost normiis reasonable. _

CD

PERCEIVED CAUSES AND GOALS

Wlhen working with existing iistititionis, it is usuallx not possible to solve problems of inefficiency and poorquality by capital investments alone. If any procedural, managcment, and supply problems are not also resolved,the hoped-for results from improving the structures 'xill not be attained.

Where som-e wvards have a consistcnt and unacceptably' higlh occupancy' rate, perhaps it may be consideredthat the overcroxvding can be resolved by conistructilng neCwv wards. However, it is imaportanit to investigate thereasons for overcrowding. Length of stay of patients may be too long because of factors such as poor staffprocedures, poor hygienic conditions, unavailable or non-functioning equipmenit, shortage of pharmaceuticals,or bad sanitary conditions. Or the numiiber of patienits may be too Ihigh because preventive programmes havefailed. The important point is that the cause must be idenitified and unlderstood.

In manx cases, dealing wvith these problems appropriately could significantly reduce the length of stay or thenumber ofp atients, and so resolve the overcrowdinig. This w'ould be a more econiomiiical solutioll than building anexx' w'ard block.

Illustration of relationship between problems and different types of causes (Country X)

bqW*-iOh4 l,-426Ce4(i7ye~cAvSRAAE LEit OF sTAk ieu y) AEr~ Ng 4wA AMi ko4

=~~~

pde,Ejgjt AkgS of 6MA ATD S 10- PA 1 tS I

~~ Pd~6Le AI4' ~ INV DL 4EStW OWA9 IMPU6A~S6r

voogP Rw Olfe lmr4t co0-rs /PA-rEsw -TA,NwcAL tmmle1tF Posi-Ve g2 LTqP*polrdej-•vs ih ± I, ote\ costs ChrL9es f b Avevmf e teS) 0b S;

aa~u~~ +i~e~hre~ ~ O~( &4t+0 wprr+ e-cm* pro rouce

Ca e-Ac es P'te. coto sur*4 o tefOC t eaIvt V ldu

, teds ArCeri etrV . ceffi t u 0 o reg

- ooV Ae ut;ek)O 1e6e W*MIW t_ ,ed lrtzevi is V)Oi- clean rls+s> PCCOUT15S TA4 p*>ukuer Wt -

&~~~~~OevmM.ng ti) 4 IVtI-ovwlke 0!ae o Fit6alnt,"Z? [et kg ,q

C~~~A e ~ ~oLAe- fU .O_ °oE 2E fi ne-, ILAb- 1_ /( rq -t, z- tes s

Av- vroFor vo--i nkoefiyl Xis. IniproveP1 051£

cW5te Poe e. _M014V OfeaWV dRzmolse L v

o P'ro>vs irt ei tiiewts o re no0t ~ itcXase 54peWIrv'l hi n s <

-'40 INCEMT(z!E'"- k . CVAre1q .4

Ytdgre , ottkALO rwot U SQc ALO69 | o4 lkP4 qce AS |6 ',k2 ?fw* sm 0e C | l Vcf -

# W05PX 6 ID49 FNe | ti be- V"-t4r w iw Nl _ { #e core 1 cziizeq + >jCa Fe

POSSIBLE IMPACTS OF CIVIL WORKS ACTIVITIES

Capital investment programmes in health facilities always raise expectationis of Iwidespread improvements.Whether work is carried out on existing facilities or whether completely ncw institutions are being conistructed,people xvill expect the nexly-comripleted facilitv to have better accommodationi and better quality finislhes, fittingsand equipmnciit than the oldcr facilitv. The max! also assumle improvements to tralnsport and commnmllicatiolls.

Health staff wvill find a nexv facility attractive as a place to xvork in. It xvill probably attract more experiencedstaff to xvork there. Staff may stay longer in post and take fexcer days sick-leave. The staff may become highlmotivated and the lcx els of efficicncx may impro e.

IMPROVEMENTS IN QUALITY AND EFFICIENCY

The local community xvill automatically gixve the nexv facility higher status thani the facility it replaced orother neiglhbourinlg facilities. This xxill almost certainly result in increased patienlt demiialnd. The number ofpatient visits xrill rise and, at loxver- level facilities, the numbcr oftpatients xvho xvould normally by1pass the local oclinic to be admittcd at highler lcvel facilities \xill decrease. Givenl the cxpected improvements in quality of staff,referral to higher level facilities xvill probably be reduced.

Increased reliability of equipmenlt and improved efficiency xill probably lead to higlher levels of production nxvith marginal hcalth benefits, such as higlher number of laboratorv tests and more X-raavs per patient. Wherethere arc beds, the average lengtlh of stay for each in-patient mav be reduced, but this may onlI provide the extracapacitx required for thc incrcascd nL11ber of admissions

INCREASED RUNNING COSTS

Generally all parties -governmclnts, donors, health staff, local populationi- xill be xell satisfied xxith thcimproxvements \-Iicli are aclieved in qxuality and efficiency in tle completed facilitv. Hoxwever, as levels ofefficicncv (output) improxve, the institutioni xill be more expensive to runL. More patients means morepharmaceuticals, more consumnables, more staff, and more encrgy. These items on annual recurrenit budgets areusually those xxhich the goverm-nent is left to finanace alone.

Certainly xx'hen planninig nexx construction and capital inxvestment projects in the health sector it is normal to z

focus on the bcnefits xvh1ich xvill be achieved as a result of improvecmenits to quality and efficiency in serxvices.Hoxevcver, int most cases tlhese benefits xwil entail extra costs.

The client must decide xvhether to dimiienisioni the institutions so that these expected increases in demand canbe comfortably accommodated. The implicationi here is that recurrent costs requirement vilt increasesubstantially: the client may consider this acceptable. But it may be more rcalistic to calculate the numiibers ofbeds, conisultationi rooms, and dclivcry bays to bc prov-ided and at the same time introduce guidelines for staff totrv to restrict the nexy demand to a realistic xvolume.

3. PROJECTORGANISATION

1-co re OM _

CLIENT Wo; Sz0o t s coritsbw*= ol ~~~~~~~~~~~~~~~~~~~~~~~~~~~nes bafloi"rvg

There are two essential parties in most civil worksprojects. A client who has money and who wishes toconstruct a new building and a contractor who onpavment is willing to supply the new building.

- F.~iDA l Whie hs )tb7ara G k &t6i

CONTW T ho i5 otble o *vi*mc-ca n

Client-contractor organisation

cm This form of organisation is sufficient for the most simple buildings. Usually, the client appoints architectsand engineers to act as his professionial and technical representatives for dealing with the contractor.

ra 1[~~~~~~~~~LENU- ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~~~~v

When building health facilities on a larger scale for Igovernments and donors this rclatively simple form of IVorganisation must be substantiallv cxpanded. ARCtlT t who mAders l ti

xpanded. Et4JIN~ERS

Client-architect/engineer- contractor 1IIII"5I|organisation)

THE CLIENT ORGANISATION

The client wvill usuallv be the Government of the countrv, which Will Usuall1v nominate the Ministrv of Worksor Construction as its representative on building matters, and the Ministry of Health as its representative onhealth matters. Each of these Ministries will probablv have resoLirce problems.

The Ministry of NVorks may appoint private firms or consortiums of arclhitects and engineers to preparedrawings and contracts and later to supervise the works.

The Ministrv of Health will usually conisolidate its owin expertise by establishing client committees at bothMinistrv and local level, wvith competence in medical disciplines as -well as in recurrent cost- related matters GOThese committees may, need to refer to external specialist consultants and technicians in dealing with somequestions.

Where financing partlv or wholly is through donor funding, the donors usually forward their funds directlyto Gov'ernmrent, either to the Ministrv of Health as the user Ministry or the MinistryN of Finanice. The donorsthemselves wvill often require close contact with the clienit organisation.

Where government financing is involved, the Ministry of Finance may be closely connected to the client team_.

Elements in the client CD

organisation %AilJ -

FogMuLATEs BA2e'AA 9i M'_ ok NIAPrt f& We/e1rrr_4

APPIeV6< FAOP-4o

CD

(N115 UIJITzVSR •t-: KM o r 4AM¶AL AA_ A-Agt 7 AS C(-IE

._JIT oPb q/ .~*_

The division of responsibility betwccn the different Ministries often causes serious problems. The Ministryof Works will probably have the most direct liaison withl the consultants and the contractor. Its usual mandateincludes issuing drawings, enterinlg into contracts, carrying out supervision, instructing on changes, and makingpayments. After handilng over completed buildings it is usually the responsibility of the Ministry of Works toprotect and maintaini them.

The Ministry of Health v ill usually be responsible for financing the recurrent costs required for providingthe services available througlh the new buildings from its owIn budgets, but will havc little dircct influence on thetcchnical content of the building or on the performance of the contractor.

This difference between Ministries is often the basis for conflicts. What is economical to design, constructand maintain may not always be most economical withi regard to the use of health staff and the need forconsumables. Where the influenice of the Ministry of Health to decide the content and f)rm of the buildings is

co restricted to the earlier stages of the project, it is important that the Ministry has the techniques and expertise- needed to formulate their requirements and approve proposals efficiently.

At the Harare XVorkshop is was agreed (unanimously) that the Ministry of Health's team should includearchitects and if necessary othcr technical consultanits. It was also agreed (also unanimously) that responsibility

Ca for documentationi, contracts and supervising constructioll should remain with the Construction Ministry.

= THE CONSULTANT ARCHITECT AND ENGINEERS ORGANISATION

m Figure 5: Consultant architects and engineersorganisation MllKi.T1KY oF HOlA

Since Ministries of Works or Constructioll maxvnot have sufficient resources in manipower and N sexpertise to satisfactorily perform design and

Ca documentation ftulnctions, thev tend to appoint private j

*U architects and enginccrinig consUltants. This is usuallyacceptable, on the important conditionl that theprivate firms will not usurp the Ministries 'client'

co ftllfctiolns. P | |

= Ije1 oest eal vThese technical consultants will usually include c

architects, landscape architects, mechanical, electrical l I Iand civil enginieers and quantity surveyors. Oin larger lprojects several firms of each type may be collected indifftercnt consortiuLmls.

Where a number of consultant firms are inxvolved AS1 L- t- z)v-it is important that they be collected withiin aniefficient containinig organisation. ULsually thearchitects are Ieaders of the organisatioin.

The Ministry of Construction should nominiateproject architects, engineers and quantity engineers CaJStLNTc, 6UI20APfromi its own organisatioin to act as couLnterparts andto be responsible tor the performance of the Iconsultants. There should be no direct dialoguebetweeni the consultanits and the Health Ministrv tJ4c-tRwithout the project techlniicianis being prcsent.

THE CONTRACTOR'S ORGANISATION

The main contractor is responsible for the total undertakin g of thc project, but may dcelcgate variousfunctions to sub-contractors. The main contractor xill provide most of the work-force, the site plant andinstallations for UsC during conistructioni and xvill be directlv rcsponsible for matters concerniilg costs and theprogrammc generallv.

Non -specialist subcontractors may be rcsponsible for the completioni ot specific wvorks w-hichi have beendelegated by the main contractor. For cxample, where a contract includes both district hospitals and satelliteclinics, the sub-contractor may be asked to construct the smaller centres.

Specialist subcontractors include electrical and mechanical specialists as well as roofcrs and joilcrs.

Contractor's organisation

t~~~f r T-

I NIIWA4

INS41N coqOT >~~~~~~~~~~c

eq. T .. ,_

or T i To

CDON141Ot4 UW°ORKAC h OL

m

PROJECT MANAGEMENT AND SITE SUPERVISION

The notion of the dlient eimploving specialist procjct maniagcmcnt expcrts to co-ordinate all aspects ofproject supervision is at present unknown in health projects in the region. The concept is increasingly used inother sectors and other countries where control of costs and quality is given priority, and its introduction tosoutherni Africa is inevitable.

Site supervision is usually carried out by consultants appointed bv the Ministry of WNorks, though support isutisually provided by the Ministry's own staff. This is important, particularly in large projects being erected over a largegeographical arca, where there is a need for an efficient response to costing of variation orders and other instructions.

The Clerk of VVorks should be permanently on-site as the client's direct representative. He should be appointedby the Ministry of Works and not by the consultanit architects, as he is expected to supervise their activities.

_ Organisation of site supervision

I0

c3aV llel9-#a7 , O

CAK. LTA:T A"4l, |

architecturalOand engineerin discipline.SThe .concto soe pren Wh

.. ~~~~~~~~~~~~~~~~~~~~~m 1 4lot- T,i cge

slTE sv- | CLrce op ivs~mto) Fs8. ap

nicotinter langtiage difficulties, it is imrportant dutrinig formiulationi of conitract conditions to insist on thecparticipationi of qualifiedl tr-an'slators.

Local represenitatives of the Ministry of Health should take part in site mctings as observers only. They shouldnit be allowed to isSue instructions at aryv time on ehalfof the client. Any comments they may wish to make shouldgenerally be routed through their parent Ministry. There may be projects where the local health authorities themselIvesare the clienlt. In every case, however, it is important that established lines of authority are followed.

THE PLANNING, DESIGN AND CONSTRUCTION PROCESS

The building process for all tvpes of facilities involves various actiVities wvhich naturally follow a logical sequence:

PNASE A: INCEPTION PNASE F: DETAIL DESIGNEvaluation of the need for upgrading an existing Obtaining final decisions on every matter related tobuilding or constructing a new building. Preparing design, specification, construction and cost. Designingthe general outline of requirements. Setting up a every part and component of the building includingclient organisation for Briefing. Establishing sources engineering. Completing cost-checking of proposals.of finance. PHASE G: PRODUCTION INFORMATION ad

PEASE B: FEASIBILITY Preparing working drawings, schedules andProviding an appraisal and recommendation to specifications for all buildings, building elementsdetermine the form in which the project is to and components. Making final detailed decisions toproceed, ensuring that it is feasible functionally, carry out the work.technically and financially. Carrying out studies of ruser requirements, site conditions, planning, design PEASE H: BCIS Of QUANTITIESoand cost as necessary to reach informed decisions. Preparing and completing all information and

arrangements for obtaining tenders. Preparing Bills

Considering alternatives and establishing the of Quantities and Tender Documents. Agreeinganticipated recurrent costs implications and conditions of contract and form of tendering. X

requirements of the proposals. PHASE J: TENDER ACTION -

PHASE C: BRIEF Advertising and short-listing approved tenderers.This is the culmination of phases A and B where Distributing tender documents. Holdingoutline schedules of requirements are handed over explanatory meeting with tenderers and issuingto the Ministrv of Construction. answers to tenderers questions. Receiving tenders a

and evaluating the winning tenderer. Agreeing timePNASE 0: OUTLINE PROPOSALS schedules and cost plans. Holding contractDetermining the general approach to layout, design negotiations and signing contracts.and construction in order to obtain approval bv theclient on the outline sketch proposals. Developing Tender documents may differ in content dependingthe client Brief further. on the form of contract used, but the substantive _

content of the phase is essentially the same. Ca

Carrying out studies on user requirements, technical PHASE K: OPERATIONS ON SITEproblems, planning, design and costs as necessarv toreach decisions. Establishing the norms and Handing over the sites to the contractor who will E

standards to be used in the project and preparing then proceed with construction. Carrying outkev design sheets for the position of all fittings and inspections and site supervision. Approving andinstallations, paying monthly certificates to contractor.

Administering variation orders. Carrying out costPNASE E: SCHEME DESIGN management of the projectCompleting the Brief and approving proposalsincluding planning arrangement, constructional PHASE L: COMPLETIONmethod, outline specification and cost. Accepting handing-over of completed buildings.

Drawing up list of defects. Commissioning buildings

Final development of the Brief, full design of and plant and installing equipment. Cleaning.the project by the architect, preliminary design by Opening. Public relations activity. Training staff.the engineers, preparation of cost plan and fullexplanatory report. Submission of proposals for all PHASE M: EVALUATIONapprovals. Analysing the management, construction and

performance of the project. Analysing performancerecords, inspecting the buildings and studying thebuildings in use.

DIVISION OF RESPONSIBILITY DURING THE DIFFERENT PHASES

The responsibility for the individual phascs in the process graduallv transtcrs from thc client, throughconsultants over to the contractor. On completion the responsibilities return to the client.

Phase Title MOH MOW CONS CONTR

A Inceptioi _ S

B Fcasibility I. Sz C' Brief L (I L (2)

D Outline proposals A L S

E Schemc design A 1. S

_ F Dctail Design A A L_ G Production ilformationi A L

H Bills of Quantities A 1.COD J 'T'endcer action S I. S N

K Operation on site 0 L Sup. (*)L Completion L S S S

_ M Appraisal I S S (**)

The following abbrcviations are uscd:

MOH Ministry of Health (Client)co mOw : Ministry of Works or Construction (Client)

CONS Consultanit_ C,ONTR : Contractor

1. : Leadcr - rcsponisible for phaseS : SupportingA : Approval() : ObserverI : InstigatorN : Negotiatorsuc( * ) : Specialists architcct and quantitv surveyor may bc added to the client team( * * ) : different consultant

In maniy agreemcnts madc witlh consulting architects and cngineers, fees are paid at the completion ofphascs D, G/H and L.

PARTICIPATION OF USERS IN THE DESIGN PROCESS

Wheni planmin- civil works projccts, represcntatives of the 'users' should be closcly involved. 'Users' here isoften takcn to mean 'membcrs of staff', hut including rcpresentatives of the local population can bringimportant advantagcs.

'Uscrs' will bc able to provide informationl on local conditions wlhich canniot be obtained from othersourccs. They can often cxplain local variations in utilisationi. WXhv are somc days so busy and others so slack?How do distances influence the local population's attitude towards the rcferral system' When evaluatingbuildings, users and staff can provide important information on conditionis which arc perhaps not apparentwhen surveys are made. The)' can describe seasonal problems with watcr supply, say wheni the drains are likely tooverflow, and tcll how oftcn the mains electrical supply breaks down.

During the design process they should be asked for their opinions of the proposals being made, for theirv7icews of the implications of decisions made. The StCCCSS wvith which new facilities producc improvements inquality of care, or the success of new programmes oftcn depend on the 'users' know-ing the ideas behind thearrangements and content of their new buildings.

'To achieve the maximum bencfits fronm involving rcprcsentatives of the 'users' in t7he client tcam wx-c suggcstthe following pointers:

* The 'uscrs' participation should be systematic. The! should be asked to nomiinate representatives andthcy should be givcn ample notice of the mectinigs when thxc' will be askcd questions.

* The Lusers' mLst be clearly told the reasons for tlhcir participation. They must understand that their W

main fLnction is the exclhanige of information.

* The 'users' must not be asked to uLndertake tasks outside their competcncc. They should not be asked tomake drawings or skctchcs; to takc mcasuremiienits; to write reports or to analyse statistics. Their timeshould be used efficiently. =

• Thc 'users' should be recogniscd and their participation in tlle projcct sh<ould bc rewarded. They should °know that thcir participation has intluenlced thie results.

In thc Zimbabwean Sccond Family Health Project finaniced by the World Bank, an impressive collaborationbetveen Ministry of Health staff at central and local levels has been developed. Nominiated representatives of the'users' attcnd regular quarterly reviewz meetings in the capital, Harare, where thev presenit papers on progrcss in -the differcnt componlents of the project in their district. In thcsc meetings, users arc also briefed on the latestdex clopmcnts at thc ccnitral lcvcl.

COMMUNITY-BASED PROJECTS

Many investment projects in the healtlh sector, particularly thosc in rural areas, are financed directly byT non-governmental organisations sucth as nationial and international doniors, missions, industrial enterpriscs (andincreasinigly by the communities themselvcs). _

The Government Ministries involved usually appreciate thc contributionis madc througlh investments bynon-govcrnmental organisations in thc hcaltlh scctor. But to prevent the problems of compatibility which oftcnoccur with the Minlistries' policies, many NGOs and communllities need professionial and qualified guidance. Thiscan probably best bc accomplishied by the Ministr-y, of Health drawing clear guidelinies for investment projects inthe health sector.

The gtuidelinies should identify the types of project which arc suitable for communLity participation. This maynot alwavs involve the rencovation or constructioni of bluildings but can incliide thc procurement of ambulances,equipmcnt and pharmaceutical and othc- consumable items. T he preconditions for initiating projccts willinclude forming an organising coiimmittec from within the community whose approval will bc asked onl prcsentand ftiture utilisation and expected recurrenit expenditurc.

Clcar procedures to be follow cd for undcrtaking and completing the project should be established, andspecifications, norms and standards as wvcll as ty pe plans for standard solitions should be given in the guidelines.Specifications can be givcn for approvcd vehicles and equipmclt.

UsefuLl guidelinies x-ill includc examples of standard forms of contract and agreemenlts, and should describchow these should bc administercd. All aspects of the project should be undertaken in a professional manner andthe Nvork should be executed to professional standards.

m

Clear instructions should be given in the guidelines (perhaps with examples) on the submission ofapplications. Other useful project information should be included.

A guide-book followinig these lines has been developed by the Ministry of Health in Mozambique. Thepresent weaknesses in the structure of local communities in the country however, mean that community-basedprojects in Mozambique are usually implemented under the control of a donor agency

In Uganda a DANIDA-funded programme has successfilly completed the refurbishment of variousinstitutions in projects directly managed by the commnulnities. Governmlent and donor have stipulated keyconditions which the communities must meet -a locally-elected management committee; production ofutilisation and recurrent costs data; adherenec to local competitive tenderinig; procurement of materialsi undertaken centrally by the project co-ordinaticon group; and use of standard plans and specifications. A fuill-time

buildings engineer is co-opted to this programme which, allowing for the modest total of completed facilities, is° considered to be very successful.

- \TWorld Bank experienec suggests that direct community participation (not organised through NGOs) canonly work if special structures are created in the project design to promote this participation and to make work

ZC with the communities a central feature of the project. Ugandan experience supports this assertion.

ox

co

C

CD

C,D

4. PROJECT BRIEF

'Brict' is a word dcriNed trom the Scandinavian 'brev' xwhich mcans 'letter of communication'. In a buildingcontract the Brief is both the communication of instructions to thc contractor and the information from theclienlt where he explains at the beginning of the project w\ hat his requirements are. It is here that the clienlt hasthe greatest influenice on thc results of the project. Major deficicencies in a clienlt Brief in health projects later otranslate into rcsults which arc inappropriate for the intended functionis.

In a health sector construction project, the Brief should originate at the Ministrv of Health whiclh describes(in its own terms) what the rcquirements arc. These are then coded bv the Ministry of Works or Construction W

into correct tcchnical terminology, before being passed on to the Ministrv's own designers or to the appointedconsultants to use as a basis for draw vings and specifications wx hich wvill evenituallv go to the contractor.

THE CONTENTS OF A PROJECT BRIEF

If the Ministr- ot Healtlh has been inxvolhed in earlier projects, it should be fairly easy to assemblc thenecessarx instructions. Once a comprehensive Brief has been formulated for a particular project it should besimple routine to formulate Briefs for new\ ones. So institutional menmory allows incremental beneefits.

At the initial stages of the planninig process the client's Brief should contain the followving information:

Phase A: Inception Phase C: BriefDescription of Functional Content Departmental Planning PoliciesDecisions Regarding Priorities and Phasing (Operational Policies)Aims of the Project Detailed Schedule of AccommodationResults of Planning Studies Building Construction NormsSite and Site Factors and StandardsMasterplan for Future Development Requirements for Individual RoomsOutline Costs and Phasing Preliminary Equipment and

Component SchedulesPhase B: Feasibility Budget Cost Plan

Activit v Schedule and Time PlanOutline Schedules of AccommodationNorms and StandardsTime Plan

Noxv for a closer look at what is labclled by thesc hicadings.

AIMS OF THE PROIECT

This statement has to be clear and concise A number of aims will probably be involved, such as improvingaccess to the health sector for the population, or providing facilitics for spccific programmes. Anv need toimprovc qualitv and cfficiency shoLuld be strongly emphasised. The main aim will not be to create monuments tomodern architectural technology.

The Main Aim of the projcct should bc described at this stage in outline. Typically the outline will includeat least: information on type of facility; whetlher new construction or renovation of existing buildings; functionsto be provided, and functionial capacity requircd.

RESULTS OF PLANNING STUDIES

=ic The results will present the criteria which will bc used to make dccisions concerning the final character ofthe project. Health planning characteristics such as prcsent utilisation of facilities in the region regarding out-patient visits, in-patient admissions, bed utilisation and changcs cxpected in future should be set out as a basisfor establishing the dimcnsions of future expansioni and consolidationi programs. The intformationi provided

_ should include:

o Catchment populationLu Demographic data

_Epidcmiological profile

Present distribution and utilisation of facilities expressed throughi:° 'Population per primary health facility= lAnnual/daily attcndanlce at hcaltlh centres

Annual/daily attendancc at hospital out-patient clinicsBeds per 1000 populationPresent admissions to hospital beds (per 000 per yvearPresent averagc length of stay per admissionAveragc annual bed utilisationDistribution of hcalth service staff

Expccted future changes to the abovc data.Policy rcgarding provision of staff accommodation

This information is important because it givcs all participants in the design process the finctionial setting inwhich the new or renovated facility will be placed. When devcloping architectural proposals for the project, thisinformation will bc necdcd for answerinig questions such as: 'Hoxv many staff will work here?' 'How manypatients will be treated every day?'. 'How many' operations / X-ravs / consultations will be required?'.

SITE AND SITE FACTORS

From the earliest stage detailed informationi about the existing conditions at facility sitcs and thcir suitability forfuture development will be needcd. Data probably already exist giving general information regarding the typc offacility and its capacity. Howevcr, now civil work will bc carried out on the site, morc detailed information is required.

This does not usually require cxtensive resources and special capability. A practical system for documentinginformation collectcd durinlg surveys of hcalth facilities has been developed during work with projects inNamibia, Mozambique, Zimbabxwe, Kenya, Uganda, sevcral statcs in India, Denmark, Jordan and the formerSoviet Union countrics. Through using this systcm, the survey of all types of health institutions up 150-bedhospitals can bc accomplished with 4-5 hours on-site inspection. Larger institutions take proportionally longer.

In Namibia the system was used to docuLmlenit all healtlh facilities exccpt ccntral hospitals. Data were collectedduring a concentratcd 6-wcek programme in wlhicli onc represcntative from the Ministry of Health and one

representative from the Ministry of WVorks from cach of the country's eight provinces visited the health facilitiesin their regions and filled-out standard observatiotn sheets. After beinig proecsscd centrally, the informationcollected formed the basis for policy decisions realigning the health infrastruLcture in Namibia.

Normallv the documenetationi is presentcd on a nutmiiber of standard sheets:

Block plan layout of buildings on site

<ge,ei. Ni CF1 /

MM X ' SITE LAYOUT

ic

Hm~~~~~~~~~e~r

A rough dravving can shov, thc bLiildings ol-site whch make up the institutions and their inter-

juxtapositioi. The drawxing could bc frcc-hand and nccd not be exactlv to scale. The north point should beshown and the bloclks should be labellcd A, B, C, D, E, F, and so on.

Layout plans of individual blocks

BKOcK A EMFEP6reWY/CAQALTY

e C~~~~~~~~~~~~~~~~~~~174

3 ~~~~~~~~ ~~ 7

e 1. 3

8 *: 7 Z ~ IIV'1 t eM___ KAe

Rough free-hand drawings can also be made of those individual buildings thought to be especially relevant.Again the drawings do not need to be to scale although north should be indicated. In all buildings, the roomsshould be numbered 1,2,3,4 5, consecutively

Location of departments with areas, capacity and functional condition

GOVERNMENT OF ZUCBABWE MINISTRY OF HFEALTH AND CHILD WE' FARE

Master plan fcr M/DffA <>srLfg 9e c4

3 LOCATTON OF DEPARTMENTS ;T71H AREAS CAPAC:NY FUNC7-O<AL OND7TN

0 2½, f_ _ I

p hIPcAhj r/jVs 7~-1 ftetws *eA, 4 j I1- 4 LAoA b Ii A !- '< -u

I A- I I I I I *

* f 4PtX c/M itz 4: Lii I B ~~ l .S tee ht to

s rovzg t.4or _____ E 1 -L f IStU - - S C i | 0 h . I ___b__

L Esis _ _ _ _ _ _ 3 I c * -h p 4!o, rkAs voni* 4co llq

0A.

o Ite 5, ce sre ! 4 1 s c!4it e z.bavi

For 3unot~onai con A cit

! 1, ttK4 I At 40 en a4 cTh Itan seict g n n g | md Cu im sw on te p o l

p (S 2. To i n f theroo d t n i,t sb v t a

capacit of the room, and theroomsfunctiona I v IuCl

.IH ~ ^s | g t ,o het^|7o ¢to I

FC m cments on the area: a m using A, Ba

an B 3 inictesthat the room is Adequate. Wob3s *iu c a and ti show tht u t 1coct a i

CO.YM--NTS: .. -tPCO

Th t° staidrd shct wtill: give inoratoS cocrit then iniida rom so4\4nhpeiuslcai

plans (sheent 2 cn Thea ifr Ato in=ids name oftero adtAnmbri a be ie;h rai

Cormments ona thns'on are ar Cdc uDi_ ,BadC veeAidcts httero stolrc o ml

an idcates that thso roir e- 'ni adqit a es c2. rd_pnae

FuCometsiona qulthe ise areomad using, A, scl and ICo, wvhere I inidicates thtthgood,2medism 3toolrg, 4 o ml

unacceptable anid 5 show s that uirgcnt corrective actioni is inceded.

Condition of building elements

GOVERNMENT OF ZIMBABWE MINISTRY OF HEALTH AND CHILD WELFARE

P I L 0 T S U R V E Y I F H E A L T E F A C I L I T I E S

Master plan for F AAt K3 /tfgpqR A.

4 BUILDING ELEMENTS EXISTING CONDITION

< z c N E u z _ X zd Y

id z a G W C, Z 8 < 8 ;< 3a a U

A ~~~~~~L1 _1~ tS. 77~ _/ 13L _ -Z/ w 4_S

_ a3 _ 1 I6< -0SG a t /2 a L/ 3 3 g rIE 4

'- 7 3 ... _2

- 7_F_ I 1-O-4 12 1 i 1 j t z f p .

7 ^o 77__<-t_ 3- 5 '1 l _ 3 3 302 f 43o e

= ___ _mo_ _ l 2 X 2 3 3-3 -2 Nra-C _ _ '7-o~~ 3 . l 17 - -a 5 Z bti-e 5- r

_ 7 __ _ _ T - -CA3D

-; l _ lee - 220 lll l 54t

Ca __M___ _7___-1__ 5 1 I 2 3 2___ 1 _ Let7 O - 395 t zs/e"9Os

J Q__ 3_ Z T 22 6 w_p

_S~W _- l _ _^t t t 2_ _ _ 2 IccohiA

77 % , ~_ __ J1S Li 'ii. _ _ 7 _ _ I 24

r -SK tft Z 2 z 2 z 2 f f tLQ( STUAIUb

- _ 1Pg 6 237z 2 f fi L . z 2 I. h q {

X L L ISo-I _q

a jse A _ _ 2 2 2 Z. 2 2 =MEDIUM

COMMEN. I N, _._.__ I~'. . _ 3 -2 v ._ 2,r ZtS

Description of condation: 1f GOOD2 =MEDIUM3 = POOR4 =UNACCEPTABLES = URGENT REPLACEMENT IS NECESSARY

Michael Hopkinson, Architect, Initiatives Inc, Boston and Copenhagen

This sheet shows the dates of construction of the different buildings and (using the scale of 1 to 5) indicatesthe overall quality of function, the roof, the walls, the doors and windows, the floors, the sanitary installations,water installations, electrical reticulations and the ironmllonigery (door and winidow handles and locks).

In the last 2 sheets it is important to keep the coding systems as simple as possible. T he system used hereseems easily readable by the many different disciplines who will take part in decision-making. It is easy to findthe 3s, 4s, and 5s which indicate possible problems. It is also easy to compare differcnt buildings and facilities.

From these registration sheets, the site lavout plans can be tIsed to graphically display the informationcollected about the various buildinigs.

A:Dates of construction \-

Al.~ ~ ~ .

4L~~~~~~~~~~~~-

B: Types of accommodation-

A~~~~~~~~~i~~A

<*w eN \l Xt + < /S~~~~~~OtA ,<, s~~~~~~~OMOATO

C:Zoning

y~~~~~~~~~~~~~~~

Lbd

*D:Departments which function badly A = = = -

/UILDINro WfICI4

A:_,,u,_,~~~~~~~~Fuero ft0L\\S0X\ t7ool R~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~1 48

E:Departments which function well i _,X

<'iieN'4 Tth <Wd~~~~~~~~d~

/ MON WELL

A~~~~~~~A\V~~~~~~ \ 4 at bFb1

F: mn

Roofs in bad condition -n

u C t // ~~~~~~~coDITiN OFX- hG _

GWalls with cracks

LU Al~~~~~~~~~~~~~~~~~

X tc.fo K/ S <S(

CnAAO w WALLs;

H:Floors in poor condition _ -

hKi9it O

Ce~ ~~ ~i t42 ULWI4YEPTAbFI

Poor sanitary conditions

y~~~~~~~~~~

IAWMWIINA\V UATIofs

Unacceptable water installations T - --

< n ,, >S z -T^S s~~~~n 6

|:~~~~~~~~~~~~ m

;VA

> \ _ \ / CtJNDt~~~~~~~~~~TION 61f\> I / ~~~~~Wh1TA IN9ST"lTlOS4

K:On-site traffic ways __

__ bdemoishedw XZ/I-

a-

B uildings which should be <- - ----

demolished K /AhnihE,:-

9X) \\ 23'<4 __,9St0

V;? r14¢< Tvaf sir

C

o�

0

-�

0

0

C-I

<7 -<

<;

47

�- , LIIi�-___ / ,---

-

4941- (

7 \\ --

<,, > Kr / 7

� I

-¾r . I

I KN A

-�.--I �IN

NN .7

'N I �>� N 7/

N

JIIHU lOllOlid #

0:Possible location of new buildings

Ao¶~ ~~~~~~~~~A

a~ at

ENGINEERING INFORMATION

The information showni in the registration so far concentrates on the condition of buidding elements andinternial engineerinig installations. But it is also possible to develop separate sheets to show the condition of waterand electrical supplv, and the availability and qL-alitv of mains sewerage. However deciding the level of detail ofengineering information calls for caution. For example, aside from registering the position of problematicoverhead cables it is nOt easy for non-technical surveyors to indicate the capacity and condition of the differentmains services. In any case at this earlv stage it is not necessary to indicate more than the reliability of services.Unless there are pressing specific problems (such as inadequate water supply) preliminary detail engineeringinformation should first be obtained throughl the engineerinig site surveys.

INFORMATION ON EXISTING EQUIPMENT

Registration sheets can be devclopcd to show the coidition of equipmenlt in the institutions. However thisintformation is often unreliable. A maintenance team could visit the institution a month after the inspection andthereby render most observations on the sheets useless.

MASTERPLANS

This is a series of documcirts wlich describe the framework for the future development of a health institution.It is usually generated from easily accessible data, and should contain at least the followinig information:

A BASIC DATA* Catchment population.

* Distance to other health institutionis.

* Present utilisation.* Present staffing.

B EXISTING CONDITIONS* Present layout of the complex.* Existing zoning of activities.* Date of construction / renovation of the differenlt buildings.* Distribution of departments in the buildings with gross areas.* LavouLt of mains services and drainiage reticulationis.* Departments which are badlyN located in relationship to other departments functions.* Departments w-hich function xvell; departments which function badly.* Condition of key building elements: roofs, external svalls, doors anid wvindow's, internal partitions, a

tloors, sanitarv installations, w ater and drainage, electrical installations.* Buildings xvhich should be renovated as a matter of urgency.* Buildings w hich should be demolished.

C ISSUES a* What is the expected fi-ture utilisation of the facilities? WVhich provision norms are applicable? o* Which priorities should be used for determining the sequence of fuiture steps?

D FUTURE PROPOSAIS* Areas of the site for future constructioni.* Future zoning of activities.* Proposed traffic / circulation routes / xvays.* Future layout plan to anticipate requirements in 15 years time.* Proposed phasing of activities. w

E BUDGETi Estimates for realising the individual projects shown.- Annual budgets for capital wvorks to realise the masterplan.* Development plan budgets.

NORMS AND STANDARDSTo make it casier to dcvelop the Brief and to ensure that the results conform to the Ministry of Health's

requirements for the implementation of a civil wvorks project, key norms and standards should be established (byboth users and consultants) which wvill theln be used for all later projects. The norms can include:

Health Facility Planning Data

* Average number of people who visit health facilities every dav. Number of admissions to wzards.

* Service requirements of people visiting health facilities.

* Number of X-ray examinlations, laboratory, tests, consultations with specialists, prescriptionis issued, ctc.

* Production capacities of health facilities and health staff.

* Consultations per doctor, X-ravs per X-ray machine, operations per operatinig theatre, lab tests perlaboratory technicianL, bed urilisationi, etc.

* Theoretical optimum distribution of health functions and facilities in relationship to the population.

* Norms for the provision of facilities, number of theatres in relationship to the number of surgical beds,numiiber of delivery rooms in relationslhip to number of maternitv beds, number and types of offices forclinical, nursing and administrative staff.

Specifications of appropriate and affordable building materials and installations for usein rehabilitation of health buildings

* Specifications of materials in the repair of building elements, roots, ceilings, wall finishes, structuralfaults in walls and floors, floor finishes, doors and windows, glazing, ironmongery.

* Standards for sanitarv installationis, water supply and reticulations, water treatmnent.* Standards for electricity supply and reticulations including over-voltage protection, lightninlg conductioni.* Standards for mechanical installations, heating, cooling ventilation, air-treatment generally.* Standards for energy conservatioin, environmlcntal protection.

Definition of optimum spatial requirements in existing departments, buildings andinstitutions, for evaluating functional standards as welU as for making proposals forrehabilitation

* Norms for number of square metres per fLnction, such as area of hospital per bed, area of ward unit perbed, area of clinic per consulting unit, distributioni of space in institution department by department.

* Dcfinition of optimtLiim planninig module.* Norms for areas and dimellsions of rooms, 6-bed ward, 4-bed ward.+ Norms for the provision of sanitary units in relationship to different departments.* Revised norms for specific functionis such as sterilisation, utility rooms, staff common rooms, cleaners

rooms, stores.* Standard schedules of accommodation for different facilities, departmiienlts, functionls.

Methodology for making masterplans for the future re-use, consolidation anddevelopment of existing facilities

* Method for registration by local health personnel of the contents and conditions of facilitics.* Agreed contents of a masterplan.* Agreed method for docLUmenlting masterplanis.X Procedures for implemllentinig proposals in masterplans, providing feed-back and tip-dating.

Tools for planning and implementing maintenance of existing buildings and contentsThese will include:* Establishmenit of a profile for the maintenanice of existing health sector buildings.* Development of standard documents for planning and implementing maintenance activities.* Evaluation of different methods of performing bio-medical maintenianice.* Proposals for includinig maintenanice considerations in procurement procedures.

Budgeting information* Square metre rates for diffter-ent types of facility depar-tmenlt in diffterent regions, for both new and

rchabilitation works.* Costs rates for equipment in different departments expressed as percentage of construction costs or

square metre rates.

Development of standard documents for tendering and procurement procedures* Buildings and works, includinig invitation to bid, tender and contract documents.* Equipment, including invitation to bid, tender and contract documents.* Consumables, includinig invitation to bid, tender and contract documents.* Consultancy services, including invitation to bid, tender and contract documents.

Development of relating norms* Staffing.* Financing.

* Present utilisation .* Present staffing.

B EKISTING CONDITIONS* Present layout of the complex.* Existing zoning of activitics.* Date of construction / renovation of the different buildings.* Distribution of departments in the buildings with gross areas.* Lavout of mains services and drainage reticulations.* Departments which are badly locatcd in relationship to other departments / functions.* Dcpartments wvhich function uvell; departmcnts xvhich function badly.* Condition of kev building elements: roofs, cxternal wvalls, doors and windows, internal partitions,

floors, sanitarv installations, water and drainagc, electrical installations.* Buildings xvhich should be renovated as a mattcr of urgency.* Buildings xvhich should be demolished.

C ISSUES -

* What is the expected future utilisation of the tacilitics? Which provision norms arc applicable? o* Which priorities should be used for determining the sequence of ftuturc steps?

* FUTURE PROPOSALS* Arcas of the site for future construction.* Future zoning of activities. _* Proposed traffic / circulation routes / wavs.

* Future lavout plan to anticipate requirements in l years timc.* Proposcd phasing of activities.

E BUDGET _* Estimates for realising the individual projects shown.* Anniual budgets for capital wvorks to realise the masterplan.* Devclopment plan budgets.

NORMS AND STANDARDS

To make it casicr to dcvelop the Brief and to ensure that the results coniform to the Ministry of Health'srequirements for the implemcntation of a civil xvorks project, key norms and standards should be establishcd (byboth users and consultants) which will then be used for all later projects. The norms can include:

Health Facility Planning Data

* Average numbcr of people who visit hcaltlh facilities every day. Number of admissions to wvards.

* Service requiremcnts of people visiting health facilities.

* Numbcr of X-ray examinations, laboratory tests, conisultations with specialists, prescriptions issued, etc.

* Production capacities of hcalth tacilities and health staff.

* Consultations pcr doctor, X-ravs pcr X-ray! machine, opcrations per operating thcatre, lab tests perlaboratorv technician, bed utilisation, etc.

* Theoretical optimum distribution of health functionis and facilities in rclationship to the population.

* Norms for the provision of f'acilities, number of theatres in relationship to the number of surgical beds,number of delivery, rooms in relationship to number of maternitv beds, number and types of offices forclinical, nursinlg and administrative staff.

Specifications of appropriate and affordable building materials and installations for usein rehabilitation of health buildings

* Spccifications of materials in the repair of building elemcnts, roofs, ceilings, wvall finishes, structuralfaults in walls and floors, floor finishes, doors and winidows, glazing, ironmongeryt

* Standards for sanitary installations, water supply and reticulations, watcr treatmcnt.* Standards for clectricity supplv and rcticulationis including over-voltage protection, lightling conduction.* Standards for mechanical installations, heating, cooling ventilation, air-treatmcnt gencrally.* Standards for energy conservation, cnvironmiiiental protcction.

Definition of optimum spatial requirements in existing departments, buildings andLi. institutions, for evaluating fimctional standards as well as for making proposals for

rehabilitation* Norms for number of squarc metres per ftuniction, such as area of hospital per bcd, area of ward unit per

bed, area of clinic per consultinig unit, distribution of space in institutionl dcpartmcnt by department.* Dcfinition of optimum planning module.* Norms for areas and dimensions of rooms, 6-bed ward, 4-bed ward.

c * Norms for the provision of sanitary units in relationship to different departments.* Revised normiis for spccific functions suchl as sterilisation, utility rooms, staff commllon rooms, cleaners

_- rooms, stores.* Standard schedules of accommodation for diffcrenit facilities, dcpartments, functions.

Ca

LU Methodology for making masterplans for the future re-use, consolidation anddevelopment of existing facilities

* Methlod for registration by local health pcrsonncl of the contents and conditions of facilities.* Agreed contents of a masterplan.

= * Agreed mcthod for docuellcnting masterplanis.* Procedures for implcmenitinig proposals in mastcrplans, providing feed-back and Up-datinig.

Tools for planning and implementing maintenance of existing buildings and contentsThese will include:* Establishment of a profile for the maintenanicc of existinig health sector buildinlgs.* Development of standiard documncits for planninlg and imiplemcnting maintcnance activities.* Evaluation of different mcthods of performing bio-mcdical maintenance.* Proposals for incluldinig maintenance considerations in procuremcnt procedures.

Budgeting information* Square metre rates for different types of facility/department in different regions, for both new and

rehabilitation works.* Costs rates for equipmenlt in diffcrenit departmcnts exprcssed as percentagc of construction costs or

square metre rates.

Development of standard documents for tendering and procurement procedures* Blildings and works, includinig invitation to bid, tender and contract documents.* Equipment, including invitationi to bid, tendcr and contract documcnts.* ConIsumablcs, including invitationi to bid, tcnder and contract docuLmlcnts.* Consultancy serviccs, includinig invitationi to bid, tcnder and contract documenits.

Development of relating norms* Staffing.* Financing.

OUTLINE SCHEDULE OF ACCOMMODATION AND BUILDING COSTS

Teams should work with realistic cost rates for budgeting from the earliest plhase. In the initial phase it isusual to use square metre rates calculated on accepted norms for gross areas of the different departments. Therates wvill be established through discussion wxith quantity surveycors and should be drawn from recentlyv-completed projects. The area nornms should also be based on recenrtly-completed projects and of course shouldbe arrived at through consultation xvith health staff

The rates will vary according to the departments involved. Taking OLIt-patient Departments and Wards as astandard, departments with requirements for better finishes and more extensive services such as N-ray, OperatingTheatre, and Sterilising Department (CSSD) should be priced at approximatelv 30% higher. More simple unitssuch as Administration, anid Waiting Mothers, should be costed at approximatelNy I5% less.

The following examDpie showvs the area norms and cost rates used for a recent project conisisting of a numberof District Hospitals in Zimbabxve with from 42 to 120 beds. Please note that the sizes and rates used areindicative only a

Type of Area Area m2 Cost rate Trotal CDUSD USD

A OUT-PATIENT AREAS Out-patient department 280 300 84 000Pharmacv 110 300 33 000Emergency 210 300 63 000 _Mother and child clinic 1(0 300 30 0((

B MEDICAL SERVICE AREASX-ray (1 diagnostic room) 80 390 31 200 =Operating theatre (1 th.) 250 390 97 500 _CSSD 140 390 54 600 (Rehabilitation 240 300 72 000

C IN-PATIENT AREASLabour ward (4 delivery bavs) 240 300 72 000Maternitv ward (26 beds) 390 30( 117 000General ward (26 beds) 390 300 117 000

D RESIDENTIAL AREASWaiting mother lodges (16) 180 255 45 900Staff houses (70/90/120 m2) 255

E SERVICE AREASKitchen 130 3(0 39 000Laundry 100 300 30 000Central store / workshops 10( 255 25 500

F OTHER AREASAdministration (6 offices) 120 255 30 600Mortuarv (6/9 body chambers) 70 390 27 300Gate house 20 255 5 100Inlcinerator (lump sUinl) 120 000

Covered area / wvaiting 100

G RURAL HEALTH CENTRESType IType 2 (Mini-centre)

mFor the rcnovation of cxisting buildings, a proportionate costs norm, sav 60% of new buildings, should be

applied. Where functions are directly similar, the same amount of space should be availablc in renovatedbuildings as in new buildings.

When the costs havc been calculated for all buildings to be provided on the sites, thc costs of site works(total constructioni costs plus 12-20%), cquipmenlt (total building costs pilus 20-30%) and fees (total project costplus 12-15%) have to be added.

TIME PLAN

rnvy time constraints rcgarding the complction of a construction programme to co-ordinate with otherprogrammes, or to comply with financing should be stated as preciscly as possible. From the earliest stages it isneccssary to indicate the ratc of investment requircd and show how this is related to the availability of funds.

e OPERATIONAL POLICIES

The Ministry of Health will issue statements concerning its policies regarding a number of key functions, in- particular, service flunctions. These functionis, which may be influential in determining the scope of the project as

well as the form and content of the buildings to be provided, include the following:

* Departmental functions * Catering* Staffing + Maintenance

- * Referral system * Medical gases* Transport * Waste disposal* Supplies - Solid

- Food - Office- Pharmaceuticals - Organic, hazardous / non-hazardous- Equipment * Sterile supplies- Consumables * Storage- Linen

TECHNICAL STANDARDS

Policy statemcnts should definc or rule on any expected technical issues, including:

Distilled water production Anaesthetics, safetv with the use of anaestheticsSun-shielding, environmental requirements Requirements for cleaningEquipment for sterilisation Wall and floor finishes in special areasToilets and sanitary installations Curtain ral7siand curtainsShelving systems in stores and pharmacy Screens between bedsX-ray equipment Access for wvheelchairs to specific facilitiesKitchen and laundry equipment (including toilets)Fuels for energy Glazing to internal walls to wardsLaboratory equipment Glazing generallyPiping generally Burglar bars, securityStand-by electricity Incinerator, refuse disposalEmergency lighting CommunicationsLighting generallyNurse call systems

CONTENTS OF AN OPERATIONAL POLICY STATEMENT

An Opcrational Pohlicy Statement means intormation about the functional actixities of a departmicnt or unit,which should be provided to the architects and engineers who arc engaged in a civil works project.

The Operational Policy Statcmenit should contain the following:

A NA.ME OF DEPARTMENT VISITORS TRLAFFICSUPPLIES TRAFFIC

B MAIN FUNCTIONSH SCHEDULE OF ACCOMMODATION

C SECONDARY FUNCTIONS WITH AREAS

D INFO(RMATION ON PRODUCTION J COMMENTS ON RUNNING COSTS

E STAFFING K COMMENTS ON FUTURE aDEVELOPMENTS

F RELATIONSHIP TO OTHERFFUNCTIONS oL NAMFE OF AUTHOR AND BASIS ON _

G INTERNAL ORGANISATION DIAGRAMS WHICH THE DOCUMENT HAS BEENDRANNIN UP

FUNCTIONAL FLOWSTAFF TRAFFIC MI RELEVANT ANNEXES)PATIENTS TRAFFIC

DETAILED SCHEDULE OF ACCOMMODATION =

In the final working Brief, more detailed schedules of accominmodatio 1 should include all the rooms of all thedepartments. The schedules should relate to earlier projects and should reflect agreements between all interests(user as well as financial) on what is reasonable to have as standard policy. Realistic and affordable room sizes areessential. Here is a detailed schedule of accommodation used in the district hospitals project.

A OUT-PATIENTS DEPARTMENT

No Room Reqd m2 Comments

01 Registration 1 no 1502 Records 1 no 1 503 MA Consulting / screclning 2 no 1504 Doctor consulting 2 no 1505 Dentist 1 no 15 06 Dressings / treatment I no 1507 Injections 1 no 1508 Dirty utility I DO 1209 Laboratorv I no 4310 Blood bank 1 no 1511 Staff room 1 no 1512 Staff toilet 1 no D13 Cleaner I no 1514 Store I no 515 Covered w=aiting area 1 no 100 For 80 people

B PHARMACY / DISPENSARY


01 Dispensary 1 no 1502 WVork area 1 no 1203 Pharmaccutical store 1 no 3204 District store 1 no 1505 Unpackiing 1 no 1206 Covered waiting area I no 52 For 40 people

C EMERGENCY, MINOR THEATRE


01 Consulting roomii 1 no 1502 Resuscitation 1 no 1503 Patient toilet 1 no 804 Dirty utility I no 10

Ca 05 Clean store 1 no 1206 Minor theatre 1 no 2407 Staff change (male) i no 2208 Staff change (female) 1 no J09 Observation / recovery 1 no 2810 Duty room 1 no 1211 Covered waiting area 1 no 12 For 10 people12 Covered corridor 2.4 metres wide

D MOTHER AND CHILD HEALTH CLINIC


01 Family planuning consultation 1 no 1502 MCH consultation 1 no 1503 Multi-purpose room 1 no 2404 Utility room / laboratory 1 no 10(5 Assisted toilet 1 no 506 Covered waiting area 1 no 30 For 30 people07 Covrered corridor 2 metres wide

E DIAGNOSTIC X-RAY DEPARTMENT


01 Diagnostic X-ray room 1 no 3002 Dark room 1 no 603 Viewinlg room 1 11o 1004 Film Store I 1no 605 Reception / office 1 no 1006 Ultrasound room 1 1O 1006 Covered waiting area 1 lno 15 For 10 people17 Covered corridor 2.4 metres wide

F OPERATING THEATRE DEPARTMENT


01 Operating theatre 2 no 34.002 Scrub-up 2 no 3.503 CSSD 1 nIo 34.004 Sterile stores (theatre) 2 nlo 3.505 Disposal / dirtv tutility 2 n1o 4.906 Staff change (male) I no 9.507 Staff change (femllale) I no 9.508 Clcan store I no 7.509 Staff room I no 7.510 Stcrile storc (hospital) 1 no 7.511 Nurses office 1 no 6.012 Recover\ 1 no 19.5 4 patienlt trolleys13 Dirtv LItilitv I no 2.5 a14 Toilet 1 no 3.515 Waitinig area/ corridor 2.4 metres wide

G CENTRAL STERILE SUPPLY DEPARTMENT


(1 Cleaning / sorting 1 no 1502 Autoclaves 1 no 603 Packing 1 no 1204 Stcrile Storc 1 no 12 -05 Storc for other departmeints I no 12 _06 Covered corridor 12 2.4 metrcs wide

H REHABILITATION DEPARTMENT


01 Multi-purpose room ) 1 no 3102 WVoodwork / crafts03 Office 1 ino 804 Store 1 no 805 Assisted toilet 1 no 1106 Covered veranda I no 2507 Covered corridor 24 2.2m wide

J LABOUR WARD / DELIVERY


01 First stage labour 2 no 20 4 beds each02 Labour room 2 no 26 2 bavs each03 Bath /XWC 1 n1o 804 Staff Toilet / clhange I no 805 Admissions room 1 no I506 Midwvife duty room 1 no 1(007 Dirtv utilitv 1 no 808 Lincln storc / kit room 1 no 5

09 Nursery 1 no 10 Could be in maternity10 Covered waiting I no 10 for 5 people11 Cleaners room 1 no 512 Visitors toilet 1 no 513 Covered corridor 2.2 metres wide

K STANDARD ACUTE WARD (IN EACH 24-BED WARD UNIT)


01 Ward (6 beds) 4 no 34Li. 02 Day space / niche 4 no 8__ 03 Shower / WC / wash-basin 4 no D

04 Duty room / nurse 1 no 1005 Dirty utility I no 806 Linen store kit room I no 807 Ward store 1 no 808 Cleaners room 1 no 809 C overed Corridor 2.4m wide

CENTRAL AREA BETWEEN TWO 26-BED WARD UNITS WITH 2 BEDS

10 Side ward (2 beds) 1 no 1611 Bath / WC / wash-basin 1 no 312 Nutrses station Il no 1213 Assisted bath and toilet I no 814 Dressings / treatmcnt 1 no 12

X. s15 Pantry 1 no 816 Staff toilet 1 110 317 Covered corridor 3.2m wide

L IITCHEN


01 Dry Store 1 no 502 Vegetable store 1 no D

03 Office 1 no 504 Preparation area I no 805 Cooking 1 no 2606 Servery 1 no 1207 Trolleys / washl-uLp area 1 no 1209 Staff dining / tea room 1 no 37 for 20 people10 Cold store I no 511 Covered corridor 2.4m wide

M LAUNDRY


01 Dirtv linen / reception 1 no 2002 WVashing 1 no 2703 Mending / ironing 1 no 2004 Clean linen store 1 no 2005 Covered corridor 2.4rn wide

N CENTRAL STORE AND WORKSHOPS


01 Central store 1 no 7802 Office for storc keeper 1 no 803 W'Vorkshop/store electricians 1 no 1604 WOorkshop/store plumtber I no 1605 WVorkshop/store carpenter 1 no 1606 Toilets 1 no 607 Covered wvav 2.4m wide

0 ADMINISTRATION


01 Office (1,2 or 3 peoplc) 6 no 1202 Meeting room 1 no 2003 Pantry 1 nlo 404 Cleaner 1 no 405 Toilet (mcn) 1 no 4 m06 Toilet (-women) I no 407 Covered waiting 1 no 15 for 10 people08 Covered corridor 2m wvide _

P MORTUARY

No Room Reqd m2 Comments -

01 Autopsy room I no 2002 Body chamber I no 8 6 bodv shelves03 Viewing room I no 2004 Doctor's change 1 no 505 Cleaner 1 tno 306 Compressor 1 no 307 Covered waiting 1 no 15 for 10 people08 Covered corridor

Q CENTRAL STAFF CHANGE


01 Locker room (male) 1 no 12 30 lockers02 Locker roonm (female) 1 no 12 30 lockers03 Toilet (male) 1 no 1604 Toilet (female) I no 1605 Cleaner's depot I no 1206 Cleaner's dutv room I no 1207 Covered corridor 2 ni wide

R CENTRAL AREA FACILITIES


01 Visitor's toilets (male) 1 no 1602 Visitor's toilets (female) 1 no 1603 Cleaners rooms 8 no 604 Electrical switchboards 8 no 105 Covered seating area06 Covered corridor 3.2m wide

La. S ACCOMMODATION FOR STAFF

_ T WASTE DISPOSAL FACILITIES

- 01 Placenta pit02 Incinerator

U WATER TANK

The room sizes showvn reflect the application of an agreed flexibility to make a limited number of standard__ room sizes provide a maximum number of different functions. The sizes relate to appropriate structural grid

dimensions. Different clients will have different policies and practices regarding room sizes.

3

_-

BUILDING CONSTRUCTION NORMS AND STANDARDS

Thc Ministrv of Works (or of Construction) c ill be rcspoinsiblc for issuing instructions to the designcrsregarding the tcchlnical specification of the buildings and their contents. But the Ministry of Health as the userMinistry should express its reqLuirmemnts / wvishcs / policies which are usuallv the result of expericnce fromothcr projccts.

Althouglh preparing a spccification of buildinig elements should be done systematically it should not bestartcd from square one every time. A specification should be developed from project-to-project as a result ofpost-projcct evaluations. It should be hcld in the planninig department in constanit rcadincss to bc issued(togcther with the design Bricf for cach newN projcct) or to be handed over to other organisations or donors aabout to carrv out civil works projects. The informiiation could be presented on two standard charts.

List of key materials, finishes, installations and fittings to be provided in the project

A list should shoxv all the variations of buildilng elements and compoilcnts wvhich the Ministry expect to -be provided in the project. The differcnt sizes of doors, heights of windows, ty pes of sanitarv units and so onare needed here. These sizes xvill accord with the fLunictional rcquiremcnits. The list could includc: C

Floor finishes HS 02 HWB in wash roomsFL 01 Normal floors in habitablc rooms HS 03 HWB for staff hand-wash m

FL 02 Floors in wvet areas HS 04 HWB for surgeon scrub-up X

FL 03 Floors in clean areas HS 05 lfctast sinksFL 04 Floors in heavy-traffic areas HS 06 Othcr sinks _FL 05 Floors in stores and otlher uninihabited roomsFL 06 Floors in covercd wvavs and wvaiting arcas Urinals X

L'R 01 Bcan type (number)Wall finishes UR 02 Slab tvpe (length)WF 01 Normal wvalls in habitablc rooms _WF 02 NValls in xwet areas Baths and showersWF 03 Walls in clean areas BS 01 Bath in paticnts xvash-roomsWF 04 Walls in heavy-traffic arcas BS 02 Bath in assisted bathsWF 05 WValls in storcs and other uninhabited rooms BIS 03 Shower in paticents wash rooms

BS 04 Shower in staff wash roomsDoors IBS 05 Shoxver in patients receptionDO 01 700 mm door internial)DO 02 800 mm door internal) WCs and other large-bore wastesDO 03 900 mm door intcrnal WC 01 WC in public arcasDO 04 900 mm door cxternial WC 02 WC in patient areasDO 05 900 mm door external, hcavv duty WC 03 WC in paediatric arcasDO 06 1 350 mm double door, internal WC 04 WC in staff areasDO 07 1 600 mm double door internal WYC 05 Slop hoppcrDO 08 1 600 mm doublc door external WNC 06 Bedpan vwashcrDO 09 Special doors WC 07 Plaster sink

Windows LightingWS 01 Windoxv scating 900 mm LI 01 General lightingWS 02 Windowv seating 1100 mm LI 02 Examination lightingWS 03 Windowx scating 1 500 mm I I 03 Operating lightsWS 04 Windowv seating 1 800 mii 1.1 04 Emergenrcv lightingWS 05 FrcIICh Nvindows

Power outletsHand-wash basins and sinks Po 01 240v socket outlet (number)HS 01 HWB in toilets PO 02 380v socket outlet (number)

MOH comments regarding specification of key finishes materials and installations

ICI

X ''''''

, I X . {Q10tolt{tlSl° 0S1~1 o'¢le tE

a-~~~~~~~~~~~~~~~~~~~~~~Li i k

F;rom the list shown, standard shects cani be preparcd stating what the utscr Ministrv wants providcd in thebuildings. It is cqually important to spccify whiat it docsn't want. Thiesc "niegative specification data" can avoidthe inclusion of unwanted or inappropriate iteiis and thc cost anid delav of removal and replacement.

In the Brief, the user Miniistrv slhould bc able to express its wishes withoLut havinig to prescent a detailedtechnical specificationi. That is the responsibilitv of thc Miinistrv of WVorks (or of Construction) which bv using thelists and charts shouild be able to develop dctailcd iinstrLuctions for the designcrs.

REQUIREMENTS FOR INDIVIDUAL ROOMS

Under the systein proposed here the Luscr Ministr y will bc able to provide detailed requirements for eachroom listed in the schedule of accommodation. In this wav onc shcct can containi detailed information on size

and specification requirements of all rooms in a department.

Example of the schedule of accommodation for the OPD expanded to give specificationsfor the individual rooms

--- - I I- -I I I Ij>- §<Nwss

'S. ;-< ________~~~~~~~~~~~~~-.~-j

iC' _ = =

2L Ico~!cO~

- t- G 5/ _____°_______ i

g~~~~~~ E 50-1 -._ -ii 2l1 : 1 4

I K:|t I-|t 1:)rD1 '2ar

| srswrw s9 v:i _, Ij

PRELIMINARY EQUIPMENT AND COMPONENT SCHEDULES

At the briefing stage, lists shIould be provided of kev equipmetnt and fittings. In combination these lists wxiliinfluence the sizes and proportions of rooms. Although final decisions regarding equipment lists should begiven much later in the process, it is important that these early lists be as comprchensivc and realistic as possible.The designers should understand that changes are likelv and must accept this.

At the early stages, the team dealing with equipment sh-ould concentratc on preparing information to beincluded in the architects Bricf: This essentially covers fixed and loose items of equipment, which require theprovision of water, electricity services or drainage, or have dimensions or requirements regarding placing wvhichinfluence the size and shape of the rooms.

The information should bc presented in the followiing sequeniceEquipment identification listsEquipment specificationsEquipment location lists, (room sheets)

=a Identification of existing reusable itemsProcurement lists for individual institutions.

Seven characteristics are kex considerationis wheni drawving up the spccifications of the variousCa items of equipment:

EconomyDurabilityCorrect capacity

o StandardisationContinuity of existing practicesEase of mainitenianceGeneral appropriateness for use in the districts.

Throughout this work it is essential to maintaini close contact v.ith representatives of the users at bothnational and local level.

It is usual to dividc the equipment into categories depending on the different services required by supplier /main contractor / user on delivery. This division could be:

Category I Equipmenlt which is procured and installed by the contractor and which is priced for inthe main contract.

Category 2 Equipment which procured by the client but which is installed by the contractor, whloincludes chaniges for installationi and attendanlce in the main contract.

Category 3 Equipment which is procured bv the client and installed by the supplier, but which mayrequll-e specific space or services.

Category 4 Small items which do not influenice the building contract.

BUDGET COSTS PLAN

This is an updated vcrsion of the costs estimate provided in the preliminary Brief and it will be compiledusinig the same square metre rates. Adjustmiients may be made to the areas involved and the rates themselves as aresult of getting improved information. An overall budget for the project should again bc set up department-for-department with additions made for site-works, equipment and consultant's fees.

ELEMENTAL COSTS

One mav calculate the costs of the repair and replacement of building materials in existing buildings bvapportioning the square metre rates uscd to the differenit building elements and components. This calculation isderivcd from experience with other projects, appropriately adjusted for expected conditions in the currentproject. The elemental percentages of cost for an average square metre of buildings will of course vary frombuilding to building and from country to country. The listing here is used onlv as a tvpical example:

Foundations 4.54%Concretc 4.39%Bricklaver 12.08%Roofer 5.11% (Roof covering 2.34% onlv)Joinier 20.18%)Metalwork 5.45%

Plasterer 6.26% (includes ceilings)Flooring 7.91%Plumber 1 3.19% aGlazier 1.51 % O

Painter 5.1 2%Electrical Installations 14.2 6%Total 100.00%

Rates for differenlt types of building work:

Building where m2 costs are estimated as:

Rate per m2 % USD 390 USD 300 USD 255of w hiclh

Roof 2.34 USD 9.12 USD 7.02 USD 5.96WallS 12.08 USD 47.11 USD 36.24 USD 30.80Doors/Nvindowvs 10.09 USD 39.35 USD 30.27 USD 25.27Floor 7.91 USD 30.84 USD 23.73 USD 20.17Sanitarv

installations 6.50 USD 25.35 USD 19.52 USD 16.57Sanitary fittings 6.50 USD 25.315 USD 19.52 USD 16.57Painter 5.12 USD 19.96 USD 15.38 USD 13.05Electrician 14.26 USD 55.61 USD 42.78 USD 3 6.36Ironmongery 2.72 USD 10.60 USD 8.16 USD 6.96

By collaborating wvitlh the project quantity surveyor the project team can establish precise and reliable rates

for the conistructioni wvorks.

ACTIVITY SCHEDULE AND TIME PLAN

The Brief should indicate the user Ministr 's expectations or -wishes conicerninig the activities which wvill takeplace, its participation in those activities and the estimated time span for cach activity. Mucih of this informationcan also bc standardised.

FORMULATING A DESIGN BRIEF

The Mlinistry of NVorks (or of Construction) should convert the Brief, which as described so far contains onlvuser-sourced informationi, into a technical Design Brief for issuing to the designi team.

o~~~'d

5. PROiECT DESIGN

This chapter presents some of the considerations pcrtinent to the design of district and rural hospitals, ruralhealth centres and health posts

The extent and contenlt of facilities in a health infrastructure directly influence quality and efficiency, andconsequently the recurrent expenditure required in the health sector. The need for staff, their productioncapacity, the need for consumables and supplies, maintenance services and energy all have to be measured inrelationship to the buildings in which serviccs are provided.

= A HOSPITAL IS NOT A BUILDING

Health facilities should be ftinctional and economical to run and maintain. Thley should not have too muchspace, should be appropriately constructed -preferably of local materials- and all the technologies used should

LO be appropriate. The buildings should be able to change and expand through the years in response to changingneeds and should be comffortable to inhabit and attractive to the staff who work there and to the localpopulation. Like all other buildings a health facility should be kind to the surrounding environiment and shouldbe safe to use.

A health facility should not be a montimenit or a coldly institutiotnalised structure. Through the years thecatchment population using the facility will increase, patterns of utilisation will change, and new technologieswill be introduced. Health facilities should have the characteristics of a flexible village.

DESIGN PRINCIPLES FOR SITE LAYOUT PLANS

These have to be villages witlh a high level of organisation and reasonable discipline. A health facility containscomplex functions, and the services required should be provided efficiently and safely. The health facility siteshould be organised so that differcnt types of functions are corrcctly placed in relationship to each other and inrelationship to internal and external traffic ways.

Basic Layout Grid

A basic grid layout should be applicd to the planning of both existing and new institutions, of all types andsizes, from rural health post to rural hospital.

In using the grid layout, please bear in maind that you are:

* InflueLncinig the precise nortlh-soutlh orientation of all rooms.

* Separating on-site traftic ways for:- internal medical traffic- v-isitors and public- w-aste removal

* Al]o\ving adequate space between traffic ways for all presentt and future departments.* Influencing the correct zoning of the different functions of the hospital, including:

- restrictilng the access of out-patients to the rest of the hospital- collecting together similar functionis in in-patient areas ( such as medical services areas,

admilnistration areas, and services areas)- providing for the correct relationishiip between departmenlts

* Alloving for futurc growth.

The followring sketches show how a standard site layout grid wvas developed for differenit sizes of districthospitals, and afterwards applied to a largge number of different sites. Ihe standard grid was also Ltscd as a basisfor choosing new sites.

C

Basic site zoning pattern

41ix<1 ui1-- Cs,lt=_

t 01rAZiIF I)X j T -ItR5 LI TI, 1 [

!~~~~L UN1j1 X40 0 tr - 'YE

\~~~~~~I ;7 C .1|1 '

- .s,.=-<9 t ! T{I~ IF t:Ll1 X1< L- l-t

IN-FATI T AEA5 - -<LilT

-' | 11 ---- L¾U8I XL rLiiTThi 7'|-1 -- IX f \ ---- ' T CLINICAL AR

tStRVItC AREAS N - N 11-

'4 0 - -snW ¢

~~~~--- -fvelx -_ -_ - -5h At _

ADiA INI ST I 4f 4ATI •t 4T A.Z I

-- VFLFL ,p -e-

\ EiMTRAN CG ctTE.

/ \

Internal and external traffic ways Plan of a 52-bed district hospital

#llACfF>115U WTFA4

LU ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~-, v- 1

ZvEZ

-~ ~ ~ g^, kc El - '-::1 '.: r !

Pli fa10ne itic optl lno 53bdds-ithsia

M~~~~~~.;;Q_t7C_1L0B_,0i - :,

-~~~~~~~~~~~~~~~~~~~~~~~

7~ ~ ~~~~ ~~~~~~~~~~~~~~~~~~~~~~~~~7

hi ;_ .1 ME

j~~~ : N 0 _.00_ 4SD

C:l Dds fTl. i.\.1 iS f L. \- ''-T''-i '' rwl ; Li0

G~~ <t 1 rD z -$ 0i.r-

Plan of a 256-bed district hospital

-- ~~~~Stanidard layoUt planis cani also bc applied to sites

- ~~~~~withi existinig buiildinigs. The locationi of the builidingoi the site m,a well influecc the Lise it will be put toV71 ~~~~after- the niew- decvelopment. Ini ilost cases, existiing

bUildinigs are best uscd for out-patienits departmecnts, coothecr clinieis anid adminiistrationi.

Site layout plan for the development of an existing hospital

CA

1I I U _,

c ~ ~~~~~~ ~~~ -- C&.- t

. I .,._ L_+l ,_ .1

r . .- _

X S: .. t I~~

_-':W [I ' _A

<1 _< tada tla ot las cl1alo c ppie t ste

DESIGN PRINCIPLES FOR DEPARTMENTS

Whlen designing health facilitv buildings for warn irm imates, long narrow forms are usually preferred tosquare ones. This is for reasons of:

* Economy: the roof structure is often the most expensive part of the construction and narrow spans arecheaper in materials than wide ones; and

* Protection of the internal environments: to protect the internial envirolnment, the narrow formprovides for cross-ventilation to all parts of the building and for natural daylight to all rooms. Whencorrectly oriented witlh the main facades facing due nortlh and south, the extended roof overhangoffers maximum shading to the facades.

=

Long narrow buildings have beenpreferred to square ones I

1- -1 ~ 4 1- / I

_I-~~~~~~~~~~~~~~~~~~~~~~~~~~~-

THE USE OF STANDARD ROOM SIZESThe sizes of rooms provided in a building must relate to the spacing and dimensionis of the structure, in

particular to the external walls and columns. To achieve reasonable flexibility in use, sizes should be related tothe maximum number of different functionis, and room widths should be related mathematically so that whenpartitions are removed the resulting spaces relate to a predetermined system.

At the earliest stages of the design process, the team should determine which room sizes can be mostreasonably provided. The svstem of standard room sizes uses a basic planninig module of 1.6 metres.

f,6 t2 1 4 l 8 }-1zLDifferent rooms sizes whichcan be formed using a1.6 metre planning module

A B e

P I Xi :XC3

Instead of measuring the space required around each separate facility or ftuntction, the project design teamshould establish wlhich of the standard room sizes wvould provide the space required for the finctioni. In this waya list can be made of all the differenit activities which can be made to fit into the different rooms.

Spaces and functions

Area approximately 60m2 A . Aprrox (Om1

Uses ClassroomWaiting areaStore9- 10-bed wardLauniidryKitchen

B. ApArox. 40 rn7Area approximately 40m 2 BUses Operating theatre

Sterilisation (TSSU) oLaboratoryLarge X-ray room

Area approximately 30M2 C C. Approx 304Uses Minor theatre a

Small sterilisation (TSSU)Standard X-rav roomLibrary Ca

Area approximatelv 30mr FUses X-ray

Laboratory F Approx. SainCentral drug-storeMother and child room .5-bed wvardObservation wvard

Area approximately 15m2 HUses Examination room H. Approx. 15 ml

Injection roomDressing roomOut-patient dispensaryPharmacy Toilets/staff changeEmergencyc roomObservation roomMother and child roomNurses duty room

The result hcre is considcrable flexibility in both design and use. For example 1 room type (G) will satisfy alarge number of diffcrent fuinctions all of whiclh in principle canl be substitutcd during use. Two rooms typc (G),side-by-side can be combiined to forml I room type (E)

STANDARD PLANS

Most Ministries of Health havc standard plans for different departments and different types of institutionwhich thev know from experience to be satisfactory in usc. It is important that standard plans be of higlh qualityand knowni to satisfty clicnt's normal requiremenits.

Standard departmental planis generally shiould be knownl:

* To provide correct standards of space with duc regard to economy (by usinig a module which givesadequate rCooIml dimensionis) and bv careful plannling

+ To make maxilmum uise of standard room sizes and standard constructionial dimensionis (by using alimited nulmnber of different interrelating room sizes and by havilng only tvo different building wvidths)

+ To allow at all times for maximum tlexibility and extendibilitv of all units departments and buildings ( bythe use of standard rooms whiclh can easily be adapted for alternative uses and by fitting the departmcntsand buildings into a logical circtulation and zoning system)

* To be based on the usc of appropriatc technology for matcrials and forms of construction (by using as

Ca far as possible locally-available materials)+ I'o provide structures which are easv to maintaini and extend* T'o promote the most economical tuse of staff* lo provide good comfort conditions withLout the use of expensive technology. I'his can be ensured by

X among other things: correct orientation of buildings, cross-ventilation to all rooms, hig7h -3.5m- floor toceiling heights, insulation of ceilings, good overhang at eaves.

96 Now the design requiremiienlts fir the different departments of a rural or district hospital are set out.

U,D

Out-patients department

LTtilisation of the differeint parts of the out-patient departnient vary signifiean tl ot t Theicjitdepartment of a rural hospital should usually be an H-shaped buildling which can also be used as a rural healthcentre. The accommodation should be zoned in relationship to titilisationi. Registration, records andconsultation rooms should be placed in the fronit wing and rooms ftr injectionis, dressings, laboratory, anddentist in the rear wring.

In the initiazl stages perhaps one wing only cani be provided. If this is made up of similar-sized rooms andwith the reguIlar distribution of waiting spaces, there is potenitial for flexibilitx, both in use, and in thedistribution and separation of differenit activities. The depar-timieint can easily be extenided later in 4 differenitdirectionis to provide space for extra or increased activities. C.

Out-patienit services should bc placed at the enrtranice to a rural or distr-ict hospital, close to the medicalservices departmeints.

Out-patients department C

CD

, 1 N Il ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~. ................. i

roorfl Llewt dns8&#~c s~t& ~ajediac ~t\x ........ t

...... ...... ...........

,~~~~~~~~~~~~~~~~~~~ 1~~ =t.X:Sf

Open~~~~~~~~~~~~~~~~~~~~~~~~~~~~~...... COD~yI~

I ;aco~ds 9e9*ttn (LMSW(C (ectif t#t'Cflr -octv r

....... ........... ....... .... ....... .......

Open~oP a"o .........

... .. .. .. .. ..… .. ..

....... ............4t ztnc

Pharmacy / dispensary

To economise on staff and facilitate correct supervision, the pharmacy store and dispensary should occupy asingle narrow building. Separate secure spaces should be provided within the building for unpacking and forstoring pharmaccuticals for delivering to other institutions in the district. A waiting space should be providedseparate from the waiting areas to the OPD.

Pharmacy /dispensarvSince over 80% of all out-patients

usuallv require pharmaceuticals, thedepartment should be placed close toboth the out-patient department andthe entrancc. Close proximity to the ..........

in-patient departments is not soessential as pharmaccuticals are . . ...-usually delivered to the wards only wwmll

to once a dav. Lockable hatches shotuldbe provided so that supplies for thewards can be collected witlhoutcdisturbing other activities in thiedepartment. r frr _

Convenient access for vehiclesshould be provided at the rear of thebuilding.

co Emergency / minor theatre,

This department should operate on a 24-hour basis and should contain the essential basic functions of areferral hospital: consultation, operation, resuscitation and intensive observation.

The illustration shows a compact layout for these functions. In normal periods this arca can be staffed byLo one nurse or technician, supplemented as necessary on the arrival of patients.

Emergency / minor theatre _ -C…I *|S Eo 1 rli . . .. . . . . . .. . . . ............................I

t-- 0-i - 1 1 ~ ~~~~~~~~~~~ -- -j I

In smaller hospitals where therc are no surgcons, the mninor thcatre should bc sufficient for all surgicalrequirements.

Mother and Child clinic

There is Much disCussion about the proximity of the Mother and Child clinic to the out-patient departmenit.Some claim that man! children are only brought to the hospital wvhen they are sick and so the MCH c]lincshould be attached to the OPD. There is also debate about whether the MCH unit should be in a districthospital at all. In order to reduce missed opportunities for vaccinations, for family planning, and for antenatalcare, all the infrastructure for these functionis should be grouped togetlher close to, or integrated in, the OPD. Inany, case, the design of the MCH unit Will be the same. A large multi-purpose room for consultations forindividual children can also be used to give health education to all the waiting mothers.

Mother and Child clinic

l ,' ,, , ~~~... ... ... ..,~~~~~~~~. .. . . . . . ... ... .. . , .. . ...

.: .. :~ ~ ~~~. .. . . . . ... : ... ................ ... .. .. .. .. ..

qh =

Diagnostic X(-ray department

This simple one dliagnostic room X-ray unit is intenlded to be operated by one technician. In mlost places theBRasic Radiologv System (BRS) wnill be uised, and developinag may be donle manaually. It is often dif-ficult to keepXautomatic Xi-ray developing machinaes in operation. Ultra-sound is becoming a standard provision in X-ray unlits.

Diagnostic X-ray departmenti ,,,...,,,,,.,,..,.,.,, .. .. .. . .. .. E. .. . .. .. . .. .. . .. .. . .. .. . .. . .

l : : ', ' ' ' j......... " .. "......... ............ ............. ............: $---~~~.. . . .. . .. . .. . . "".'.'... . .. . .. . .. . .. . . . . . . . .i~ ~ ~ ~ ~~ ~...... -'':''"': I .. I........ .............

Operating theatre department

Operating theatre department

- ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ 6 -2--000 -l I t2-ffi nz

__ ~~This operating theatre should onlly be provided ini larger institutionls, and whlere surgeonls or surgerytechnicians are available. Having two theatres allows one to be reserved for septic eases. A one-thleatredepartmenlt could be provided by omitting the end-thleatre.

This department has been extensively rationalised. Only twvo changing rooms are provided, one for male andOneC for female staiff There is onlly one staf'f rest room.

Limited room reserved for \vaiting has been provided. Having roxvs of patients wvaiting to be operated on iscnot practical. In normal staffing conditionls there would be no-onle available to observe them. Akny patients

waiting can be parked in the eorridor where SOmel supervisionl is possible.

C0

ThIn-department tlitreshould ov be been kept to a minimum. In higher-level hospitals responsibilityfor the recovery of'the patients is with the anaesthetist; in rural or district hospitals it vill probably be with theward ntcrse.

The Central Sterile Supply Dbepartmeni t (<,SSD) is placed next to the operating theatre and benefits fromusing vertical drum (sputnik type) autoelaves. Long experience shows these as the most consistenbtly reliable.XVork in the CSS1D will be carried out by the theatre staf'f after operations and on days *vhen no operations arescheduled. A separate store with outside access is provided for keeping sterile goods for other departments.

Hehahilitation department

Rehiabili tatiOnI deparltmenlt

In most hospitals this is becoming a most important departmenlt. Even wit two separate dividable spacesfor physiotherapy and occupational therapy (as shown), a arge proportioni of activities will take place out ofdoors, on the crafts veranda, or other adjacent areas.

oartly because there re cat present very few qualified rehabilitation stafif i most southern African countries,these departments will not always be given high priority.

Labour ward / deliverv

The delivery unit is designed to simplifA the wvork of the staff. The scmi-opcn first-stagc labour beds areeasilv supervised, and arc immediatelv across from the enclosed delivcrN, beds. These facilities have beenduplicated to allow' separate facilities tor septic cases.

The nurser in this examplc is locatecd insidc the delivery unit vherc there xvill be qualified supervisioll.

Labour ward / delivery

~~~~~~~~~~~~~~~~~~~~~~~~~~"

.... .......... . ......

Standard ward c

The layout of this ward unit, wh}ich can be standard for all categories of ini-patienits, differs in several vaxvsfrom historically-acceptcd solutions.

The wvard uinit is built up of a ntimber of ftlly cnclosed self-contained 6-bed wvard rooms each wvith its oxntoilet and washing facilities. Patients call be effectively segregated accordinig to diagnosis, and according to secxand age group.

This is highly appropriate because hygicinC and the conitrol of inifectioni are major factors affecting efficiencyand quality of care in the institution. It also allowxs much greater( degree of flexibility in use and for the allocationof rooms to differenlt patient groups, alloxving for seasonal variations, using a smaller number of beds.

The ward Unlit is also designed to make maximumn utilisation of a small staff, in particular during theafternoon and night shifts. In this xvay it is possible to pool central facilities such as treatment roomr, pantry, andassisted bath and toilet, betwvecn twvo 25-bed wvard uinits.

I ----- ee;C- d~~~~~~----------i 2 J l_____A_____+@PtmI]vt mS 4 Z ~~~~~~~~~~~. .. ......

F~~~~~~~~~~~~~~~~~~~~~~~~~~~~..... .....L~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~..

....... X

l :': ' '' :''~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~... - ' i ...___

1~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~.'.'.:'..:...___ _ -_____ ____ _ _ __ _ __ _ ,_l Wq~~~~~~~~~~~~~~........

- - - - - - -- - -- - ~ ~ ~ ~ ~ ~ ~

............. ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ pe prp4

N a I s I 0 1 03 I1 0 H d S

Kitchen and laundrv

The lavout shown for a kitchen is based on the assumption that electrical equipment will be used. Where no

mains power is available, an alternative traditional kitclhen with a good ventilation svstem can be used. A smallcanteeni for staff is provided.

The kitchen should be planned after dIe conlsiderationi of the number of staff wt-ho xvill be working there as

wNell as the number and type of meals which uvill be prepared. ArouLnd the southernl African region there is asubstantial number of kitchens xxith designis borrowed fronm ELul-opean models. These kitchens are usually muchtoo big and complicated in design. Examliple: a 200 rn2 kitcheln for a district hospital xvith baking alcoves,

vegetable preparation alcoves, special alcoves for tish and meat preparation, a multiplicity of stores. (The local

staffing norm is 1 cook and 2 general hands.) C.

The canteen should be so dimiienlsioned that one can also tIse it for staff meetinigs.

A layout for a small laundry USilng electrical equipm-ent is shouwn. Wlhere there is no mains power available, a

traditional design should be used. A covered drying area is required. a

Kitchen and laundry

rn

le~~~~~~~~~~~~~~~~~~~~~~~~e

7 , - - ' ' _<,'-'','.,',,,,~~~~~~~~~~ ~ ~~~~~~~~....-. ....

Central stores and workshops

This is a block with a largc ccntral storcs roomii and withi thrce small workshops or stores for maintenancestaff. Providing this cluster should improvc the general mainitenianice serviccs at the institution. Facilities are alsoprovided for vehicle maintenanicc.

Central stores and workshops

CZ~

.. .... ... . .. -

Administration

TIhe administration departmenit is made Up of a suite of 6 standard rooms each with space for 1, 2, 3 or 4staff depending on their level and the activities which they carry otut.

The meeting room can also be used for teaching smaller groups.

Administration

The publie wvill often require access to the t 4 1EX:|l Cashiers room to make payments. This should r- --=--L_ =_ D=tS0000000II

be provided through a hatch in an outsidc X00at00000000e,wall withl a covered canopv over it so that the| 5 5 3! 1t X000000)000000§I

ptublic do not need to enter the administrationl-2=,'l><<A0btiildi n...........

i i.*¢ve rt2nWc 1 K t9 a r y < tit.. .........

rr_ __h _U_ * ~~~~~~~~~~~~... . . . . .

LU~~~~~~~~~~~~~~~~~~~~~~~~~~~ 0F

Mortuary Mortuarv

A completc mortuarv conlsists of an autopsyroom and a lay ing-out room com letely separated bya specially constructed bank of double-ended bodychambers. The unit can accommodate 3, 6 or 9shelves as rcquired. Positioning a mortuarv onl ahospital sitc is extremely difficult. It should not bevisible to the -wards or be in close proximity to thekitcihen and putblic areas. It should have its ownaccess, vet bc under the close supervision of thehospital.

Central staff change °

Central staff change

A small block is provided with toilets, lockers andchange facilitics for malc and female staff. -....

rEq

CA,.,-- I _

! I

HEALTH CENTRE DESIGN

Thiere are many ways of dcsigninlg hcalthi ccntres and most are reasonable. The fuiictionis involved do notplace large demands on zoning, interrelationiship of departments, or traffic patteris. The basic principlcsregarding the form of buildings and orienitationi still apply. In most cascs four or five of the 15 m' type (G)rooms and a covered waiting area (which also can be used for demonistrationis and tcaching) would provide whatis needed. The result would be a flexible building xwhichi could adapt to manv different applications.

Many health centres are still much IIUndcr-used: this low use has only slight relationship to architectural andplaniniig decisiois. Usually improving the supervision of the cenitr-es by medical practitioners and at the sametime improving cominiunicationis and transport Nx-ill increase utilisationi of healthi centres and reduce by- passing.

Wards attached to health centres are also oftcn verv little used. Many centre staff do everything possible toquickly senid potential in-patienits on up thie referral system. Staffing is often instficient to provide qtalirv in-

patienit care. Staff know that if the patients stay in their facility staff will have to stay tip all night to m)onitor them

and that the staff mav' havc to prepare in their own kitchens any food that the patients eat. If there arc in-patientfacilities in a health centre, it would be reasonable to provide modest traditional cooking and laundry facilities.

Use of natural features on the sitc should bc encouraged. Most patients in rural areas much prefer to waitunder a tree than in a roofed concrete waiting area. However, a covered area which also can be used for teachingshould be provided.

Figure 54: Examples of health centre layouts from several Southern African countries

Country A

u l Count41t Gryoto*J BGG .- .........................l .,.,.,., ~~~~~~................ ,.I

L1 1 ~~~~~~~~~~~~~~~~~~~~~~~.-..........................stre..lie.y...e.iew

..... -, , I.…

3 Coulltry B 5X> ACountryiC

r - : : O-I ;

tn~~~~~~~~~~~~~~~~~~... .... ........

Country C hhs -..............

......- 1X.. ..........

CD~~~~~~~~~~ Coutr B uv^ 1---

SW~ 4QA~ "Cu X IKW lr-q St 'J2

Countrv D

f~~~~~~~~~~. ... :...

1 I,~~~~~~~~~~X

..- . a~~~~~~~~~~~C

C'ountrv E X....

.... ',:.. :............

. .

..... ..... ~ ~ ~

USE OF EXISTING BUILDINGS

Hcalth buildings in the socutherin Africa region arc usually of varying quality, particularly from a functionalpoint of view, but usually thcir fabric is surprisinglv solid, even after many years without maintenance. Even incoloniial times, most buildings for hcalth scrvices in the region (though few in number) wcre sited and orientatedcorrectly and very solidly constructed.

Depending on the age of the building, in 90% of cascs conventionial rcpair work will bring the buildingsback to reasonable condition.

Functionally however, thesc bLuildings arc usually very unsatisfactoryt When comparing their functionalstandards with those proposed for the standard type plans in this chapter, wc obscrve that the greatestdifferences bctwecin what exists and what is required usually occur in:

* the wards, w hichi are usually the multi-bed type with little possibility of isolating patients, orachieving flexibility of allocation. Wards usually do not have the facilities needed forachicving good hygienic conditions.

the theatres, wlherC usually it is difficult to maintain correct hygienic conditions. The theatres areoften closcly connccted to other traffic-ways and functions in the hospital.

c * X-ray rooms wvhich oftcn are unsatisfactory rcgarding protcction of radiologists and passers-by fromradiation, and wlvere the equipment and electrical installations are often dilapidated,sometimes evcn dangerous.

co laboratories which (if cxistinig at all as defincd locations) are often inadequate in space, location,equipment and installations.

In existing buildinigs, many different functions are usually collectcd together in single blocks, and as a resultseparate extension of individual facilities can be very difficult. Where there is more than onc block, groundconnections between the different buildings may bc neither paved nor covered. Over and above the problemsand inconvcnience for patients and staff therc is oftCII an increased danger of soil erosion because of this.

In most existing mral heatlt facilities, buildings are adequate for use as offices, consulting rooms, class-rooms, stores, dispensaries, but inadequate for use as wards, operating theatres, and medical services facilities.The last applies to most of the rooms required for in-patients.

Proposed procedure

WXhen upgrading existing rural hcalth institutions, the following sequencc of activities xvill be usually be relevant.

Ni Activity Effect on recurrent costs

1 Establish circulation pattcrn of covered Negative, should improve quality and efficiency andwalkways betwcen existing blocks allowing for prolong the life of trolleys and containersfuture connections to new buildings

2 Provide acceptable accommodation for staff Neutral, should improve quality and efficiency3 C'onstruct new wards Neutral if bed numbers stay the same, may well imply

savings in staff with efficient dcsign4 Construct new opcrating theatrcs, X-ray, Neutral, may imply slight increases if equipment

laboratory, maternity delivery, etc. which originally did not work is now made to work5 Convert existing facilities to out-patients, Neutral, but with proviso as No 4

administration, stores, etc.

6. ENGINEERING X l' , m

This chapter, while not a comprehensive dcscription of ccrv aspcct of engineering relcvant to planning and -

designing health facilities, souLnds a few notes of warning derived from our experiences in the region. =

The most serious hindrance to a health institution's efforts to provide correct hygienic conditions withinrcasonable cost is often the malfunctioning of various inappropriate mechanical installations or equipment.

High-technology autoclaves

The types referred to here produce their ownvi steam and are intended to control each cycle completelv mautomaticallv. But the fine-diameter copper tubitig in -which the steam is passed is sensitivc to hard and mulddv

wvater common in most African cotiuntrics, andi quickly becomes blockcd. It is not always easv to find rcpairmenwho can weld copper expertly. Electronics problems are also common. Usuallv within a matter of a few monthsthe ncexv units work only intermittenltlyn and the hospitat (and in particular the operatiing thcatrc) is deprived of

properly-sterilised utensils. Simpler, pressure-cooker-typc autoclaves arc strongly recommended.

Notice in a Zimbabwean district hospital

O nce4 tt, MRCH IPuE

ce NIt S ET S| CENnUV es rcVINK 0 U

m

Medical gas reliculations

Built in mcdical gas reticulations present potcntial dangers, such as contaminationi throughl cleaning, peoplcmixing-up connections at the stupply cnd, and maintenancc problems. A frequcntly observed problem is theextremely high wastage of gas.

During a large rehabilitation project at a tcn-storcy high 1400-bed university hospital in East Africa, it wassuggestcd that thc hospital should be provided with its owni oxygen manufacturing plant. This could be justifiedeconomically, and a teasibility study showed that, according to the acttial consumption of oxygen in thc hospital,thc plant w-ould pay for itself within 6 vcars. ThrotughoLit the hospital there was a regular monthlv consumptionof plus or minus 25 000 cubic mctres of oxygcn, giving an annual total of 296 000 cubic metres. This amount

co initially scmed reasonable until it was compared withi the British DHSS Technical Memorandum on MedicalGas Systems, whichi showed that an annual consumption of 42 000 cubic metrcs was considered reasonable for aBritish hospital of comparable size. It was difficult to identify the reasons for this 700% over- consumption. Theoxygen reticulationi was in good condition. It was cventually found that the problems werc apparently caLtsed bytfaulty valves and concctions at one end of the system or by faulty user procedures at the other end.

In most situations it is difticult to recommenid bLuilt-in medical gas reticulations. From expcrience the mostefficient and safe provision of mcdical gases is by cylinders. Therc are now on the markct cvliinder trolleys andanaesthctic machinles whiclh transport gas cylinders safely and conveniently.

Air-conditioning systems=

Discussiolns of air-conditioning casily bring oLit myths and fantasies and can bccome highly cmotional. Itcertainly is not only a Tfhird WNorld problem. Eveni in Elurope the claim that normal air-conditioninig can be usedto crcate positive prcssurc in the operating cnvironmenit and so control the movemcnt of bacteria, is very shortof positive proof (with the exception of high velocity and laminiar flow systcmis).

CA

A rcsearch project carried oLit with the support of the Danish Hospital Institute in Copcnhagenl in the carlv80s invcstigated operating theatrcs in various hospitals, usilng colourcd smoke to test the efficiency of gasrcmoval from the opcrating area. The rcsearchcrs observed that in evcry instancc, the heat build-up from thcoperatiing lamp crcated a static but rcvolving sphcrc of air and gases complctely isolatcd from air-movemcntscreated by the ventilation systecm in the rest of the theatrc. In short, the volume of air in the theatre mostcontaminiated by gases and bacteria, is usuallv not greatly intluelLced by the air conditioniing system.

In Africa the concept of bactcrial control through air-conditioniing is even more debatable bccause thequality of the air being pushed into the theatre is often the most critical factor. In a rccent discussion withEuropcan-based constIltanlts offering 'totally' filtered air in thcatres, experienccs in investigatilng the thcatres inpublic hospitals in a country in southc-rn Africa wVClC recollectcd. At that time not oIIC of the fourteen systemsinvestigated was functionin1g as intended.

Somc werc not working at all (perlhaps the ideal situation). Of thosc workinig, all had very badlycontaminated or dcfective filtcrs. There was no organiscd mainteniance of the systems at that time, and thcre wasprobably no money available to buy replacemcnt tilters. Thc worst situatioll was cncountered in the newest andmost sophisticated installationi (5 vears old). Herc the rolling filtcr had run out and thcre was a great gap wherethe filtcr should havc becn. It was unfortuniate that this system was not functioning since this theatre had notbcen provided withl windows or any othcr natul-al form of vcntilation, and workinig conditions werc clearlyunacceptable.

When drawing-up a performance specification for air-conditioning systems a basic requirement is that theoperating theatre temperature should be kcpt at a constanit 21-22 degrees Celsius, to provide good workingconditions for the surgeoni and nurses. This can be achicved in a number of ways. Asking for or promising morethan this is very optimistic.

An appropriately designed operatinig theatre in the southelrn Africa region should bc in a building orientedprecisely on an east-wvest axis, with windows facing due north or south. Tle roof should have 80 cim overhang,the roof space should be well ventilated and thc ceiling should be insulated. Floor-to-ceiling heiglht should beover 3 metres, preferably 3.5. There should be adequate tloor spacc in the theatre, and high cross-ventilationfrom windows. With sim,ple easilxr-cleanied Ciniishes and minimulll horizonltal dust cOllectinlg surftaCces to promotehygiene, in most climatic coonditions normal in the region, it should be possible to maintain reasonable workingtemperatures by having simple split units mounited on the ground outside the theatre or by using fans mounltedon the theatre ceiling.

APPROPRIATE MAINTENANCE m

Maintenance should be a key factor in the designi of anm healtlh capital investment project. Governmentsusually are not able to pay the high wages required by technicians, and it may be difficult to finance the training m

of specialised maintenance teclhnicianis for the healtlh sector, or to fLunid the establishmenit of teams of biomedicalcngineers.

0

In proposals made for investmients in buildinigs and equipmiienlt, probletlms with maintenance should be anticipated in the following ways:

* Materials and items should require a minimtim of maintenianice, or be maintained by simple meancs.

* In all procurcmenits of equipmenlt and plant, adequate spare parts should be included tor 3 years mainitenlalnccand service. Further service contracts with suppliers should be proposed and funded where possible.

* Small workshops and maintenance stores shoul(d be provided at all facilities being upgraded.

* providing improved transnport and commnllicationis in new projects will help the correct utilisation otmaintenance services.

Maintenance is as muLch a managemcnt problemii as it is a technlical problIem. For many individuals andorganisations it is also a psyclhological probleml.

Much of the maintenanice requir-ed for health facilities (particularly in rural areas) can be done uSilng basiclevel skills, requiring fexv spare parts and very little organisation.

Appropriateness is a key wvord when discussing maintenance. Regrading is the process of changing thecontents and com,ponents of a building in order to make it maintainiable.

Establishinig an effective system for- dealing with simple routine mainitenianice requires the following activities:

* The team should meet the maintenance workers cmployed by the health directorate

* Workers should be asked to help preparc the documiecnltatioil on1 wN hicih mainitenanicc planining can bcbased. This will include:

- a list of all medical, kitclhenl and laundry cquiLmenllt and its location;- a list of all sanitary fittings and their location;- a list of all preventive maintenance jobs which have to be unidertakeni evcry da! / week / monitlh 1year;- a list of all repair / maintenance jobs wvhich normally occur, with somelC indicationi of frequencv;- a list of the tools and equiipment required to carrv out the repair and maintenance activities which

have bcen described;- a schedtule allocating the tasks to the memi bers of the maintenianice staff.

This approach will entail the project team and others:

* Drawing-up work programmes and schedules and allocating rcsponsibilities accordilg to the differentproposals and lists made;

* Inviting proposals from staff miembers for documenltillg information regarding breakdowns and theneed for maintenance;

* Listing the spare parts required to carry out the tasks described;

• Listing any maintenance task not becn included above.

CaDespite sincere efforts, not all maintenance work will be covered. However, the scope of work which will

= have to be programmed and undertakeni by higher level expertise will be significantly narrowed. Maintenance ofmincdical cquipmecnt is dealt witlh in chaptcr 8.

FIRE PROTECTION AND FIRE-FIGHTING SYSTEMS

The layouts of the different health facilitv sites and the design of the form and contents of the individualbuildings should reflect consideration of fire safety. An effective system achieves maximum safety by safeguarding

_ against the possible occurrence of fire and, when fire does occur, by ensuring the protection of the occupantsand contents of the buildings, and by providing the means to quicklv extinguish the flames and restrict thedispersion of futmes and smoke.

=___ Generally health facilities should aim to rely on passive protection, rather than technology:

A Ensuring low combustibility• Usc low ignitable and nonie-combustible materials suchi as ceramic tiles, concrete, brickwork.

* Ensure absence of thero-plastic materials such as polystyrene, PVC, or vinyl, materials which easilyignite and wvlhich give off toxic gascs.

* Remember that thoujglh bed lien can easily ignite, it never bursts into flames. Normal bed sheets andmattresses have been proved by experiment not to be easily ignited by a cigarette.

B Preventing the spread of fire• Leave adequate space betweeni buildings so that fire cannlot easily spread from one building to another.

• Ensure that all parts of the complex have reasonable access for fire-fighting appliances.

* Properly locate stores for consumables and medical gases, so that these are not kept in large quantities inclose proximity to other buildinigs.

C Giving proper protection to people and building contents in case of fire* Consider each ward and room as a fire compartment. Make sure that there is easy access directly to the

outside.

D Providing reliable fire-fighting equipment which is easy to use and whichdoes not require maintenance

• Fire blankets, sand buckets and water buckets are more effective than fire extinguishers which have notbeen maintained. Choose types of extinguisher according to appropriateness and ease of propermaintenance.

E Taking maximum advantage of the situation where health facilities are staffed bytrained individuals who will (with proper instruction) be able to maintain a highlevel of safety with non-technical devices

One task of the Hospital Engineer member of the Hospital Maanagement Team, shotuld be to evaluatethe fire protection quality of the buildings, and to drawL up instructions to the staff to make anyimprovements needed.

F Understanding the limitations of patient mobility

This influences the distribution of fire escape routes. Agree on the desirability, suitability and positioning offire alarms wvith those limitations in mind. (It is often safest for patients to stav where thev are, protected bv thepartitions and doors wvhich enclose the room.o)

* Implement regular and unscheduled fire drills for staff

* Monitor and record the time needed to evacuate the buildings of patients and staff.m

A high level of tire safetv can be achieved in the newx and refLrbislhed facilities without substantial _requirements tor technical installations and maintenance. With a good system in place (no matter the financialconistraints) the system will be continually sustainable with a miniimum requirement for recurrent costs.

Simple inistrLuctiols should be provided to the facility staff during their traiting, be rcpcared duriiig on-thejob training, and be subsequently repeated at reasonable intervals.

a,

lo COSTS MANAGEMENT DURING CONSTRUCTION»

coo As part of carrvim g out the scrviees of cost maniagement the Quantity Siurvevor usually produces:

-l A CASH FLOW REPORT

A cash flow report for each site is submitted to the client at the commencement of constructioni work andupdated periodically as required. It is usuallv prepared by the Consultanit Quantity Survevor (not the contractor)and is based on the programlnme of works drawn up by the contractor.

B COSTS REPORTS

Costs reports for each site are financial statemenlts whiclh are drawn-up monthly by the consultant QuantitySurveyor. The costs rcport incluLdes:

S 1 Originlal conltract SUIml

2 Detail list of approved and costed variation orders* 3 Balanec of contingency sum / anticipated variations__ 4 Increased costs of labour and materials

CI D Value of sub-conitracts placed*e 6 Revised anticipated final cost of contract

ox C PAYMENTS CERTIFICATES

Payments certificates are issued montlhly with the costs reports for each site. Certificates are drawn up by theConsultant Quiantity Survcyor and calculated oni valuc of work done, plus value of materials on-site, less previouspayments, less an agreed retentioni amount, and should indicate how much the client should authorise to bepaid. The costs of services provided by the client, such as water, electricity, and accommodation, are subtractedfrom the payments certificates.

D VARIATION ORDERS

Variation orders should be drawll up by the Architect or Enginieer for all proposed changes to the contractand be proecssed by the Quantity Surveyor.

The variation orders should be numbered sequenitially and should describe the items in the bills of quantitiesto be omitted withl costs, the new items to be substituted, again with costs, and the cost-value of the difference.

The variation orders should be submitted to the client who must sign his approval. Usually the costs can betaken straight out of the bills, but sometimes the Quantity Survevor has to make his owvn estimates. It isimportant that these estimates be as accurate as possible.

MONITORING COSTS REPORTS BY THE CLIENT

Clients are often intimidated bv the technical nature of Costs Reports and have difficultv in monitoringthem. A good method of analysing the different figures supplied is to transfer them manually or by computer toa simple graph.

Graph showing costsreports for the first 10

Xj= ;-lt t | i t I tt- H _t t ~~months of a24-month

construction programme.-4

Ca

t~~~ tr, .i 7r >>^:

.1 ' - -- ; /- Z

> !t ~~~~~1 /o _

>*e ~~~~~~~~~~~~~~~~~~~~~~~~~~CD

2~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~0

The graph shoxvs the following e

The rate of constrLIction is reflectcd bvr the moritlik, certificatesI(1)Th-is Nvas sloNN, in the begininiiig oftltheCDprogramime buit noNv (betxNvceii months 7 and 9) can bc seein to be moviiig at a ratc wvhicli should facilitatecomptetion of the project xvithliri the 24 nmonths .

TIlhe amount otfpayments so far in additions (2) is under USI) 10,000,000 F

8. PLANNING OF- HEALTH EQUIPMENT

Carefuil planning for equipment enhanccs the efficienc,v and effectiveness of the whole health sector. Healthequipmiienlt includes medical equipment and general equipmenit to support the functioning of a health facility,such as gcnerators, laundry machines, and kitchell apparatus. In the planniing for equipment, as part of healthplanning, three steps coIlIC immediately to mind.

As the first step, the sector has to decide wlhich healtlh services it wanits to provide, and at which level of thehealth system it wanits to provide these services.

As a second step, the human resources who will use this equipment must be considered. Rational planningfor equipmellt requires an assessment of the likelihood that the equipment will be properly used. Is the necessarystaff available? Can staff be trained in its proper use, once the equipment is provided? The most common reason

__ for break-down of equipment is improper use. This improper use is often traceable to lack of training.

s Thirdly, one has to verify' that the capacity is available to maintain the equipment. Maintenance requiresstaff, infrastructure, such as workshops, vehicles and tools, and it requires a budget for recurrenit costs. Many

,__ investmenits in maintenance are wasted because no recurrenit budget was provided with the investment.Unwillingness of doniors to provide for the sometimes large recurrent cost implications of their investmentprojects often adds to this problem.

THE STATUS OF HEALTH EQUIPMENT=

Most facilities are fiull of eqLuipment wlhiclh is not fuLnctioning or ftictioning only poorly. These reasons areoften given:

* the equipment is too sophisticated* no-one knows how to UsC it* (inadvertent) misuse* ovcr-utilisation* no-one knows how to ilstall it

a- * the equipment was broken whenl it arrived* no spare parts available in the country* no proper utilities available (electrical power, water supply)

co * no proper space for the equipmiient* no1 maintenance plan* insufficienit budget for maintenanice* equipment is not resistant to dust, humidity, or high temperatures

* no-one needs it* equipment is not appropriate for the local context

Each hosspital hSas twlo

The reasons for this situation fall into several categories: mortuaries,oniefbi- patients and

Lack of' train iitg, experience and a ivaren ess amno on decisionimakers another for equipmcinentregarding the management of modern techlniology Too often, dc ision-makers see equipmenit in the same xvav as drugs or buildings. Equipmentneeds continuous care, maintenance and a reliable supplv of spare parts. Itoften requires relatively sophisticated users and well-trained service personnel.

Equipment is ofteni prim;arib' conlsideried a staituis svmbol. In1stead of purchasing items that would adequately CImeet the needs of patients, many' doctors insist on equipmeent that is superficially the most impressive, regardlessof price, performance, even efficacy and safety. Computers, which are being used as typew,riters (or not used atall) are the prime example. Procuremeint is often handled by administrators or physicians sith little knowledge oftechnology' management.

Greed anid short-siqhtedncss oJ >nanufŽcturcrs and suppliers. Tle industry often pushes the sale of excessivelvsophisticated equipment to a health system, which lacks the technlical and finanacial resources necessary to soperate, maintain and update it.

Somte prora nmines and donations are motivnated by donor self-interest. This has resulted in large donations ofcostly equipment, but no commitment to dealingg with problems of operation antd maintenance. Shoort-termbenefit for tlhe donor nation rather than long-term developmenlt of the receiving nation mav motivate the donor.The receiving nationi or the health facilitvN will find it extremely difficult to refuse a seemingly attractive gift.

Shortage offh-inds. All these problems are greatly' exacerbated bv shortage of present financial resources and Ouncertaintv of future resources.

TASKS OF A HEALTH CARE TECHNICAL SERVICE

Proper planning and management of equipment can only be done through a team effort, involving stafffrom different departments of the health sector. Such a Health Care Techniical Service (HCTS) needs a multi-disciplinary staff, including planners, users and engineers.

Proper management of equipnieiit requires a healtlh equipmenit policy', which outlinies the goals andobjectives of the sub- sector. A countrv needs a Board for medical equipniciit technology, xhich canl help decidepolicv and develop an action plan for equipmenit management. Such a HCTS action plan involves a manpowerdevelopment plan, training prograns, standard lists of equlipment for each level of care, requirements ofinfrastructure for equipmiienit (workshops, tools, vehicles), and a plan for the procurement and mainltenanice of X

equipment. All these aspects are interrelated. Fortunatelv, the literature on this is not as scanty as it was only aefewv vears ago.

Careful planning is necessary for sustainable delivery of good-quality care. It entails assessmenit of therecurrent cost and future investment implicationis of the equipment investments decisions. Healtl plannlers oftenignore the costs of maintenance andi replacement of equipment. The costs of maintenance may be 5-10% of theinvestment costs. One has to plani for a piece of equipment's replacement on the day of purchase. If the life of a mpiece of equipment is 5 s'ears and the annual maintenance costs are 10% of the purchasing price, the total annual Mcosts to keep that equipment in running order Xvould be 30% of the capital costs. In fact, the figures will be evenhigher sincc prices alxvavs rise. Careful planning balances what is needed with ws'hat can be afforded.

Rationalisation of procurement can result in enormous short-term and long-term gains for the healtlsector. In procurement one has to weigh maniy issues, including:

tlhe mnethod. Intcrnational competitive bidding (ICB) can result in the best price for a piecc ofequipment. But I(B may be too cumbersome, if the quanitities or the costs of the goods are low.Reasonable alternatives arc local shopping or nationial compctitive bidding. Whatcvcr the method, thereshould always be space for competition to guarantee good value-for-money,

* Standardisation. 'I'his will have enormous implications for staff traininig, availability of spare parts andefficient planning for maintenlanice. Howevcr, too much emphasis on standardisation may lead tointefficient procurement or poor value-for-money. It is unlwisC to become too dependent on a few

- suppliers. Overemphasising standardisation may also lead to lack of innovation.

* Installation and waintenance. For fiuture uise of the purchased piece of equipment, it can make all theLU difference if its installation and standard maintenlanice is included as a requirement in the tender

documenit. At the same time as one procures a piece of equipment one should procure the toolsand spare parts wlhiclh are necessary for its mailtenianicc. One can ask to include the price of mainitenanice

96 contracts for standard rcgular maintenanice in the bid price of the cquipment. Inclusion of training in- the proper use should be standard in the tender documellt wlhcn procuring a major piece of equipnient.

If the equiipment requires specialised maintenlanicc by the supplier, the supplier should have arepresentative in the country or at least in the rcgion.

DEVELOPMENT OF A MAINTENANCE PLAN

Rather like general health care, maintenanice can be divided into preventivc or rcgular standard maintenanceand repairs. After an inventory of the available equipmiienit and its regular maintenance requirements (time andspare parts) it will be possible to develop stock requirements and efficient maintenance schedules for each healthfacility. 'I'hese are lists for estimating the maintcnance requiremenlts for many pieces of standard healthequipment. Most equipment will be bcst mainitainied on-site. Some equipment which need specific testing mayhave to be transported to a workshop or laboratorv. Always remember that maintenance costs are a substantialpcrcentagc of thc capital costs of equipmenit. Establishinlg maintcnance contracts with spccialised firms maydeliver the services more efficiently and with a highcr quality than the health system itself can do. In smallerfacilities it may be advisable to combine care for mainitenance of the civil works with maintenance of theequipment in one unlit. Well-organised planning for maintenance requires good management, since many entitiesare involved: the health facility, the district, thc province andl the nationlallevel. For most pieces of equipmenlt, contracting of mainteniance will not bethe most efficient choice. Maintenance is like

,general health care:A key task of the HCTS team is manpower planning and training. Thc there is preventive care

extreme variety of health equLipment and its sophistication require qualifiedstaff, from tcchnicians, wlho operate and repair equipment, to managers who and curative careare responsible for planninig and procurement. If the general educationsystem does not provide the necessary training, the health sector will have totrain its owIn equipment staff. It may be necessary to send some HCTS staff abroad for specialised training.WHO has stimulated the creation of nationial, regional and inter-regional networks of training institutes toprovide the necessary traininlg capacity, especially in TOT (training of trainers).

The HCTS organogram is a pyramid, with few staff at the top and large numbers of craftsmen at the base.In general a HCTS team consists of the following 3 categories (A, B, C) of staff, each group with increasingtechnical and managerial skills.

A. Staff with only primary education, or some secondarvy educationi and a few years techliical training orexpcrience, such as craftsmen (carpenter, plumber) and polvvalent technicians.

B. Staff wvith spccialised technical training in a pol technic school or university, such as specialisedtechnicians for maintaininig basic medical equipmcnt and cold chain cquipment, or enginieerinigtechnicians such as managers of a district workshop.

C. Staff wvith advanced training in managencnt or engincering such as cliniical cngincers for advancedtechnical work in provincial or national workshops. Flis category also includes clinical enginieer-managers for policy devclopment at provincial and ccntral levcls.

Training in managemcnt of healthl equipment should be ilcluded in the curricula of health w orkers, such asnurses and laboratorv technicians. There arc two good reasons for this: minor preventive and curativemaintenance can often casilv bc done by the user of the equipmcnit, and misuse of equipment is the mostimportant and frequLent cause of malfiunction.

a

The following reference material has been used for this chapter on equipment:

Manpoxver Development for a Health Care Tcchlnical Service, XVH() 1990, Rcport Nr. WHO/ SHS/NHP/90.4.

Bloom G. and others, The Riglht Fquipmet ...In Working Order, World Hcalth Forum, Vol. 10, 1, pages 3-27

WHO Global Action Plan on Managemenit, Maintenancc and Repair of Health Care Equipment. c

Bloom C., and Tcmple-Bird C., MIedical Equipmiienlt in Sub-Saharanl Atrica, IDS, Research Report, WVHO (Rr 19).

_,

.- I

9. COMMISSIONING

coThroughout the design and construction stages it is important to be aware of all the tasks which have to be

undertaken to commission and take into use the completed buildings. The King's Fund for London hasC03 published two vcry good reports on the subject and the followinig check list is based on those publications.

- FUNCTIONAL CONTENT OF THE PROIECT

o> This includes considering the implications of the new development on existing services; on theirorganisation and management, and the implications of the Brief and schedule of accommodation. Minimal

D requirements call for:

* Description of services to be provided compared with existing services* Data on present and anticipated numbers of patients, staff, out-patients, operations, x-ravs, in-patients,

patient days, lengths of stay, rates of admissions.

MANAGEMENT OF THE COMMISSIONING PROGRAMMEThis requires establishing the commissioninig team at both central and local levels by:

* Appointing team members* Drawinig-up Terms of Reference and Job Descriptions for the members of the commissioning teams* Nominating team leaders and team secretaries* Drawinig-up a list of tasks for all departmental managcrs, medical, nursing and other staff, including

infornmation required for planning, procurement and training, as well as a programme for occupation ofcompleted facilities

* Describing the task of the Project Co-ordinator and the project implementation unit. Circulating a timeschedule of activities and a list of information which will be available

* Helping the finance department to liaise with co-ordinators and departmental managers and draw-upbudgets for the revenue consequences of the project

* Reviewing the programme of activities, ensuring implemiientation of activities in due time, includingprocurement of equipment, recruitment of staff, approval of budgets, procurement of supplies andconsunmables including uniforms and stationerv. Ensuring that everyone is aware of the most criticalfactors (usuaIly staff and finance) and that these are properly dealt with

• Drawing-up final check lists for the commissioning programme. Separate lists are required for managers,clinical staff and other members of the team

* PavTing particular attention to commissioniing those departments wvhich are completed early in theconstructioll programme (often so that other buildings can be emptied prior to refurbishmellt). Herethere will be particular questions concerning the earlv procurement of equipment (which is usuallxdifficult), status regarding insurances, the contractor's liability period, and securitv.

OPERATIONAL PLANNING

Drawing-up comprehensive descriptionis of the finctions of the new departments anld the activities whichvill go on in them. This wTill essentially involve the reviexv and reissue of the operational policy documenits

dcscribed in chaptcr 4 THE BRIEF

EQUIPMENT AND SUPPLIESA specialist team should be involved (from early in the design process) in planning the procurement and

installation of the equipment and supplies wvhich wvill be required. On a recent project in Botsuvana the commissioning team had the following memllbers:

Project Co-ordinator: in chargc of the overall management of the project ce

Commissioning Officer: chairmani of the Equipment Committee (vith representativesfrom different disciplines in the hospital / MOH also orepresenting the hospital in the construction process)

Equipment Specialist: responsible for all project and tendering documentation _

Commissionilng Nurse: most active during the actual commissioning process

Commissioning Engineer (civil works): liaison in earlier stages wvith designi team

Commissioning Engineer (equipmenit): liaisoni in later stages with the conitractor, supplier, and others

Supplies Officer (MOH) : responsible for ordcring and tendering procedures

The Equipment Specialist liaised wvith the Project Architect, and submitted proposals directly to theEquipment Committee, which then instructed the Supplies Officer MOH.

In addition to drawring-up the documents required for procuring equipmeint, the Equipment Committee isresponsible for managing the receiving and installation of new equipmenlt

PERSONNEL MANAGEMENTThis key function wxill include drawing-up and agreeing policies for the organisational structure of the

completed facilities and for the recruitmiient, training and deployment of staff. The number of nexv staff requiredshould be assessed and the revenue required tor their employment should be negotiated with the authorities.

MThe proposals made are also discussed with staff groups. A programme is drawn-up and implemented for the

induction, orientation and traininig of existing and ncw staff. This may include a programme for transferring stafffrom the old tacility to the new one.

COMMUNICATION STRATEGYProviding information is an important task of the commissioning organisation. This includes providing

information to the public by means of press anno)uncements and meetings, and conveying information tohospital staff and others affected by the project (such as residents of adjacent properties, patient groups andorganisatiotis) bv means of circulars and group meetings.

- PRE-HAND-OVER ACTIVITIES=

o As the buildings near complction, the activities of the commissioning team bccome more intense. Plans to beinitiated for co-ordinatinig the final effort will involve meetings witlh architects and the contractor- to agree the finaldate of handing-over and to finalise handinig-over procedures. At the samc time the process of commissioning

co engineering services must be implemented. Althouglh the responsibility for this is the technical consultant's theclient (through the commissioning team) will need to be fully Briefed on any problems observed.

* HAND-OVER

The taking-over procedure wvhich has been agreed must be implemented and carried out at a formalmeeting. All questions regarding the liability of the clicnt and the contractor will have been cleared andarrangements should have been made for hanidinig-ovcr responsibility for security. Thc staff who will work at thefacility must be kept informed and be invited to visit the new facility as part of an orientationi process.

THE TASKS IMMEDIATELY AFTER TAKE-OVER

After the client has taken-over the buildings, programmiles for staff training and trial runs can be initiated.Staff must be fullv aware of how the new buildings work and how thev should bc used; the client must be verysympathetic to comments made by the staff. At the same time the public must be kept fullv informed of thetaking-over activities and the date of the opening the t'acility. Arrangements for the opening ceremonv should bvthis stage be well advanced and invitationis should have been sent out.

IMPLICATIONS OF THE DEFECTS LIABILITY PERIOD

Alter handing-over the complcted projcct, the conltractor is usually held responsible for an agreed period forall defects wlhich may be found in the buildings and installations. Staff must be encouraged to report anv defectswhichi they observe. At an agreed timc after handing-ovcr, a formal meeting is held at the new facility: this isusually attended by the contractor, architectural and engincering consultants and the client. At this meeting, anvdefects are poilted out to the contractor and agreements are made regarding their rectification. Once all defectshave been corrected, a final inspectioni is made and the last pavment (wlhich has been rctaincd bv the client), ishanded-over to the contractor. In every stage of this process it is most important that the clicnt is activelyinvolved and competently represented.

INTRODUCING THE NEW SERVICES: IMPLEMENTATION OF OPERATIONAL SYSTEMS

In the first months of operating the new facilities a number ot small (mid sometimes not so small) problems xxillappear.

Items of equipment mav not have beeni delivered and commissioned on time; consumables which arcrequired may not be available; mains services ma' be erratic, floors may be slippery if not treated wvith thecorrect cleaning material, and so on.

Such problems, if not attended to promptly and competently, can disrupt the services being provided. Forthis reason it is important that the members of the commissioIning team at both central and local level areavailable and read) to assist wvith helping to solve the problems.

It is often difficult to open all newv wards and departments at once: some phasinig may be required. Hereagain it is important for the commissioning teams to wvork closely *vith local staff to make sure that services CDprovided arc fully operationial, even though some activities are not in place. This is particularlh importanit inphased schemes Nxvhere selected dcpartments are completed earl)' so that cxistinig buildings and departments can °be renovated or demolished.

The process and result of commissioning activities will have long-lasting finanicial consequenlces for the Uinstitution,- in staff time, increased requiremenit for consumables and increased use of energy and services. It isessential that these requirements are planned for and that the finance is in place when required.

OPENING CEREMONIES -CD

This most important activity should be planned w'ell in advance. Presidents, ambassadors and pop stars are not =usually xx-illing to appear at opening ceremoniies at a moment's notice, but xwithout these personages in place, it willbe difficult to give the Govxernment, the donors and the local community the ftull public recognition thev dcserxe.

The commissioning team, in collaborationi with donors, consultanlts, contractors and local officials, shouldplan the opening ceremonies fron in ea rly stage.

REVIEW OF THE WORK OF THE COMMISSIONING TEAM

The main aim of a civil works project is usually to have a newv or refurbished building completed on time andwvithin costs limits and for this building to be fully and satisfactorily operational. This alwvays requires thesucccssful collaboration of a large number of individuals and organisationis.

The memlbers of the commissioning team are usually staff working for the Ministry of Health at local orcentral level: in most instances they have not been trained for this xvork. Outside their knowledge of the healthsector, the personalities wvorking wvithin it and the activities which take place there, they are often poorlyequipped to negotiate xvith technical consultanits and contractors, or to issue reports and directives, or to visitsites. Important members of the commissioniing team may havc other demanding responsibilities to discharge.

In every instance, it is vitally importanit thiat the cliCent give the commn1issioning team the tools, the time andthe recognition needed to perform optimally

After completion of the commissioniing process, the cxperienaces gained should be reviewved. Many membersof the commissioning team, particularly' at local level may do this only once in their careers and they should beencouraged to pass on to others wvorking in the Ministry of Health, the importanit insights which they havedeveloped.

10. PROJECT EVALUATION -.

THE NEED FOR FEEDBACK3

Eaclh project has a cycle: once the building has becomle a fuLnctioniing health facilitv, the process starts allover again witlh a new planning cycle. At thc start of each project it is importanit to take account of lessonslearncd from previous projects. WXhat worked well? What wenit wronig? How can improvements be made in theproject initiation, organisation, design, commissioning? Were the results intended really achieved? Did thestaffing of the new facilities go according to plan? Are the users satisfied with the facilitv? Does the facilityrespond to the cxpresscd needs of.thc COmLunitv? Each aspect has to be reviewed during the evaluation.

a Receivinlg SUChI feedback can also be importanit wheln making the nccessary adjustments in the present facility.Without this feedback, planner-s and architects will make the same mistakes over and over again.

HNOW TO ORGANISE AN EVALUATION

Here we give an outlille for the evaluationi of the building comiipoincent of a health- programme. Please notea6 that this is not the ovcrall evaluation of the programme, which has to look at all inputs, outputs and outcomes

in the sector. Evaluation of the building componienit can be part of such an overall evaluation.

Evaluation of the building component can bc organised according to two metlhods, which complement eachother. The first is the evaltIationi done durinlg rcgular supervisioni visits to the facility; the second is a more-cxtcnsivc study. In rcgular visits to the stacilit, a SLpervisor/planniier necds, among many othcr thinlgs, to receivefecdback from the health wor-kers about the conditions in which they work, including the condition of theactual facility. Two aspects of the facility deserve particular- attentioni: its conditioni and its suitability. Leakage,breakdowns of equipmenit, poor ventilation, and broken winidows all need to be reported to the appropriatelevel; the supervisor needs to note where the btildinig as a whole or certain parts of it do not well sLtit theirfuntctioni. Working spaces mav be too small, too dark, poorly located in the facility, and so on. Only wlhell suchissues are systematically registered, can thesc bc taken into account in the next planning cycle for civil works.

Before embarking on large constrUction and rehabilitationi projects, a more thorouglh evaluation of previousexperiences is needed. This wvill oftCI require more time thani regular staff has available. Because of this thesector tends to resort to consultanits. It is importanit that the evaluators (consultanits or others) are indepenident,to prevent biased results, antd that they are well skilled in their task, to give their conclusions andrecommendations the necessary wveight in discussions witlh officials of the Ministries. The investigative part ofstich an evaluationi may well have two components: analysis of the data with regard to the facilities, and site visitsin which interviews with those imimediately involved are ilcluded.

This analvsis of the data includes a review of the supervisor's rcports, a review of evaluation reports of otherprograms of the health sector in which the facilitv is cnrollcd, and a calculationi of the recurrcnt costs of thefacilities. It further includes an analysis of the documnents which registered the wvhole process of theconstructioni/rehabilitation and a comparisoni of the original plans wvith thcir actual implcnieiitation. Threeaspects deserve particular attention during such a analvsis: time, costs, and the role of each partner. Were theredelays? kVcre some steps unexpectedlv rapidly implemented? WVere therc cost overruns? W7\erc somc stcps chcaperthan expected? Did each partner fulfil his obligations? Wiere there coniflicts during the building process? Adescription of the causes of anv discrepancies betwNcen the plan and the actual implemcntation xvill thcn lead torecommendations for improvements in the next projcct cvcle.

An evaluation is incomplcte xvithout a survey of the people who use the facilities. The main uscrs are thehcalth workers and the patients/clients. Such a survc is of special intcrest because of gcnder issues. While the _

,world of constructors, architccts is still very much a man's world, most uscrs of health facilitics are female nurses,and women and children. It would bc appropriate to look at the working conditions for staff, and at the °improvements in comfort which the new tfacility means to them and to the paticents. One wxould look forimproved efficiency in the dcliverv of services and for genCeral uscr satisfaction wvith the new tacility. The data canbe gathered from interviews and should be complcmentcd by actual statistics. To ccolnomise, the data could bcgathered as part of a more gencral survey whlaich studies the quality of carc. Suclh an approach puts the dataabout the building in the contcxt of the genieral delivery of services. These data wvill give health plannersindications of particular (felt) nccds and the interests of the workers and clients. C

Timelv disscminationi of the results of the evaluation and an open discussioni of the rccommendations of theevaluation rcport among all the pcoplc involved in the planning process for n fw facilities is extremrvely iipopotanMost mistakcs in the planninig of newv facilities arc madc because of poor com1nmuniicationi between thc partnersinvolved. Lack of co-operation betwveen the partncrs often stCe1s from limited undeistanding of all the aspectsinvolved in making a building a fuLnctioniniig health facility.

e

C

s-

p-

CD

11. EPILOGUE

MISTAKES-AND HOW TO GUARD AGAINST THEM

There is nothing exceptional about making mistakes. Most progress is made by people who risk makingmistakes. The important point is to learn from the mistakes that we and others have made. Making a firstmistake can be an expression of over-ambition, excusable perhaps through lack of experience. Making the samemistake again may demonstrate inability to learn or unwillingness to change.

This concluding chapter describes some of the mistakes we have seen during our wvork with health constructionprojects in the southern Africa region. The idea is to stimulate a discussion about how the mistakes came about,what could have been done then to avoid them, and what can be done now to avoid repeating them.

WVe have camouflaged the location and concealed the identities of those involved because we would like tokeep the discussion not on uselessly placing blame, but on the importanit issues that we can do something about.

COUNTRY A

No maintenance has been carried out on hospital air-conditioning systems for the last ten years butarchitects still design operating theatres without windows and with high tech air-conditioning filtersystems

The country has 14 hospitals. In every single operating theatrethe air-conditioning svstem was in bad repair. If the systems workcdat all it was usuallv the filters which gave the biggest problems (dirt cte cal suicide" says chief matronand fungi sometimes 1 cm deep on both sides of the umwashedfilters). In the best situation, the plant did not work at all and the We must plan for the future" sa,ys

ar . r 7n~~~~~~~~~~~~~~~~~inister' of hea-lthstaff opened the windows to reduce the temperature.

No-one was employed to maintain the air-conditioningsystems; consequently these were becoming absolutely dangerouLs.

When a hospital was constructed in City X, the operating theatre suite design was taken straight out ofEuropean Hospital Building Notes, so providing theatres without windows and with very advanced airconditioning plants with expensive non-washable filters (ncot with split-units as in other hospitals in the country).

Within a year, these filters wvere destroyed and hanginig in the air-boxes. At about the same time, the plant wvasturned off because of a lack of spare parts.

The hospital is situated in a very hot area on the edge of the desert. With no air-conditioning or ventilationplant working, and no wvindowvs, conditions in the theatre, onlv one year aftercommissioning, can be imagined.

COUNTRY B "That liquiz;dfall1ing On y1our

A 600-bed hospital requires refurbishment for USD 8.5 millions only 10 head is urinle"years after official opening says hiead of

operatingq theatre

* This high-prestige project obviously suffered during its development from a depart7ient

serious round of cost-cutting. That is a charitable explanation.

* Ten yvears after completion, the building is in a very bad state of repair.

* Flats roofis of building paper are leaking very badly, and much equipment in the floors belowv has been ldestroyed. _

* Thermoplastic floor tiles, expanded polystyrene ceiling tiles, softwvood doors and wvindoxvs (completelyinappropriate when installed) nowx require 90% replacement. o

* Seventy percent of all sanitary fittings are damaged and useless.

* Waste pipes are in PVC and leak badly, allowving urine to fall through the ceiling to the clean corridor tothe Operating Theatre Department (and to nearlv evernvhere else).

* The steam reticulation leaks badly. Is a central steam plant really required in African hospitals?

* The medical gas reticulation leaks. The hospital uses 296,000 cubic metres of ox! gen in a year, althoughthe British standard for a hospital of the same size xvould be about 42,000 cubic metres. It is unlikelvthat Britons require less oxygen.

COUNTRIES C and H

Donor-funded psychiatric hospitals are completed but there are no patients "Wc habve a

differe,nt socialA consultant sent out by WHO to southern African countries to advise on structure to

psychiatric health services quickly established that in Countries C and D an increased Easter;znumber oflin-patient beds was required. This finding did not take into account Europemodern methods of psychiatry or the fact that social and familv structures in Africadiffer significantly from those in his ovn country. S 1 i"'

As a consequenec of his recommendation, in both countries significantinvestments wvere made by donors in building psychiatric hospitals and setting-up psvchiatric departments inexisting hospitals. These are today appropriately staffed but very much under-utilised.

In the next country he visited, the same consultant established a need for over 350 acute psychiatric beds atcentral level, plus several smaller psychiatric departments at district level. There svas to be a total of over 600 nexv beds.

'Then luckily' (said an official) 'the man died'. He wvas replaced by a younger consultant, who helped toestablish an efficient district psychiatry care service in the country by mobilising the village health workers, andrestricting the need for newv beds at central level for dangerous and chronic patients to a total of 80, theappropriate provision.

COUNTRY E

Impossible to achieve correct hygienic conditions in new maternity hospital

* The hospital staff complain that very little attempt was made by thecdesigners to find out about the procedures usCd in the country.They say that important activities, particularly around the sterilising "The donor never askedprocess, can in no way fuLnctioni satisfactorily. about our ivork

procedures" sanys 7nenihber of

* This indicates problems of commiunicationl with local users at two stafnjdifferent points of time:

LU - During formulationi of the Brief, too little attempt was made totunderstanid local practices.

- During handing-over and commissioning, too little was done to explain to the users the ideas onWvhich the project was based.

co

* It seems that no-olne really bothcred to relate the project to the traditions and practices of country inwhich the project was situated.

COUNTRY F

The 300-bed high-tech orthopaedics tower block in a 2,500-bed "We thought that if wvelow-tech single-storey hospital is not sustainable says government showed how things are

done in Europe, people

* The central hospital is made tIp of 60 bed wards. The sides of the rooms would wvant to follow suit"are open above cill level. Thle environmiient is pleasant and cool, and certainly sains donorvery easy for the nurses to supervise. This is very differenit to the experienceof Northern Europc.

The miulti-storcv orthopaedics surgery block built by the donor agency had maximum 6 beds to a ward, andconsequenitly required a 4 times higher ratio of staff to patients.

T his new block used a lot of imported high technology. Even the lamp sockets came from Europe and were notcompatible with those locally made. CoonsequLenltly a separate technical service department writh its ow n workshopshad to be established for the new block. ( It now had a larger technical staff than the rest of the entire hospital).

After the donors withdraw from the project there is no chance that these higher levels of provision can be sustained.

COUNTRY G

All x-ray machines were useless within two years of delivery due tolack of spare parts "Even the installation

instructions and parts listsThis is self-explaniatory. The counltry, had for many yvears satisfactorily are untranslatable" says chief

used well known brands of X-rav equipment. Service and spare parts wcre eqincer

readily available and local technicians could easily keep the machines inoperation. It woould have been reasonable to continue with the same policy.Doonors thought otherwise.

COUNTRIES G, H, I, K AND I

Mains water clogs up hi-tech autoclaves so that within 6 months AInrica shl70v.ud bcmost are destroyed and useless d a

7Tchnicai Adiriscr

Generally the w ater supply in most African countries is hard -and muddyand quickly clogs the niarrowv eoppcr pipes used in the stcam-geleratiollsection of moder autoclaves. These expensiive machines then become disposable itcms.

Simpler units do not haxe this problem. How%ever, it is very difficult to get donors to supplx these. Donors,like politicians anid senior doctors, believe that the degree of sterilisationi is higher in the expensivze macllines. Inreality these v-ery soon make sterilisation imppossible.

COUNTRY M

Pharmaceutical stores and production units designed for a staffcomplement of 35 even though the national norm is only 4 workers "ll have a lot of

utn emplo.yed pharlacistsThis was a huge departmiienit Nwith v ery special facilities (sterile in Europc" sis donor_

production room Nwith laminar flowv air-conditioning, staff room and ^reprLsc1ta tirj _change rooms for 35 people). The Governmcrenit is noNw trying to conv,ertthese buildings into other lhospital departmiients such as OPD andPhysiotherapy.

COUNTRY N

Newly-completed 350-bed hospital must have 25technical service staff or correct conditions will not be

'147 .have also a lot of unemploved sustained, claims donor"tehlcl' aves Isoalot dof in-czzIvsteehuicianls" sagsW donor7 Since this hospital wvas built by a donor, ev\erything wvas

"Thatfigutre is morc than thc total imported from Europe, even the thermiioplastic floor tiles

nuiliber of technzicianis emploYed inI (differenlt dimensiofls from i locally-produced tiles). All spare parts

thte whole of the countryvs heaIth and scrv7ice blad to come from nEur)opc.ser lices 'sa,vs,4 q1'crnllt nt officiayl

Twco specially-trained techlniicianis werc looking after theautoclav'es. Eveln after the provision of watcr softencrs, theautoclaves still broke doxvwn regularlv.

CAUSES OF MISTAKES

These mistakes -and others like them- can be collected in three different groups:

1 Inappropriate matcrials and techniologies hav7e becn used

2 Interv'entions do not relate to local traditionis and customs

3 Lack of professiolnalism in project design and implementation

From this we may deduce that:

* The designers did not bother to find out which materials and technologies were appropriate

• Dialogue with the users has not been adequate- lack of time- language problems- no respect for local expertise

* Local politicians and chief doctors wanit the technology, appropriate or not- high level of political ambition

__ - cannot accept "secondi-best"- prefer technical to human solutions

* Donors often have their own agenda such as to export their own technology (usually high-tech)

C Donors don't always spend enough time thinlking about local traditions and customs

* Governments are not always able to influence donors

e Donor government aid officials prefer not to work with professionals because they are difficult to supervise

• Aid activities are a competitive business for specialist aid contractor organisations and professionals aretoo costly

• Recipient governments are weak in demanding proper standards, and in carrying-out supervision

* Professionals are not always interested in working in or dealing with difficult conditions

Thcsc lists are a good start. What about the possiblc conseq eClces of these mistakes' These are again wvide-ranging.

CONSEQUENCES OF THE MISTAKES

e The desired results arc not obtaincdThe project does not answer acknowledged needsPopulation does not utilize the facilityThe users do ncot understand how to utilise the project resultsThe tisers do not understand the technology incILided in the projectThe project is not completed because of costs overruns

• TIhe results are obtained but are not sustained

Breakdowns caused byProblems in maintenanceAbsence of spare partsIrregular water and electricity suppliesUsers not trained to use

Sustainiing the results require resources which are not availableManpowcrFinance

Other conditions for sustaining results are not available:No functioning referral systemNo political interest in using the results

* The results are sustaincd but require too many recurrenit costsNumber of staff requiredNeed for raw materialsNeed for fuelIncreased utilisation bv populationIncreased needs

For now, the most important issue is to discuss how to avoid these mistakes in future.

RECOMMENDATIONS FOR AVOIDING MISTAKES

* Involve the users at all levels in project design

* Be awvare of the implications of Lisinig inappropriate technologv

• Make detailed feasibilitv evaluations and investigate the recurr-ent costs implications of the projcct proposals

* Reasonable sustainability of the project results should be a prerequisite for project consideration

* Insist on total professionalism from everyone at all times.

=n

APPENDICESA List of Participants at the Harare Workshop 90

B Example of a Standard Building Specification 95

C Key Activities to be Undertaken bv Health and Constructioln Ministries 106

D A Preliminary Brief Prepared bv a Miniistrx of Health 107

E Use of Non-techniical Solutions 127

F Calculating the Need for In-patient Beds 128

G Example of Facility Use and Capacity Figures 130

H Setting Priorities 136

J The Re-use of Existing Buildings 138

K Checklist for Approving Design Proposals for Hospital Projects 140

L A Practical Masterplan 142

M Other Sources of Informationi 143

Appendix A.List of Participants at the Harare Workshop

An interesting surprise at the Harare Workshop was discovering that most of thedelegates, although all wvorking in the same region, were meeting for the first time. Allagreed that they and future delegates to similar workshops should be able to contact andsupport each other. This is in itself a good reason for publishing this list.

md ANGOLA Mr. Tidimogo GAAMANGWECZ Principal Biomedical Engineer,

Dr. Braz DIAS FERREIRA Ministry of HealthAdviser to the Minister, Private Bag 0038Ministry of Health GABORONEP. 0. Box 16 514 Phone: 302165/352000LUIANDA Fax: 353100

E-mail: [email protected]. MaFernanda PEREIRAArchitect, Mr. Moabi Tebogo MADISAMinistrv of Health Technical Officer,P. 0. Box 5669 Department of Architecture and BuildingLUANDA ServicesPhone: 244-2-334035 Private Bag 0025Fax: 244-2-338147 GABORONE

Phone: 351901Mr. Jose Alberto PUNA ZAU Fax: 374832Vice Minister,Ministry of Public Works and Urbanism LESOTHORua Friedrich Engels 92, 5Mutamba Mr. Moorosi E. LATELALUANDA Principal Technical Officer,Phone: 333745/334842 Ministry of HealthFax: 3332866 Ma Tsosane

P. 0. Box 7775BOTSWANA MASERU

Phone: 09266 - 325693Mr. Jode ANDERSON Fax: 09266-310375Principal Architect,Department of Architecture and Building MALAWIServicesGovernment of Botswana Mr. Davie KALOMBAKopanyo House, Nelson Mandela Drive Health Planner,Private Bag 0025 Ministry of Health and PopulationGABORONE Falls EstatePhone: (267) 351901 P. 0. Box 30377Fax: 374832

LILONGWE NAMIBIAPhone: 7830044

Mr. Kuutumbeni B. KATHINDIMr. Joe MANDA Deputy Director, Architectural ServicesController of Health Planning Services, Ministry of Works, Transport andMinistrv of Health and Populatioln CommunicationP. 0. Box 30377 Private Bag 1334LILONGWE WINDHOEKPlhone: 783775/783044 Phonie: 264-61-208431

Fax: 264-61-226737Mr. Sam NGOMASenior Architect, Ms. Kautoo MUTIRUAMinistry of Works and Supplies Director of Health Planning,Flat No. 10/10, Area 11 Ministr of Health and Social Services rnPrivate Bag 316 Private Bag 13198 =LILONGWE WINDHOEKPhone: 784200 Phlone: 2032817

Fax: 227607MOZAMBIQUE

Mrs. Miriam VAN ZYL Mr. Mario ALMEIDA Health Program Administrator, CCo-ordinator GACOPI, Ministrv of Health and Social ServicesMinistry of Health Private Bag 13198Av. Eduardo Mondlane WINDHOEKP. 0. Box 264 Phone: 061-2032869MAPUTO Fax: 227607Phone: (258-1) 427056Fax: (258-1) 32103 SOUTH AFRICA (RSA)Email: almeida @malmeida.uem.mz

Mrs. Annelene BESTERMr. Dino Albino COUTINHO Deputy Director, Health Facilities Plaining,Technical Engineer, Department of National HealthMinistrv of Public Works and Housing Room 2422 Civitas Building,Av. Karl Marx 606 Struben (corner of Andries Street)MAPUTO Private Bag X828Phone: 426081/3 PRETORIA 0001Fax: 421368 Phone: 27-12-312 0678/0683

Fax: 27-12-328 6117Mr. Dionisio ZAQUEUArchitect in GACOPI, Mr. Johan BLAAUWMinistry of Health Director, Kwazulu Natal WorksAv. Eduardo Mondlane 191 Prince Alfred StreetP. 0. Box 264 Private Bag 9041MAPUTO PIETERMARITZBURG, 3200Phone: 258-1-32083/33593 Phone: 27-331-947828Fax: 258-1-32103 Fax: 27-331-425063

Mr. Malcolm JONES P. 0. Box 5Director, Health Facilities Planning, MBABANEDepartment of Health Phone: 268-42431Room 2428, Civitas Building, Fax: 269-44296Struben (corner of Andries Street)Private Bag X828 Mr. Paul D. NKAMBULEPRETORIA 0001 Chief Building Engineer,Phone: 27-12-312 0682 Ministry of Works and Construction,Fax: 27-12-328 6117 Government of Swaziland

P.O. Box 58Mr. Patrick MASOBE MBABANEConsultant, Planning & Financing, Phone: 268-41936/42321

Ca Department of Health- Room 2417, Civitas Building, Mr. Bhekie NTSHANGASE= Struben (corner of Andries Street) Bio-Medical Engineer, Ministry of Health= Private Bag X828 Mbabane Hospital

PRETORIA 0001 P.O. Box 8Phone: 27-12-312-0958 MBABANE

a. Fax: 27-12-328-6102 Phone: 268-44045IL. Fax: 268-42829

Mrs. Carolina A.G. STEYNDirector Raubenheimer and Partners Inc, ZAMBIAConsultant to Department of Health1261 Burnett Street, Ms. Mulela AMATENDEHatfield, Senior Architect, HealthPretoria Buildings DepartmenitP. O. Box 11440 P. O. Box 50800Brooklyn LUSAKAPRETORIA 0011 Phone: 260-1-251323Phone: 27-12-436773/4Fax: 27-12 3422479 Mr. Felix CHINDELE

Health Planner,Mr. George B. ZONDAGH Ministry of HealthArchitect, P.O. Box 30205Department of Public Works LUSAIKARoom 702B Phone: 260-1-228385/225785Central Government Building Fax: 260-1-225785Corner of Bosman/Vermeulen StreetsP. 0. Box 842 Mrs. Bwalya MUMBAPRETORIA 0001 Physical Plannler,Phonie: 27-12-205 2338 Ministry of HealthFax 27-12-325 8095 Ndeke House,

Haile Selassie RoadSWAZILAND P.O. Box 30205

LUSAKAMr. Thulani MATSEBULA Phone: 260-1-253180/2Health Planner, Ministry of Health Fax: 260-1-253173

ZIMBABWE Mr. Osten RUTSATEDeputv Director Family Health Project,

Dr. Joana BARROS Ministrv of Health and Child WelfareAngolan Embassy P.O. Box CY 1122Doncaster House, CAUSEWAY26 Speke Avenue PHONE: 263-4-730011HARARE Fax: 263-4-729154Phone: 263-4-790070/790675Fax: 263-4-790077 Mr. Jackson TAIVAVASHE

Seniior Mechanical Engineer sMs. Najwa GADAH ELDAM Ministrv of Public Construction & NationalResearcher, Housing lMinistry of Public Construction & National Newv Makombe Complex,Housing Leopold Takawvvira Street4 Hurlington Close, Mount Pleasant P.O. Box CY 441HARARE CAUSEWAYPhone: 263-4-744387 Phone: 263-4-704561

Mr. John T.T. MANYANGA Mr. Gibson TINARWOPrincipal Civil Engineer, Architect,Ministry of Public Construction & National Ministry of Public Construction & NationalHousing HousingN7ewv Makombe Complex, Newv Makombc Complex,Leopold TakaNvira Street Leopold Taka-wira StreetP.O. Box CY 441 P.O. Box CY 441CAUSEWAY CAUSEWAYPh1one: 263-4-704561/ 700811 Phonie: 263-4-704561

Mr. Ronald MUGANDIWA Ms. Eppie USHEWOKUNZEArchitect, Planning Officer,Ministry of Public Construction l National Ministrv of Health and Child WelfareHousing P.O. Box CY 1122New Makombe Complex, CAUSENVAYLeopold Takawvira Street Phone: 263-4-730011P.O. Box CY 441 Fax: 263-4-729154CAUSEWAYPhone: 263-4-704561 Mr. Moses Addison S. UTA

Quantity SurveyTor,Mr. Willie J.W. PFUNYE Ministry of Public Construction & NationalAssistant Secretary, HousingMinistrv of Health and Child Welfare Newv Makombe Complex,Fourth Street/Central Avenue Leopold Takawvira StreetP.O. Box CY 1122 P.O. Box CY 441CAUSEWAY CAUSEWAYPhone: 263-4-730011 Phone: 263-4-704561/9Fax: 263-4-729154

Resource Persons Mr. Thierry RIVOLArchitect GACOPI,

Mr. Michael HOPIINSON Ministry of HealthArchitect, Initiatives Rua E. Noronha 1Winster, Derbyshire MAPUTOUNITED ICNGDOM MozambiquePhone: 44-0-1629-650 621 Phone: 258-1-32 083Fax: 44-0-1629-650 621 Fax: 258-1-32103e-mail: 106166. 727@compuserve .com

Ms. Evelvn SERIMADr. Kees KOSTERMANS Director-Family Health Project,Public Health Specialist, Ministry of Health and Child Welfare

ea World Bank Kaguvi Building,1818 H Street N.W. Fourth Street/Central Avenue

X Washington DC 20433 P.O. Box CY 1122USA CAUSEWAYPhone: 1-202-473 4058 Harare,Fax: 1-202-473-8239 Zimbabwee-mail: [email protected]@internet Phone: 263-4-727951

Fax: 263-4-729154as Mr. Basilio Alfredo MANDLHATE

Architect,Ministry of HealthNo 797, Avenue Eduardo MondlaneP.O. Box 264NMAPUTOMozambiquePhone: 258-1-427056Fax: 258-1-32103E-mail: [email protected]

Appendix B.Example of a StandardBuilding Specification

A standard building specification is the client's means of expressing his wishesregarding the types of construction and materials to be used. The specificationrepresents his decisions regarding what is an appropriate facility for the activities heintends to carry out at a specific location. It further conveys the client's attitude toissues regarding quality and economy.I

The specification will be the result of years of experience and will continually be revisedand extended. The following specification, developed for projects in Mozambique, zcontains details wvhich are special to the Mozambican situation (the use of locallyfabricated pre-stressed concrete beams for the ceilings, for example). These standard _specifications have been drawn up in collaboration with KIen Lever of Architects Design cmGroup, Harare, Zimbabwe. Both the form and content showvn here should help otherclients to develop their own precisely appropriate standard specifications.

Typical cross-section

EL I

________ ~~IIzE

.... .. C , e ... W n1. pe~~~~~~~~~~~~~~~'I_T -

Specifications of Building Materials and Labour

SUB-STRUCTURE

SITE Mark out positions of all buildings and clear top soil to a depth of 150 mm for aCLEARANCE distance of 1500 mm beyond wvall lines in all directions. All vegetation matter,

roots, trees, boulders, termite and ant nests to be removed, before placingcleared top soil in piles away from building works and material storage in

v2 ,heaps n1o higher than 1000 mm high.

EXCAVATIONS All foundation trenches to be properly marked out using square and stableprofiles and approved by Architect or Engineer or both before beginning

- excavation. All foundation trenches to be excavated in accordance withX foundation layout drawings.

Depth of trenches to be ascertained on-site and approved by Engineer orArchitect or both. Bottoms of all trenches to be cleared of boulders,roots, termite and ant nests and any other foreign material, and wellrairammed to accept foundation concrete.

FOUNDATIONSOption 1Ground Beams 350 mm wide x 1000 mnm deep (av.) trenches to take 350 mm wide x 500 mm

reinforced concrete beams. All beams to contain triangular profile reinforcingcage set 50 mm above trench base. Reinforcing cage to consist of 3 No x 12 mmdiameter reinforcing bars 250 mm apart in triangular profile with 8 mmdiameter ms stirrups at 300 mm centres.

No ground beams will be required under internal partition walls -floor slab tobe thickened accordingly to 400 mm wide x 200 mm deep strip belowpartition walls.

Option 2Strip Footings 700 wide x 900 deep (av) trench, with all foreign matter (as above)

cleared and trench base rammed to take concrete. 700 wide x 250 deepconcrete strip footings to include flat profile reinforcing mat consisting of3 No. x 12 mm diameter ms bars set 300 mm apart and linked with 8 mmdiameter ms strips at 300 mm centres.NB. Stub column option -where concrete columns are used to supportroofs and ring beams 4 No. x 450 mm long x 12 mm diameter ms starterbars are to be set into either ground beam or strip footing at all columncentres, all to be in accordance with foundation and layout drawinigs.Concrete grade -all foundation concrete to be 20 MPa strength with1:3:6 mix using only approved aggregates. River sand to be washed andcleaned of all soil and vegetation matter to Architect's approval.Stone aggregate to be 15 mm diameter to 25 mm diameter granite, schist orother hard igneous-type rock -no soft, friable or particle-type rockaggregate to be uised.

FOUNDATION WALLS

Option 1 11 5 mm wvide x 75 mm thick ( minimum) burnt clav brick or block ratedat 15 MPa crushing strength set in 2 1: 8 (cement: lime: clean pitsand) mortar mix.Pit sand to be clean and free of all vegetationi matter. Stones must beobtained from source subject to Architect's approval.

Option 2 230 mm or 115 mm wvide x 150 mm thick cellular pre-cast concreteblock rated at 15 MPa crushing strength. mAll bricks and/or blocks to have a water absorption rate of 15% maximumby w,veight.

FLOOR SLABSOption 1Surface Beds After all top soil, vegetation matter, boulders, termite nests, and otherl

detritus have been cleared from below floor areas, the entire area betwveenfoundation w alls, including all foundation trenches is to be treated withapproved ant- proofing chemicals to comply wvith WVHO and Governmenrt o

of Mozambique standards. A twenty-year written guarantee wvill be m

required from the Main Contractor. Under-floor fill is to consist of inert, eagranular, clay-free fill laid and rammed in 1 50 mm thick layers tounderside of slab level.Damp-proof membrane is to consist of 2 layers x 250 microni black PVC wvith300 mm long double-velted junction seams. DPM to be turned up 250 mmat all wall faces to allowv structural separation of floor slabs from wall faces.Floor slabs to be 100 mm thick x 25 MPa-grade concrete. (1:2:4 mix toEngineer's approval) wvith light-weight 2.45 kg per m2 weldedreinforcing mesh mat laid ovTer entire floor slab area and fixed 25 mmabove slab bottom.

Option 2Suspended Slab 175 mm x 125 mm pre-cast, pre-stressed concrete T-beams laid at 400 mm

centres betweeni ground beams, with either well-burnt hollow cellularclay filler blocks, approximately 400 x 400 x 150 mm thick, or pre-castconcrete hollow filler blocks approximately 400 x 400 x 150 mm thickmanufactured to Engineer's approval.75 mm x 25 MPa grade concrete topping including 2.45 kg per m2 weldmesh reinforcement set 25 mm above filler blocks.NB. Pre-cast T planks and concrete slab topping to be cast integral xvith top250 mm of ground beams. Floor slabs generally to be set 300 mm abovefinished ground level.

SUPERSTRUCTURE

DAMP-PROOF COURSEOption 1 3-ply reinforced bitumen asphalt strip supplied bv approved manufacturer,

300 mm laps to ends and sides as required.

Option 2 Two layers of 250 micron PVC sheet strip cut to wall thickness. End lapsto be 300 mm double-welted.

EXTERNAL WALLSOption 1 230 mm thick fair-faced external quality well - burnt clay brick (230 x 115 x

75 mm) or cellular clay block (300 x 200 x 150 mm) laid in 2:1:8 cementlime sand mortar (clean pit sand as above) wvith minimum crushingstrength of 7 MPa and maximum absorption rate of 15% by weight.

Option 2 Pre-cast, well-cured cellular cement blocks (300 x 230 x 170 to Engineer'sapproval, or by approved manufacturer, with minimum absorption rate of

LU 15% by weight.ea All clay brick or block walls to have vertical movement joints at 12 m

maximum centres, and all cellular cement blocks to have vertical= movement joints at 6m maximuLm centres.

Option 3 230 x 230 mm reinforced concrete columns of grade 25 MPa concrete atapproximately 6m centres (as indicated on layout drawings) withreinforcement cage of 4 No. x 12 mm centres in both directions. 8 mmdiameter ms rod stirrups wired to vertical reinforcing rods at 300 mm centres.Clay brick or block, (or cellular cement block) infill panels between columns.

AIR BRICKS 300 x 150 mm pre-cast cement air bricks with aluminium gauze vermin-proofing fixed to internal face, will be required at high level in allhabitable rooms and store rooms at the rate of 1 no per Sm2 of floor space.Any louvered openings through walls are to be mosquito and vermin-proofed.

LINTOLSOption 1 350 x 230 mm reinforced concrete eaves ring beams.

Option 2 170 deep x 11 5 pre-cast concrete lintols for openings up to 2500 mmwide, built into briclkcork or blockwork. All pre-cast concrete lintols toinclude 3 No. x 12 mm diameter ms rods.

Option 3 5 No. coLtrses of approved brick force reinforcing strip manufactured of18 gge galvanised wire wN ith welded cross stirrups at 300 mm centres maximum,and to Architect's an-d Engineer's approval -for openings up to 1500 mm nvide.

WINDOW CILLSOption 1 230 wide x 150 mm pre-cast concrete with splayed cill to Architect's

requirement in 1200 mm lengths. All of 1:2:4 grade 25 concrete.

Option 2 20 mm wide float-finished plaster over brick on edge cills laid at 30degrees minimum with approved DPC beneath.

Option 3 Approved 150 x 150 x 25 mm well-burnt clay qt at minimum 30 degreesfall laid in 50 mm minimutm mortar bed over approved DPC.

DOOR FRAMESOption 1 1.2 mm pressed galvanised steel, factory-made, door frames (kit form for

assembly on site or pre-welded at factory). Approved epoxy paint finish afterconstruction.

Option 2 Ex 175 x 50 mm selected knot-free chamftita or approved cqualhardwood frames wvith all joints tenoned, doweled and glued (or dove-tailedand glued) -sizes as in Door Schedules.

WINDOW FRAMESOption I Factory-xvelded galvanised rolled steel frames (as in WindowZ Schedules).

1 No. coat epoxy paint all round before fixing and twvo coats approved lepoxy paint finish after completion of all wet trades. l

Option 2 Ex 175 x 50 mm selected knot-free chamfuta (or approved equal) -hardwood frames (as per Window Schedules).All external doors and opening window sections xvill be fitted Nvith hingedor sliding aluminium mesh mosquito/flv screens - frames. All door and -

wiindoNw f-ames to bc fitted wNTith galvanised fixings lugs, minimum 100 mmlong at maximum Im centres for building into brick or blockwvork.

CYCLONE SCREENSAll external glazing (xvindows and doors) are to be fitted wvith framedand braced hardwood cvclone screens supported on external galvallisedsteel brackets or channels or both. Cyclone screens to be removable forstorage when not in use.SpecifiT storage positions for each building.

ROOFSOption 1 0.8 mm galvanised IBR profile long-span roof sheeting over 75 x 50 mm

knot-free selected pine or hardwood purlins at 1200 mm maximumcentres, over 150 x 50 mm selectcd knot-free pine rafters and verticalbraces at 1200 centres. 18 gge galvanised strap fixings over 75 x 50 mmsoftwood or hardwood wvall plates bolt-fixed over structural wvalls and atcentre span of ceiling slab.All roofing timber to be insect and termite-treated to Architect's approvalbefore roof fabrication. All cut ends to be treated on conmpletion of roof timbers.All roofs wvill project 1 m minimum beyond wall faces at both eaves andgable ends. No metal gutters to be used and only pre-formed concretegutters wvvhere detailed.

Option 2 Approved textured latex-based roof paint over wvood float finish 75 mmconcrete topping to include 2.45 kg per m2 weld mesh reinforcing (set25 mm above clay or cement spacer blocks laid between 175 x 125 mmpre-cast pre-stressed concrete T-planks at 400 centres formed over timbercentring profiles to be used at approximatelv 3000 mm centres duringconstruction to form vaulted concrete slab construction, all betweenreinforced concrete ring beams and concrete gutters.

All habitable rooms and high-security store rooms to have flat or vaultedconcrete slab ceilings. Elsewhere, 9 mm wvood particle board (Bison Board orequal) sheeting with 30 mm 12 mm treated softwood cover strips to be used asceilings, on 50 x 38 treated sw brandering at 400 crs, skew-nailed to u/s ofrafters witlh 50 x 38 x 150 long treated sw droppers at every third rafter.

FINISHES

FLOORSOption 1 25 mm thick x 1 : I 4 (cement: granolithic : white sand) tinted

granolithic cement screeding laid parallel to floor slab joints atapproximately 3000 mm maximum centres. Clean off all constructionmarkings and rub down as necessary before applying 3 coats of clear bestwax floor polish.

= Option 2 35 mm thick x 1 1: 4 (cement: granolithic: white sand) tintedLu granolithic cement screed laid between bands of 150 x 150 x 25 mm9L well-burnt quarry tiles to form borders and cross bands at approximately

1 500 crs. See Architectural Layout Drawing for floor patterns. Clean offand finish wvith wax polish as in Option 1.

Option 3 20 mm sand: cement screed (1: 4 mix) bedding for 200 x 200 x 10 mm-thickglazed ceramic/encaustic floor tiles by specialist manufacturer. Clean offand finish with wax polish as described.

Option 4 10 mm-thick self-levelling approved epoxy floor coating laid on site tomanufacturers' recommendations over 20 mm-thick 1: 4 cement: screedall e dges to be coved and tLrned up at side walls, projecting nibs andcolumns to form skirting integral with floor finish.

Option 5 300 x 300 x 30 mm-thick pre-cast tinted concrete floor tiles on 15 mmlevelling and bedding screed; all 1: 4 cement: sand mix.

SKIRTINGSOption 1 100 mm-high coved tinted granolithic cement skirting (1:1:4 mix) to match

g-ranolithic floor finish. Form joints to meet floor screeding joints.

Option 2 100 mm-high quarry tile skirting formed of 150 x 150 x 25 mm well-burntquarry tiles, cement mortar bedded to structural wall face wNith wallplaster dressed into top edge of skirting.

Option 3 100 mm x 19 mm selected, knot-free approved hardwood (chamfuta,meranti or equal) standard timber skirting. Steel nailed fixed to wall faceat approximately 500 mm centres. (No quadrant required).

WALLS (INTERNAL)Option 1 12 mm thick x 2 : 1 : 8 (cement : lime : white sand) mix woodfloat finish

plaster (internal plastering only) for painting.

Option 2 12 mm thick x 2 1: 8 (cement: lime: wvhite sand) steel trowelled finishplastering (to general quality wet areas onlv, for silicon sealer or paintingas directed by Architect.

Option 3 12 mm wood-float plaster as above, finished wvith 3 coats best qualityweatherproof and washable acrylic PVA-based paint ("4 Waterglo" orArchitect or Engineer-approved equal).

Option 4 150 x 150 x 10 mm-thick glazed ceramic wvall tiles bonded wTith approvedquality ceramic tile adhesive to wvood float finish cement plaster base,with all vertical and horizontal joints pointed With best qualit, wvhite cement.

Option 5 10 mm-thick approved epoxv trowel applied wv-all finish over 12 mm-thick lw¢ood float cement plastcr base, all wvork to follow manufacturers'recommendations.

WALLS (EXTERNAL)Option 1 20 mm thick x 2: 1: 8 (cement: lime: white sand) mix external render.

Option 2 Flush-pointed, bag-rubbed, fair-faced brick or blockNvork to Architect'sapproval for finish wvith 3 coats cement-bascd exterior quality-approved cpaint applied followiing manufacturer's rccommenldations.

Option 3 All horizontal joints to brickwNTork or blockwork walling to be wveather-pointed during construction, wvith all vertical joints (perpends) flush-pointed. Entire face of wvall to be cleaned-off and left "as is" or to receiveexterior qualitv-approved paint (lime-based or PVA-based) as specified.

Option 4 20 mm-thick x 2 No. coats Tyrolcan finish, colour tinted at 2 1: 8(cement: lime: white sand) exterior quality rendering.

CEILINGSOption 1 2 No. x 10 mm thick coats wood-float finish cement: lime: pit sand

plaster applied to underside of in situ concrete ceiling slab.

Option 2 9 mm-thick timber particle ceiling board (Bison Board or equal) fixed to50 x 38 mm selected swv or hw brandering at 400 mm centres, skew-nailed with droppers to underside of roofing rafting members (seeOptions 1 and 2 under Roofs).

CORNICESOption 1 10 mm x 5 mm recessed groovC in plastcr at junction betwveen wvall and

concrete ceiling slab.

Option 2 Ex 50 x 32 mm selected hardwood machined writh 2 edges rebated 10 mm x 5 mm.

SANITARY WAREOption 1 Ptrpose-made factory-formed and welded sink and wvash and basin unlits (see

Architectural schedudes) made of 18.8 ss-jointed NNith equivalent ss-xvelding rods.

Option 2 Factory-moulded 10 mm-thick approved epoxv (with stain retardant)sinks and wash-hand basins by approved manufacturer.

Option 3 Wash-hand basins only glazed cast-iron standard factorv size (seeArchitectural Schedules) on mild steel tubular legs and framing.

WATER CLOSETS AND URINALSOption 1 18:8 ss, factory-formed and wvelded fittings to detail and Architect's Schedule.

Option 2 Best-quality vitreous china units by approved manufacturer.

BATHS AND SHOWER TRAYSCa Option 1 Glazed cast-iron factory-made baths and showver trays to Architect's Schedule.

= Option 2 Glazed ceramic tile-finished, cement screed-formed shower trays.= All taps, fittings and other hardware to be of robust, "limited

maintenance" varietv.*1

HOT WATER SYSTEMSElectrically-boosted solar hot water systems to be considered.Alternatively, solid fuel/waste matter water heaters to be considered.

Outline SpecificationsSUBSTRUCTURE

EXCAVATIONS- Clear all top-soil over arca of construction.- Store separate from sub-soil for later.- Re-use. Do not pile higher than 1 000 mm.

- Remove all vegetative matter, roots and burrows from trench excavations.- Ram all trench bottoms for inspection and approval.

FOUNDATIONSground beams - Excavate trench 350 mm wide by 1000 mm deep.

- Fill with 500 mm depth of reinforced concrete.- 3 No. 12 mm m.s. reinforcing bars.- 8 mm stirrups at 300 mm centres.

strip footings - Excavate trench 700 mm wide by 900 mm deep.- Fill with mass concrete strip 700 mm wide by 250 mm deep and inlay

flat, 3 No. 2 mm m.s. bars at equal ctrs 25 mm from top.

stub columns - Provide starter bars for concrete columns.- 4 No. bars.

- 8 mm stirrups at 300 mm ctrs.- CONCRETE TO BE TO 20 M.P.A. (1:3:6).- Use CLEAN approved river sand.

blockwork - To be fired clav or concrete to 15 M.P.A.- Maximum absorption by wveight not to exceed 15%.

sub-base - Sub-base shall be inert granular fill.- Compact to 95% H.C.E.- Layers not to exceed 150 mm thickness.

non-compacted - To be inert granular backfill under suspended slabs.

fill damp proof - Shall be thoroughly wvet 24 hours before pouring slab.- Shall be 2 No. black polythene sheeting to 250 microns wvith 300 mm =

dotible-welted joints.ant-proofing - Ant-proof all foundations and slabs to WHO standards.

- Provide minimum 20-year guaraintee of effectiveness. -

CONCRETE SLABS- All finish slab levels to be minimum 300 mm above natural ground level.- Concrete test cubes to be provided by the Contractor during the works as

requested by the Engineer.

aggregates - Shall be 15-25 mm clean, conforming to CAS A34.- The Contractor shall supply a 50 kg sample of each aggregate as

requested by the Engineer.

compacted bed - 100 mm mesh r.f. concrete slab.- 25 grade concrete.- 3000 x 3000 mm maximum panel size.- 10 mm kaylite sheeting betwveen slabs.

suspended slab - 175 x 125 mm precast pressed T-beam.- 400 mm centres.- To Engineer's approval.- Fired clav, p.c. concrete topping.- Welded mesh inlaxy 245 kg/m2.

damp-proofing - provide double laver bitumen asphalt strips between slab and walls.

WALLSblocks - Shall be fired buLrned clay or pressed cellular concrete block.

- Shall be at the approval of the Architect.- Shall be to a minimum conmpressive strength of 7 M.P.A.

mortars - Shall be cement/lime/sand in the ratio (1:1/2:4).- Shall use clean pit sand.

- Shall have weathered joints.

expansion joints - Shall be a maximum distance of 6000 mm apart.- Shall be of 10 mm flexcell or similar non-hardening sealant.

columns - Shall be reinforced concrete.- 4 No. 12 mm r.f. bars, 8 mm stirrups at 300 mm centres.

airbricks - Shall be 39 x 150 mm pre-cast concrete.

lintol - Shall be prc-cast concrete.- Shall bc reinforced brickwork

- cills - Shall be pre-cast concrete to detail.- Shall be 150 x 150 mm quarry tile.- Shall be plaster-formed.

ROOFtop cover - 0.8 mm I.B.R profiled steel sheeting.

06. - Profiled aluminium sheeting.- Profiled pressed cement/clay tiles.- Epoxy sealant on conicrete slab.

structure - Sawn softwood timber rafter and purlin.- Triangulated reinforcing steel trusses.- Vaulted precast concrete slab.

WINDOWS- Shall be of standard sizing.- Shall contain permanent ventilated openings.- Shall have fixed lights.- Shall have woven mesh mosquito screens over openings.- Shall have external brackets for demountable cyclone protective screens.

timber - Shall be of selected chamfuta.- Shall have frames ex 125 x 50 mm.- Joints shall be dovetailed, tenoined and glued.

rolled steel - Shall be hot-dipped galvanised.

DOORSframes - Shall be of selected chamfuta.

- Shall be of pressed metal.- Shall conform to standard sizes (2030 x 815).

leaves - Shall be of selected chamfuta.- Shall be solid core flush-panel.- Shall be semi-solid core flush-panel.

- Shall be hollow-core flush-panel.- Shall be panel doors.- Shall have externally-fitted mesh flyscreens.

FINISHES

FLOORS- Shall be 25 mm cement screed wvith granolithic additive with joints at

3000 mm centres as for slab.- Shall include a colouring agent.- Shall be granolithic with quarry tile edging.- Shall have a 100 mm coved grano skirting.- Shall have quarry tile laid on mortar bed in panels 1500 x 1500 mm.- Shall have a 2 mm self-levelling epoxy coating.- Shall be of 150 x 150 mm ceramic floor tiles.- Shall be 300 x 300 x 40 mm p.c. concrete aggregate textured tiles.

WALLSinternally - Shall be plastered wNith a 12 mm (1:1/2:4) cement lime mortar.

- Shall be woodfloat finislhed.- Shall be stecifloat finished.- Shall be painted with water w,ashable p.v.a. paint as "Waterglo".- Shall be painted with exterior qualitxT p.va.- Shall be glazed with ceramic wall tiles.- Shall be finished 12 mm plaster wvith epoxy coating.

externally - Shall be of fair-face concrete/fired clay block.- Shall be painted exterior quality p.v.a.- Shall receive a 20 mm textured plaster finish.- Shall receive a 20 mm coloured textured plaster finish.

ceilings - Shall be painted flat concrete slab.- Shall be plastered and painted vaulted concrete slab.- Shall be suspelnded 9 mm particle board with 50 x 38 mm branders at

400 mm ctrs and 25 x 10 mm hardxvood strip covers.- Cornices shall be cx 50 x 38 mm s.v.

Appendix CKey Activities to be Undertakenby Health and Construction Ministries

A central aim of this publication is to persuade Governments and clients responsiblefor health facility construction projects that it is possible to effectively perform thefunctions of a client wvithout appointing specialist consultants. The text specifies howvarious important activities should be carried out. The following list sets out these key

_ activities in their proper sequence.

1 Make a statistics-based overview of all health facilities in the countrv.

LU 2 Begin to assemble surveys of existing conditions for the involved facilities.

3 Establish a permanent 'client-core' team to work in future projects.

4 Agree relevant lists of priorities to use in future discussions.

5 Draw-up operational policies.

6 Make Masterplans of relevant facilities.

7 Draw-up schedules of accepted space norms and construction standards.

8 Develop standard specifications of materials and labour.

9 Drawv-up and agree standard layout plans for department types and building types.

10 Train staff in procurement procedures.

11 Develop agreed checklists for important functions such as:Contents of a MasterplanApproval of proposalsAttendance at site meetingsCommissioning.

12 Establish a permanent team to undertake commissioning of finished buildings.

Appendix DPreliminary Brief Preparedby a Ministry of Health

The follo ving working documents show how a Ministry of Health was able tostandardise information and give efficient instructions of its wishes to counterparts inthe Ministry of Construction. The documents exhibit some omissions, for example,electrical installations. However, these were discussed later.

-U

F"

A P P E N D I C E S

[;r-' OF (DIr-fVEMT FWCPOhDl f<U1NtAW_-tIPl\ rf r r-Cy 11A-IF V2MLG r-'IKlCIlS l+4tv 1T%

_Wtl OL4) HooS In _ _VL t__a:cLc __ _ MSOtM;qv d- __j _ _

05 F_oo ion sl a ws and ofAler richs h___ete ___m, _O &$ 63 rl"Ovl__<&KJ----- --h~~~~V eove4-c waq aiA Se opetes___ wuHtt o4-fkEte lAe 0 AVo 7-S£C

6- KL los irh Wdetqrl oecs - is dS pwt5 oSivs Jzd &HP J9 S tr/l B6 t6 oW-4._ ors Mne,> @csdora _ _ = M 1(_ ____ _ f I

PO 03 e hi InA AG93estcor RVOA-W __ 5° pro _ -- -i--_

Dw LA= __ _ _ - -K° t norel ; g g h

K o °F c__ _ eV _ - - - - >-Y lebroov vas.04k _ _ _

A P P E N H I C E S

v~~ _ __ ____ ___- '

_____ __ _*p-/afle __ ____ _____ MA& 97

20 5_

_ ___ -- - - 1F )V t~I -4Q~--------------

~~~~~~~~~~~% .k~ . __ ____ __ __

__.__--- _ ._ _ _ - - -.-_______________________ --_-_.- - - - ----- - - , _-- _ _____- - v _ N _ ---7 4 a I W SM

-~~~~~~~~~~~~~~~~~~~~~~~~~~~~I -40 - 0 --o W <:?AM¢!W

- ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~WAwAIP+- U l 511V

~~__ __._. - igTi -k1Q - jaAty v<O -14 : °

_.,_ _ _ _ .._ _____~~~A~~ _ Q-

-4aAa5 A __ ___oo _ _ o

~/p- P-rphnflj) *t '~I15 Wv> a|<l ~ - 4 q JOO 4 v-4SO

49H4 -@ o 5D _XA984 XP I0 T0 a4z~~3j- -

18 ~4Q}4~. ivno ct J71f4-~tePi5b-p -s-t --- 5qul I,FooLi Od

~~~~- .- _ _ _ __._ _ _ Ar4k _

3~2NULJ ) V(N1l-VflVAJNJ 5-1frAf'0U --IVMAIVVV Y J 0A AO 5Jd1VN1i JNWi4iQ ft0L-113- A()~25N

-ma9 N<245 UVJPi 49 JA5Ift J1z1JV1U HL13V't /'1iv1W a-oo ,r.ijWvr2 49 ,3_i*2aV

:t 7-b}tya=4S I l 2

_____ ___ ___ -~ta 4~ng 44£Q Z°

___ * A ~~2~~y2 A' 7w

___ _ __ __ __ __ __ __ _ __A 1o _

- '4A 1 lS d Q

___ - -- } 6'Q ?- w w- ---------------- ---- -_ --- ---- -___~~ ~ ___X 7 __w 1tZL ';f2 77 S DV -_ __ __ _

t ---- ~~~~~~~~~~~~~ - sUns @ W-sg--Za---lX~~~~~~~~~~~~~-------------------a

_ _ _ _ _ _ _ _ _ _-- - -- _ _ _ _ _ _ _ _ _ _-- Y n~~ ~ - -k S _ _ _ _ - r4 A W I EO 1

__ _ _ . __ _ __ _ ___ _ __ ___-- V)IVQ2 0p~

- !WA'UtxW8 2(~Z

YM,.h U,71q " AGO545 4vQ

-- ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ _- Vu4fi - h--

_____ ..M U~ 4~4 t Ijfr S

-- Co---90 - -4avm -I V-4Y - -)O q - 2- IM ' VI 5

SI 0 I U N I d d V

bt7c'F Z l 0 ft4Eco rAwL- ' T[Ay M T AA IN lt1 - 146 ALPl 16F P F : t, tLI tJ . -

"VicB Sg,Ct-'(PO PLApJS 1 J4I rpwT DEPAQ.h1I&¶JT _ 7_004

t C ' 1 N ,2M il X u L C. Wi 0 15 1. !'~~~~~ ~ ~ ~ ~ ~ ~

<' _____ n ___ _ 39 ______ o3-_ _ _. _ =. I0 _. ____ L3 4-> H___ e |_ __t ___ oj L °t _ --- _ _ _. A'. O09 _ ____

0-1 i -Cs i - - -s

OP c-4 Q pec w t _34_ t I -/ 2 03 1 ° _t)

OP C5 M'\ joer I~ ho _ _1 _ _e _Y o 3-30 __ _ _ o; l o1_I - ___v_ ____ I-I Of1 OZ 01 -I _Xt l o __ _ -- -1 -* -_- _ _

OP C7 ____slwcZ5re t I_no_ !1 _ _ o 2 _z o0 ol ol _ -

cp 20~ 4s2~ I~,c*~r6 ___ _o2 O- 03 0 03 -1 = - ol 0 01 _ ____

('P _CO Gtnev4 Ai I Ci o1 _~ 12 0 c'i ci O22~ _ _ -_ _ __ Filol _-_~ ___--___

OP 07 lo e~ L bod l no. _ i __ _ & f2 L 0 °o - _Ic L folLs i eT; l _ 11 __117 0 o2 O_ I ol -c - _

or6 IZS eav ~iwe -- I ho. _1 12 oK, ; 02 -°-Z o3 2 a ol _

0__1?''i tonf ILn - _ŽD_ CS_ -o _= _ _1 _l _~ o _ ______tbeZc §CI(9 If C4Wi Y ri ui _ __ _ O S _2 __ _ = = ._ _= __ _ _3 - - IZ_ -_ _12 o _ _ _ __ 1 _ _ ___2_ ./o 0.3 _ _z ' _ o_ z -

(' I 0 -- 1=~i -"c -" -. 0- f----- --- --- - -- -- - -- -= --- = -

-=---____ __ r- ---- - -- --- --- --- -=-- ----- =_ -_ --- - to = w-c;44- ~~~'

SI 3 I N I d d V

A P P E N D I C E S

(vFvgthrf rc -rY E •CZiRO MniuY 1i7t1I f-rOSCCT, MIN VfcPJfe-m4 kt _- WCJF ?;I__EF~C~ _ _ i f -- | --? -)

(vfVt-EP evroc4c-TYlPe fANs IP4APAAC Y /t'1J M AFZY(

(i~~~~~~~~~~~~~~~~~~~~~~l

L V~~~~~~~~~~~~~L S

Pp00~~~~~ o- k:us _ _

X 1 _1 g tfl_ - _ '_ l Ah_ ,

__ cI pifR I FLh 11 __ __ 13/ _ +_= = __ - -. .- 1 /- _I_FD ~~~~ ~ ~ 2~ otP oj c_ n g l _-- -/--- - - -- ---CV? _ q _ I -- W I _ _ _- _ _'~ _ _ __ _ ___ _2 ~M Ph jL 1 '-1. i f _ _ _~ K -L._ _

0 _ -.- -- _ I= 3/0-* _ __ _._I0__ 0'_._ . - .- =_ rp . __ __ _ _ __ _ __ __ _. _ __-__

VP _ __ -. . _ _ _ _ __P 07 _idor -_ _ . -, _ . . , _ _ , ___ ____

- _ ____- __________ ~ _ _ APVLANIZt/t4 $ _ .l4vL __W1?h tI _o

-_ _____ .__ ___ _ _

AleCUtA16 %ot _ ______

N¢* MM4 42X . 104 E2 * z

lRVISEP tSrcK-TYPE P 5AW _ MReGrKCY MI 0N*, T1EAT __ _ _ s 2_

(,l [2 ED

t:F oz Wscu 1 17 1 ?~~'Z 3 1 s |- 213+{u -+Y

f)b t)3 5ot *1 __

Pti I _ Wu, -so -6 o 1

£1 W) LM y __1 _ W _ __ 1/ _ oocc q/ =4(11l cJ3 PbF7^iw 1- ii ½ __ .4 -3 - 2 _ ___Id __ _V

Sk BVteL t-F_ ___. 4 . 3 1 / _ _ _[ T 3 __ __x_3_t__

Th1 O°&tiVmw b4 1 11 - -1 V 3Ž»/ e --- ~t(+§Th -- - --t# If) Hic 3t~-;i#l 1 2 _ _ ' 42 _ _1 ? _ A I/ -4 t/_ _ 2 _ _ - =

SM1t 2tj A0A _~ I _ _ _ .t _ ?jt~i _. _ _ -_=__

EfEe~ ~ ~ _3 _wiZ3 3,4 _ 3 _3l _-*-.S - _- 1_t -_ _

f__ _ _ ~4ff- I.............._ __0 _ ''' _ = __. __=I

_~ f ~ T __. _ =oi __ _/ _ =- _ WLSl)<&~ ~ ~ Gz (440l -9frl1 3, 1( 1 - _ V

__ ,ire 12t Iz . t,_ I I/I_

~He vw _0 ___ __g __-_

L~: AL kb:~e_ 2_4_~ i~ ( ~~~V~ij.- _ __

S 3 0 I N N 3 d d V

A P P E N D I C E S

h.F<rJvTor z8,zP gcumwrDt4nillz11"L-t" rrO-Te-Fc, ltY ljfmAt-l+ Vrtolerqf WFfrs J¢X vu >X. Ai f1l

zM1<2~~~~~~~~~~~~~~~~ -Swvwfs pD- -l#e -C#tU -T C{^JI .- - --- ;-. 00 4 i. . __ _ _ __ _ _ i.t~

111Cl _ F _____________ eu __________ ___________ _ 1S 3 I /s~ _~ _ _ _ ___ _

ItEC+I°g /h41tipr--TYA r A. -- ----Il 2-~~ /w- ~~--l3lgb .

tAICIA 0o3 kltOpwkosy r/l . / l llg . ._4k K i v__l_ __ 1t3114 /s- __

Q r4~~~~~~~~~~~~~~~~~~~~~~~~~~

- _ __f .= ~~~~~~ _ ~_ __f f_= _~=_ = L ~_ _ _.'

W RVLIC- PWA(,CW3 I -A

__l 1 ~2 _A~fic"1 __,__ _ _ _ _

__ . _ __ _ ,_ _ _ __ _ , __ _ __ ___-~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~___ __ ___- Is__>{ __ ____r~r1 _. ,_ _, _ __ ._ __L __~ _, -. _ __ __

4 ~ __ _ _ij~k'b _ ___ _ _ 2 ,, _ _

_, 1iI4 __ _, ____ 1. /Z _ ,Jw~ __h~ __ __ __ __ . __-

._- O~C i & I ,.3 ,3 _ _ _ _ _ _ . _ _-

_,C~ _ ._ __ _ _ _1 __ _ _,- __ _ ___ .. ._ _.

py:14/ G o1f wPfelN1 Xt~ ec. . _

&UetALAtOt' % 5r o >WwDfR es . I3 5 ____ __

V4t,ff ~I .tJ

A P P E N D I C E S

.~~~~~~~~~~~~~~~~~~~~

_ _ < t.t if ' be wew 1wM~~~~~~~~~~~04j-l yrnzzzz --- eV4)___________ _ __.__ ___._ _ _ __ _ _

_ ____ _ _ =__ _ _ [_c J-Wi3t3 f__ 04 00, =f _ _ _

_ _ _ __ . _~ __.___. ____ ___

=.=- __ _ _ .- - _ _ _. __ _ _ _ ' -

_ _ = ~- X7 -- -- -z - - - -C- _~ - 0 L4 -

_ ~~-. - _ _ _ _- A _47 _ _ _ _ _ |_5 5.__ _ _ _ s __W _ L0 4

, _~____ I4/ _r _ _- -i- _ . -i--- _~- -I I 9 _ I | _ .5i 1 E4 xX)- --- l*7 -- - - ' i10 -_ aIQJ5 Ilj490 Z)

__ >/' 41 *. \0 ItA i _ XiS 1 e t £ f I -| _-~ F 0 da -?Y 8; 19 ----I-/I - -- ---- - - -- - - - - - - - -- - _ _ _ _ _ _ - ~ '~I 5 g-104 -4 9

L______ -5 ---- _ _ _ __ I X 'i19.I 4 -

CO 3NLtt w, ~ -

am T~

A P P E N D I C E S

B2N s< c zr4s ,, w, gc 5f F411.Y L-t { O J MI <f Y< ll l-}t t<1 W SE m ,%oW Ek

( 0 Z 5C~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~-4- t-- 9 -9--3 3--- -- --3--~_2 -

'IVI_; 03WftLC Ee N-T I 1 _ 2 t3 1 lt,_ 3 2 (; o t :+cz04y Lt- L _w _! / 3 11l

_°F~ NNL- t4ww 9 Pss _:__ 3_ _ - 8_= - b wl(f_ 7Kw w*ov A| -- '|I-f-- |--= -_|t I__-

b^ATF

.erfVRP4tryV Ct Z-It AP O r(11'EALtli fmOi•T, vAINJ9fleYct th2Atrn t4•I• Y rr=, JWf '(),I AI4

-_ _ _ ____ _ rr- -fi-.~ ~ 1?I r

IZEV1SC- S1VCC-TYPV- PR-ANJs _ C,F wk- |J _-

:- }2 ,Zr E zX Z|t :D l=X =

,5- Cxe to Tsll i __l_1 g 3 3 3 _ _ __ e111- -

0 z ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~~~~~V -

t 5_ 6&_\tth ^ F_ _' _ '__1 ___ _

K __cv94&rl __ .__ _ , _ _ __ ___._ __ _ C• O SZe -f _

._ _ _ ~~~__ _ .__ ._ . t. _

_X# S1vet____ _ _ . __ _1 _ _ _ . _ . -

. ____ ___ I __ _ _? _ __ . __ . . -_ ._ __ _ .

lPtb G WS N-____ . __ _ __ _ _ s _ _ _ __ _ S ____

6tALAltOt'J % _____ _____ N

S 3 I H N 3 d d V

A P P E N 0 I C E S

bT-JC Zl,AAJE 1 DC61O rAFlI_L.Y cALTh r CL AINtAt1eY6- 11A(fT4 IC W4h p5 e 1091 M1

i, ( _ W [e i'1' ~~~1 ( S l__ls1

Kfi 2Ivcted rSF on l __3-3_ I_ _ 1- _fi _ -- _ ; / _____

RC3 OZ SIre~ SIZ.CK I 2T_1 I I _' 3 - __= - I _ _ __ _CC O XCG -_-_ _1- 11 __I _I_ I I -/s - _ I 1-|

kC <s, i84t t_-1_ IQ 4 l _ 3 I - - - I/Zl/2. _ _. _ _

l4t __ S__eHod I jt L4 1 I . 3 3 ~- _ - _ I .--- -

••_ _ cre °pem __Kct"vlxN _ __-1Z_ . -_ - _ - _ - - __!7.TcV Ie _ vleK I ___; (z' _~ ~I,I 1/i,- _ ,I_ -_ ___-

-'V ST'=8W FtA10 rsro T PZ 9G. _>311 __0 =

-i_-~ lI0i' ._ _ _ _ = ___ 3I ~/-- _ _= = =_- __ _ _._

__ __ __ ___ P¶4'PPVUA; __ ___

_~ALIO _Z ____ ___.___.____._._ ____ ___

v1'A1tN f_r q 11 _l2idSIf 2lfH 4tJK, t1q i cn __

)$Nd7164j~~~L iLp }t

.~~~~~~~~~~~A

,tr'1JF f or .--- PHE --- F->L. - FLt Mf0,j -tlt -- gl 41< ,¢ 9 X1

A~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~A15gD croor-_p "AN5 PSo" WAW, Suba ST OOK _

~~~4 I,~~~I

5 W _ i ^ i, 1, 1 10 : !Ii V| !

C l I jIlLii

U)D 01 Ih:;rsts_.eiibc'ur I _f8 _ _ Qk ._ _ 0 _ _ _ _- I .l - _ _Yi _zb>u___ B_ S _ 2 5 - :7 3 /g-, i,'e, .- _ l - __-_ ( ) _-oq 51A

-&I"I /odk- i _ _ __ Z _ Vz s I/un I/1k -i/u - -- .C-bi) 4 I V -

Ct7 ~~OS D$Y-VO1______ _ I- __ i____________-__- i_____ L0 =U)- X v, l OI4 Zo~ ½/2 M7 I< , _ 3 _3 ILZZ - - .= _24 -J7 X _ _

_LI) C <IIjssiov l __2_ _ I S_ 3_3_ =_ _ _-__LtD °8 RcewtjB, _'A 'I IZ _ 1 _3I . -t _____ 173t _ £1 =R~ BOFr,r bcrj'1

___e .' _ _ __- ___ I I 3 I I/Ii- - _ -/ _

_Lv II _he __ I _3 3_ .I/Z _V1 h -t ___ = 1 - _ ___ _A -i i 6 ~ ioi - - - ~ _LI) _ Z yt t ,4$tI. _ _ - I. W -4 = - _ ._ I_ -__.

CAfel2AtA-tIIN('J-

. _ _ _ N ___

_ __ ___ _ _ ............................ _. __.___

_~~~~~~~~~~~ _ __ _ _._ __ _ d............. .. .V . . __

A P P E N 0 1 C E $

c-i: iM~ApJE, ~2'5OF44lhQY OALTh VP-0-TRT 10IN#539h'Y6C~rA- r ~4 I-I'1- i Ne,I n 44 A

7;H p~~~~~~T~rAP- _ _ _ _W_ _ _ _ __ P 6e D_cfev -crA 'PAN -t WARb Ws 5- 01-0-

L4-- z-( L . bs_L _ $_ _b l_ AL = -6

St __gD>_ _ 4 _ Qo I(Qc _ _. _ t9LI _ - =_ _. =- ,l, _

*L)J > >9 r?r 9 I n __rs _ __12 4W(e -O-s _1 4i/nHIre% l - _ i_ 0 i0' i3 - . 2_ __ _ Le /k -

§5\) _O(c,a_ t L.jSbA I _i 'I' l2 __ -_ ._ __3__1/n__ __ n-__sx_ ~T/Th Ri __ lW4zzz_ 3_ - Km I/In - ft -. _

jt0 Q>s_nsfpi+l 1 3 _ i __ Z _3 I]Hi/ _ __ _ I (- __n _ _________

swA -M&~ °9 1s_ Sb 2 7i _;~ -s_--- 3 /iXih - 1-L-i l/i __-__--_--__--

5X_ l e __ 8 I Il _ __ 1 1 - _ __D;1_1_4 _ __ - - z <T :_st9____ ____ Sv _ __ _

£Lu _1 11IL S1X _ _ 2 ' 3 11 _ _ _ /l - m½ I/ge ____ sls o

O - ;___ s _ z _ - - - - - _I -I _ Z

sn-5Ft __ __ - G-- 2- / -? 1/41l0 - 0--___=

tISj g16 ovct {l%- wFiA _ 1 - -_ - . -t ---2 -- -i ---~ = -- !___.__V _L ._ . - _ _ _ _} _ _ _ _ __

_ _A __ _HL _~~ - _ ___ _ _ I--- - ----- -- ----- _ _ PYr9AL _ -__,2AI~~~~~~~~~~~1tz Tf4 6 WltOW JE9efir11it < t? t __ _>/AtlDhJ % £ i"~~~~~~~~~~~~~~~~~~~~~~~~~~~L

I. N

0~~~~~~~~~~~~~~~~~1~~~~~~~r

tPV . ¶2flz .2 - - - L- ef r~

S G -I- PS _ 01 _ J i4SS-

S 2 < -.- _tD _~ (--8§ Z_ 3 3_ -_ -- __ ___ _Fy_ _____a_ _ _ _t _ 3 3 _=__ 1

14 ,CI _ _ ½ _± . _ _ .~~ t - _- _ ,09 7 17}__I___%_M2 2I/l { D1 rt+S_ __l3B3_ 2- - - _ - - I - -1

j4 Xh~~j/ _ __ _ _ _

.S _T@h 1A' W~fThT I - -f _ _1_ =_____-

WAr44LAUC7 EMEN

,. _, _ _,N _ d V

A P P E N B I C E S

(,rrvr-rNrvw t= 1tv, e,cIj rAPIIIL.Y litAL-h 11F,AANT?Y~ IAt:Tlf~VT Pt o,J&Wwr E'),)l A14

Lb~

MT

t-A -Z -

~~ s-rocjc-1Y~~~ ~ G L~~jwip~ _ _ _ _ _ o12__

li idvm i r

4~~~~~~~~~4

_ _? _____ ___e4 _'c~± I _ __ _ _ ~ __ z - _ ___ _ __ _ _ _._ __ . _ 3_ __ _ _ __ _

_4 _3 _4AAIk __ ___ ._ ._ _ ._ _ _ _

. = X__ _ _ _ X -= 5._ X == - -- --

___ ___ _.__ . . ...... . .

_ _ _.__ _ _ __ _ _ __ . ______. _____

(M$v. _ W _ ___ _ = T,0 1_ . . _ _ _=._-__ _ _ _

__~iVA~1I .__ - ._.____ __ __ ___ ___AFe8-TD-ft G WS wyNX X w t : -~~~~~~~~~~~~~~~~~~~~~~

AfAtAttN * % q t . _2

bWW MMS 4 . 0 .& 4 _ ~~4-

eJJQ1 MPtAry 7AIp,AT Ct ZCl, x) AMwruy NtALtU MI-, IneYc 'lEAF AA c4~~~__ - py~rT - - PFT (5iU 'luEs (c'yF

>PVI'SW 5,TOcW-1PS PLANS ; _ L-Mlr=E APJV 1gopK54ioPS }ST CW Jtb I~~~~~~~~~t1l

LrW 02 (X: _sii _ _1 .2 _ e _ s I 3I_ _ 11 Ci~9 elf ewh-qAtre I~ _ ~~

C W _ _ _ _ _ _6 3 2 - h CTh 03 l4 Sho1* didc• JIL r _ l l$ 1 3 -- = - -- IftF -(C W -f Ws=1t. id _ _1' _ i , I1 1 g-5 3 _ _-__ .... _

cl 05W~r I. Y 1 ! -JJ 1 S 7 7 3 - 7- i - .-C (±•ftfe I ___ _ '11 1 -- J

__ _

____ r ~ .OLe(r .\. °1 Lod _ _ *1___ -_ - _ - = - - __ -

_ ______~i 1 S __ _ .. 2 3 __ _-_ -

_ -- -- - -;- ,~- '0 - '_ . . _. 9 -~- .-

V0VA~f&IIW'V ~1Eo'C. _ _XX _= __ ' __ __. = . . _ _ __ _ O_f____ _=

S- -- t ._ _ _ _ __ _ .__ _ _ _ I- - - -N

S 1 0 I Ul N I d d V

A P P E N 0 1 C E S

17ATF

Mnil[.y OML-tti llbokt-Vt vt-f--Ie5�N P--Ir-r er�JUVC(0,11. 44H

-D STMX-TYPE! PLANS AIDMINISTIZATIOW."VfCr ST C-11 -4

M

LL::�� . i -113 13

--- -- -- -- I -- I - --- I�l - -- -- -- --- - --- -- --- ---- - - - - -- -,--f) 03 13D-

AD o�- Cffce 13--- - 13 I1

Cff ke 13AD LC) Oftiq- - I �'. - i� --- Tvj,

VZ4

AP ig Iz-ty-

AO

V-1

�WTA-� ftLE PEPIMN-TCAffMCA'TtVN

~I1-NMAort ZlA4Oe, ECeAC) F4Aflt)1 NW-hM rOTF6, AAIfAtY&CVf1At7J14 £wV4\3 prfr OG f (dCq4I. /14

___15VI56 2 _r_T_ PAK M ___ __

~~ ~L A,r n__t 'Z4 L ' I ½ § fit a Wsxsm ; - l i ' _ i _5 _ ; - h - - |- - -iCZt OZ I 8 3 _- - _ _ e

bt o i4;en>v _ l t _ _% I __ 8W 3s/i _ '~ _ _ _- 01C 0

6 A - - _2 3 Z I I - - - I _ .

xR _0 fI\22KY7vcfw1 T 31t {Z 7_ _ _ _- _-_ _ ._-_ ,__ ___ .__ 12 ,

_ ___ __ _ _ __ , -_. _ ____ _ _

lVlA-6 WI*vLA- LMFMN-T1fN O1 7

__ALAT tON __ _____

,~~~~~ 1_ __ ___________

__~~~~I -___ __ ___ ___._ roa

. I 1 I U N I d d V

A P P E N D I C E S

tvr-T~~~~~EM~~~~~E

_ __ _ _ _ _ rmTr~~~- l

_c,Ol I_~je 1124 t _ Z_4 _g_ _ _ _ %_~~' 4W .1 - __- __ W__

v__ __ _ _ _ _

~~ OS6C~~~~~~S~~~)E1~~~~TT '~~~~~ ~ ~ ~ -1 _D

I6 ~ 3 ~ __ ,_ _ _ 2 _ . .-.

_ __ __ . . . ,,A f. . _ _ _

>(TWAt Mf7P Jc .ifLN*b Mt19 . t 4

z~~~~~~~~~~~~~~~~~~~~~~~~~i

Appendix EUse of Non-technical SolutionsBASIC DESIGN REQUIREMENTS FOR OPERATING THEATRES

In a field widely influenced by technical consultants, architects and engineers, there isan increasing tendency for technical solutions to be proposed for natural problems.Automatic door openers and closers, hand-drying machines, automatic bed-pan swashers, temperature monitors, and air-conditioning systems are being introduced linto health facilities at all levels. When functioning efficiently and effectively, thesedevices give satisfaction all round. However, problems usually occur when any form ofmaintenance is required.

In this exciting environment perhaps we may rely too muclh on technical solutions? Forexample, to claim that air-conditioning systerrs in operating theatres will simultaneouslI _control the temperature of the room, removTe toxic gases, guarantee the quality of the air andcontrol the movement of bacteria around the different rooms of the operating theatre suite iscertainlv optimistic and may be credulous.

Here xve hope to showv howT conditions in operating theatres can be improved and sustained bynon-technical means.

W.hen constructing neiw operatinig theatres the aim must be to provide good workingconditions for the staff, good conditions of hygiene for the patients, and secure conditions ofsafety against explosions and fires for all.

Good Working ConditionsTemperature 22-24° CUnpolluted airGood lighting

Good Hygienic ConditionsVolume of air around operating area should be close to

sterileControl of bacteria

Safety against Fire and ExplosionsMinimal amounts of explosive gasesMinimal danger of electrical sparks

GOOD WORKING CONDITIONS

Temperature in the operating theatre canl be controlled by a correctly-designed air-conditioning system. This should go some way to conitrolling pollution, assuming that thesystem is properly maintained. Electrical ventilation and ceiling fans can be less effective butmore economical alternatives. Satisfactory lighting can be best provided by electricity.

However, no matter how many resources are available to design, provide and maintain thesystem, the passive means of providing good working conditions should be recognised. Theseinclude:

* Specifying the good insulation of buildings with ventilation of roof space.* Ensuring the correct orientation of buildings wvith shading of vertical w alls and wsindows.* Insisting on the good natural ventilation of all rooms.* Limiting the use of indixidual theatres (using over more weekdays, or building more theatres).* Limiting the number of people in the theatre.* Testing the anaesthetic equipment for leaks.

ve, * Instructing staff in the correct use of facilities.* Providing correct maintenantce.

GOOD HYGIENIC CONDITIONS

Some important means are available for ensuring good conditions of hygiene by passive means.These are:

* Careful personal cleanliness.* Correct procedures for staff with regard to cleaning.* Strict observance of clean and dirty zones.* Careflul handling of sterile packs.* Reasonable time bctween operations.* Separation of septic cases.* Floors and walls should be easily cleanable.* Minimum of equipment standing on the floors.* Surplus old equipment should be given away.* Shelving should be durable, easily-cleaned and 5 cm away from walls.* No ledges to collect dust.* Space should be provided underneath internal doors.* No sliding doors.* Number of peoplc in theatre kept to minimum.

SAFETY AGAINST FIRE AND EXPLOSIONS

Aside from the provision of fire detectors and sprinklers, only passive means are available forensuring that conditions of safety in the operating theatre are acceptable. Thesc are:

* Not using explosive gases.* Using leak-proof connections and regularly checking for leaks.* Using spark-proof electrical contacts, placing socket outlets at high level.* Not using electrical extension cables.* Not using unprotected electrical suction units and hand-tools.* Anti-static flooring, shoes, anaesthetic masks and tubes.* Good natural ventilation.* Maintenance of electrical equipment.* orrect treatment of floors to maintain anti-static properties.* Appropriate instruction of all staff

Appendix FCalculating the Need for In-patient Beds

Many variables affect the calculation of the need for in-patient beds; for the overallrequirement of beds in a defined district, the following formulas can be used.Normally one should aim for an average bed occupancy rate of 80 percent whenplanning for the number of beds in a health facility.

CALCULATION

(A) = Catchment populationi to be served.In our example 120 000.

(B) = Annual admissions / 000 population.This figure is based on present statistics from the area or from the province nto whichi the area belongs.In this example 42 /000. Ca

(C) = Existing total number of admissions pcr year = (A) x (B).Example: 120 x 42 = 5 040.

(D) = Average length of stay in hospital per admission.In our example: 8 days

(E) = Total number of bed-davs at present a year = (C) x (D).Example: 5 040 x 8 = 40 320.

(F) = Average number of bed occupied per dav = (E) / 365.Example: 40 320 / 365 = 110 beds.

Therefore:

(F) / 0.80 = Number of beds required to provide lor an average occupancy rate of 80 percent.Example: 110 / 0.80 = 138 beds.

In calculating the number of beds required in a new hospital, annual increase in populationmust be allowed for. It can be expected that wNith a new v facility the number of admissions tohospital w ill increase. At the same time the better conditions provided will imply a reduction ofthe average length of stav. In considering these variables, anv assumptions arrived at should befounded on professional experience.

Appendix GExample of Facility Use and CapacityFigures

It is often difficult for the Client to calculate the extent and number of services whichwill be required at different facilities. Where powerful donors are involved with

CA interests in specific areas, there is often the risk that particular services (for examplemother and child care) will be over-provided to the detriment of other services.

The following figures were collected on many field visits in Mozambique during the civil war.The figures are shown as an example of the relationship between different types of data and arenot presented as an example of the efficient use of health services.

a-

FACILITY USE AND CAPACITY FIGURES

General

The following figures were assembled from a number of

sources, partly from the statistics available in the

Ministry of Health in Maputo, partly reflecting Mini-

stry's policy for the development and utilisation ofrural health services in Mozambique. The figures werealso checked with observations made whilst carring outfield work at a large number of facilities in all

parts of the country. >

la

The original intention in developing these figures wasto provide an aid for dimensioning new rural healthinstitutions and with this purpose in mind they were m

checked and where necessary adjusted, during a studytour of 18 health institutions in Mozambique, under-

taken in 1983.

It must be pointed out that the figures themselves arefor general use, and will always be the subject ofvariations due to seasonal, geographical and topologi-n

cal conditions. They must also in future use be the Csubject of constant reappraisal, to take account ofthe constant developments taking place in the morbidi-

ty patterns within the population, and the changing

aims and policies being defined for the rural health

network in Mozambique.

While emphasising that the figures in themselves arenot, (and most probably never will be able to be) very

precise, it is suggested that they can serve a usefulpurpose in a number of different ways.

A. First and foremost they can be used for the purposefor which they were originally intended, that is inthe drawing up of room schedules for new health

institutions in rural areas.

B. In the same way the figures can be used in

evaluating the uses which can be made of existingrural health institutions and thereby as a means of

giving an indication of the possibility ofincorporating extra services in existing rural

health institutions as requested.

C. Further the figures can also form a basis forcomparing the level of health service provision indifferent rural areas and finally as a basis for

rationalising and centralizing activities in therural health service network taking into accountthe requirements of the population, and economical

considerations.

A. USE OF HEALTH FACILITIES BY RURAL POPULATION

Al. Visits to health facilities per day - 0,6% of populatior,A2. Mother and child visits per day - 0,15% of popolationA3. Dentists visits -0,12% of populationA4. AdmiSSions to wards = 0,016% of populationa

of which maternity - 0,005% of populationsurgical =0,013% of populationmedical

A5. Number of births per day = 0,014s of population

A6. Number of deaths per day = 0,005* of population

The above figures are based on the following:

Al. Visits to institutions - Average 1,5 visits per persoll per Yr,250 days per year.

A2. Mother and child visits - 20% of population age 0-5 years, 4,dZ visits per year, 40% attending, 250

days per year.

A3. Dentists visits - 30% of population attend averaje I LI,

per year, 250 days per year.

A4. Admissions - 1 bed per 1000 population, averagelength of stay 5 days. 80% occupancy.

XMaternity admissions - 40 births per 1000 population, 4D0 fall births in hospital.

Surgical/medical - Total admissions, less maternity

A5. Births - 50 births per 1000 population

A6. Deaths - 20 deaths per 1000 population

SEASONAL VARIATIONS.

Maximum Minimum

Al. Visits to institutions + 20% - 20%

A2. Mother and child visits + 20% - 20%

A3. Dentists visits + 10% - 10%

A4. Admissions + 15% - 15%

Maternity + 20% - 20%

Surgical/medical + 10% - 10%

VAMRIATIONS DUE TO DISTANCE OF POPULATION FROM FACILITIES

10 km or less 30 km or less over 20 km

Al. Visits to institutions + l0% - - 20C

A2. Mother and child visits + 10% - - 5u%

A3. Dentists visits + 10% - - 50s

A4. Admissions to wards + 10% - - 20C

B. PATIENTS REQUIREMENTS FROM HEALTH FACILITIES

% of total No. of visits

B1. First consultations 100B2. Injections/treatments 40B3. Dressings 10B4. Consultations with doctor 20e5. Laboratory tests 15B6. Prescriptions 85B7. X-rays 10B8. Minor operations 2B9. Major operations 2B10. Emergencies x)

This is difficult to calculate statisticallyas often emergency is systematically used for1. consultations. Some administrative limit-ation of patient's access to emergency mcould be considered. =

C: TYPICAL PRODUCTION/CAPACITY FIGURES FOR HEALTHPERSONNEL/FACILITIES PER DAY c

m

Min. Max.

Cl. 1st consultations per health technician/nurse 70 140C2. MCH consultations per health technician/nurse 40 70C3. Maternity consultations per midwife 40 70C4. Injections per nurse 40 105CS. Dressings per nurse/health technician 84C6. Consultations per doctor 40 70C7. Laboratory tests per laboratory technician 20 45C8. X-rays per X-ray machine 10 4BC9. Operations per theatre (major + minor) - 12CIO. Prescriptions per pharmacist - 210Cll. Births per midwife - 3C12. Consultations per dentist - 30

The above figures are based on the following:

Cl. Average 3 minutes per consultation per 7 hour dayC2. Average 6 minutes per consultation per 7 hour dayC3. Average 6 minutes per consultation per 7 hour dayC4. Average 4 minutes per consultation per 7 hour dayCS. Average 5 minutes per consultation per 7 hour dayC6. Average 6 minutes per consultation per 7 hour dayC7. Reference WHO offset publication number 72C8. -C9. 8-16 per day depending on complicationC10. Average 2 minutes per prescription per 7 hour dayCll. -C12. 15-20 minutes per consultation per 7 hour day.

D. KEY PROVISION FIGURES FOR NUMBER OF INHABITANTSPER HEALTH WORKER/FUNCTION

Dl. A health technician can see 120 patients a day(120 is 100% of 120)(120 is 0.6% of 20,000)

Therefore there should be 1 full timehealth technician per 20,000 inhabitants for

consultations.

D2. A doctor can see 60 patients a day(60 is 20% of 300)(300 is 0.6% of 50.000)

Therefore there should be 1 doctor per 50,000

coo inhabitants for consultations.

w D3. 1 laboratory technician can do 35 lab. tests perday.(35 is 15% of 233)

_ (233 is 0.6% of 38,000).

Therefore there should be 1 lab. technician per

2c 38,000 inhabitants.

am D4. 1 x-ray can do 40 tests per day(40 is 10% of 400)

'6 (400 is 0.6% of 66,000)

Therefore there should be 1 x-ray machine per

as 60,000 inhabitants.

D5. 1 operating theatre can do 12 operations per day

(12 is 2% of 600)(600 is 0.6% of 160,000)

Therefore there should be 1 operating theatre per

160,000 population.

If 80% of operations in theatre are on in-patientsand average bed stay = 8 days then 1 operatingtheatre will serve 75 surgical beds.

(If 30% of all beds are surgical, and there are1,2 beds per 100 population, then there should be1 theatre per 100,000 population. Usingalternative method of calculation).

D6. A health technician can see 70 MCH patients perday(70 is 100% of 70)(70 is 0,3% of 23,000)

Therefore there should be 1 full time healthtechnician per 20,000 inhabitants. (The differencehere is between actual use as shown in A2, andanticipated future use).

D7. Births in hospitals.A midwife can assist at 2 births per day.(2 births are 0,003% of 40,000)

Therefore there should be 1 midwife per 40,000

population. (i.e. in health institutions).

D8. Dentists can treat 30 patients per day.(30 patients are 0,12% of 25,000).

Therefore there should be 1 dentist per 25,000population.

D9. Admissions: There should be 1,2 general acutebeds/100 population

Therefore there should be 120 beds for 10,000population.Of these: 20 beds should be maternity. (Accordingto births)Plus an extra 6 beds in emergency (5% of allbeds).

MD

APPLICATION OF THE FACILITY USE AND CAPACITY FIGURES. la

Using the figures given in section A-D, the theoreticalprovision of health facilities for a rural population of100,000 inhabitants can be established as follows:

Technicians for general consultations = 5Nurses for injections and dressings = 5Pharmacists = 5Dentists = 4Laboratory technicians = 3X-ray machines = 2 CA

Doctors for consultations = 2operating theatres = 1

Midwives are not included here due to the reevaluation ofprevious policy.

The distribution of these medical staff and functionscould be for example:

HP HP HC HC RH

5 Technicians 0 X X 0

5 Nurses 0 0 0 05 Pharmacists 0 0 0 04 Dentists 0 0 0 03 Laboratory technician 0 0 02 X-ray machines 002 Doctors 001 Operating theatre

Key: HP = Health PostHC = Health CentreRH = Rural Hospital

Obviously where wards are provided, extra staff will berequired.

The above model does not take into account problems suchas communications and transport, which of course must alsobe considered when applying the systems in practice.

Appendix HSetting Priorities

The different users involved in a health facility construction project may each have verydifferent ideas of the priorities which should be given to different types of intervention.Some may be hoping for the latest types of diagnostic equipment, others for improvedstaff housing, others may be aware that the leaking roofs seriously reduce the efficiency

co |of the services provided in the institution. The following notes are included to assist informulating project priorities.

Ca

Issues to be considered when inspecting existing facilities

Two governing concerns are:. The suitability of the buildings, installations and equipment for proxiding the health servicesrequired,X The influence of the spatial and funictionial aspects of the buildings (and the condition inwhich these have been maintained), on the quality and quantity of the health servicesprovided to the population.

The separate issues will concern primarily:Space,Function, andHygiene.

These will lead to considerations of:Construction,Building Finishes,Technical Installations.

The next key issue is:Availability and condition of medical and non-medical equipment.

A universal and essential field for monitoring will be:Cleaning,Maintenance, and the need for improvements.

Any interventions should use the following order:

Priority 1: Make urgent repairs where the buildings and contents are in danger of serious damage.For example, where therc arc holes in the root; or where there are leaks in water pipes andplumbing. (Water is the most destructive element for buildings). The same urgency applieswhere there are serious cracks in walls and floors due to earth movement.

Priority 2: Make repairs where function conditions are unacceptable and the buildings are inefficient.

For example, where hvgiene conditions are unacceptable. Wlhere it is difficult to clean (aswhere floors are damaged), or where sterilising and sanitary equipment does not wvork.

Priority 3: Take action to improve efficiency and reduce running costs.For example, to improve insulation or provide more efficient heating in order to reduce theuse of energy.To reduce the use of water.To make laboratorv tests more reliableTo reduce cross-infection.Here, the provision of better housing as a means to improve staff morale can be considered l

Priority 4: Provide needed facilities which will improve the quality of the services provided as well as efficiency. mFor example, improving sanitarv conditions, providing space where it is not possible to

wproperly separate infectious patients (particularly -where there are no fiunctioning patienttoilets) or wvhere the staff are not able to correctly supervise activities. -

m-C3

Appendix JThe Re-use of Existing Buildings

Although countries differ and the hopes regarding health infrastructure varysignificantly, similar conditions are often observed when visiting health facilities. Thereare important lessons to be learned from country-to-country especially on theimplications of the re-use of existing buildings.

In many places, existing health buildinigs are of varying quality, particularly from a fiunctional poillt ofviewv, but their fabric is usually solid, even after many years of neglect or even disuse. Even in colonial

- times, btuildings for health services in Mozambique were generally wvell-sited and solidly constructed.

Depending on the age of the building, in most cases conventional repair work xxiii bring thebuildings back to reasonable condition.

Functionallv however, these buildings are often seriously deficient. Comparing their functionalstandards with those proposed for the standard-type plans described, we see the greatestdifferences in the following areas:

W'ards, which are usually the multi-bed type with little possibility of isolatingpatients, or achieving flexibility of allocation. Wards usually lack the essentialfacilities for achieving good hygienic conditions.

* Theatres, in which it is difficult to maintain correct hygienic conditions, and wherethe theatres are often closely connected to other traffic-wvavs and functions in the hospital.

* X-ray rooms, which are often unsatisfactory especially as to protection of radiologistsand passers-by from radiation, and where the equipment and electrical installationsare often dilapidated, and sometimes dangerous.

* Laboratories, which (wrhen existing at all as defined locations) are often inadequatein space, location, equipment and necessary installations.

In existing buildings, many different functions are usually collected together in single blocks; as a result,separate extension of individual facilities is very difficult. Where there is more than one block, connectionsbetween buildings are usually inadequate, often being neither paved or covered. Over and above theproblems and inconvenience for patients and staff there is often an increased danger of soil erosion.

In most existing rural health facilities in Mozambique, the buildings are:

* Adequate for use as offices, consulting rooms, class-rooms, stores, dispensaries andsimilar purposes.

* Inadequate for use as wards, operating theatres, medical services facilities, or to meetthe usual requirements for in-patients.

Proposed procedure

The following scquence of activities will usually be relevant.

Activity Effect on recurrent costs

I Establish circulation pattcrn of covered Negative, should improve quality and efficiencyWvalkwv,avs between existing blocks (allowing and prolong the life of trolleys and containers.for future connections to nev buildings). M

2 Provide acceptable accommodation for staff. Neutral, should improve quality and X

efficiency.rm

3 Construct new wards. Neutral if bed numbers stay the same, may well z

implv savings in staff wvith efficient design. =

4 Construct necv operating theatres, X-ray, Neutral, may imply slight increases if equipmentlaboratory, maternity, delivery and other wvhiclh did not wvork is noNv functioning.facilities.

5 Convert existing facilities to out- patients, Neutral, but xvith proviso as no 4.administration, stores and related areas.

Appendix KChecldist for Approving DesignProposals for Hospital Projects

After the formulation of the Design Brief, the most important task for the Client is toreview and approve the proposals submitted by the Architect and Engineer. This is not

co always easy. Problems of time and manpower resources, and difficulty in understandingdrawings or other information are common reasons for the serious mistakes which occur.

1. Prerequisites

= Before beginning to review the drawings, it is important to be awvare of the information onwhich the drawings are based.

* What was asked for in the Brief?. Was an operational policy document forwarded?* Are there anv cost limits?* WVas a maximum area in square metres stated?* How much will each square metre cost to build?* How many staff will work in the departments in question?* What comments were made to earlier submissions on this project?

2. Drawings

Drawings have to be understandable. As the Client, if you find drawings difficult to read, or cannoteasily see zvhere there are door and window openings, or cannot see the difference between internaland external areas, ask for explanations. If you do not understand the drawings (and there is no-oneat hand to assist you) send the drawings back and ask for better drawings to be submitted.

All drawings should show:. Scale,. North-point,* Total gross area in square metres,* Clear images, renderings, plans, sections or views of existing and proposed buildings.

3 Location Plan / Site Plan

It is most important to exhibit the new departments or buildings on the site as a whole, andwith the position of adjacent departments / buildings clearly delineated.Check that:

* All habitable rooms face due north or due south;* Existing site zoning-of out-patient areas, in-patient areas, medical services,

kitchens-laundries-stores-workshops-is maintained;* Visitors and oLt-patients have n1o access to internal hospital areas or areas with high

security requirements;

* The new buildings are so placed on the site to provide for future extensions;* Entrances to the newv departments are easily located by visitors and can be correctly

controlled by staff,* Adequate waiting areas are provided close to entrances;* Internal court-yards / light-wells have ample access for gardening, mainten-ance, fire-fighting.

4 Layout Plans 1:100The layout plans at 1:100 should show all internal walls anud partitions, and should indicate w hichwalls go tull height to the ceiling, and w,vhich are stub walls. All external and internal door and Nvindowopenings should be clearly showvn, as should door openings and the direction of the door swings.

Check further that: l* The area shown is the area which has been budgeted for; l* Corridors and circulation wayTs are economiiically planned, and wvill facilitate the correct m

movement of people -particularly if patients are involved- around the departmenit;* There are onlv necessary entrances to the department, and that these can be

satisfactorily supervised by the staff,* There is adequate room for xvaiting xvhere rcquired; -

T Internal corridors have natural daylight and good natural ventilation; CD* All rooms including toilets and internal lobbies have direct natural daylight and m

natural ventilation;Toilets in areas whlIere wvater supply problems may arise are approached from the outside;

* The size of the departmenlt, the numbers of toilets, offices and xvork-spaces allreflect and relate to the number of people who wvill be employ ed;

* Clean functions are kept separate from dirty futnctionis;The production (functional) process is logically expressed;

* The movement of staff wvhen at wvork will be kept to a minimum;The department is correctly zoned, wv7ith, for example, patient/public areas, serviceareas, staff areas, restricted areas, and so on, all correctly separated;

* Rooms are big enough for the equipment wvhich is to be provided;* Similar functions are provided with the same size of room;* The architects provide an environtment vhichl is pleasant yet efficient.

5 General CommentsSome general recommendations:

As the Client, insist that you are given the time you need to review7 the drawvingswithout haste or pressure.

* Draxvings presented at meetings must be comprehensible ancd complete.* Please do not give ansxvers on behalf of the users before you have discussed the proposals

wvith them.* Resist any impulse to redesign half-finished proposals at a meeting where a large

number of people are present. This never wvorks.* Always hold your internal discussions before yTou arrive for the meeting, or vou wvill

risk confusing the Architects (w>Nho may be inclined to listen to those argumentsxvhich best suit their oxvn purposes).

* Refuse to be persuaded to give approvals hastily or wvithoLt proper consultation betweenyou and other stakeholders. If possible, agree a standard review/approval time wvith theArchitect for this.

Appendix LContents of a Masterplan

Before proposals are made for any changes (no matter how small) to existing healthinstitutions, Masterplans should have been drawn up for the long-term developmentof the site and buildings. This ensures that short-time activities do not limit futurepossibilities. Fortunately, a Masterplan can be surveyed and presented in a

CA lcomparatively short time, using limited data and few specialised resources.

cD

A Masterplan is a series of documents wNhich describe the framewNork for the future development of a- health institution. It is based on easily accessible data, and should containi the following information:

A. Basic Data,, - Catchment population.

- Distance to other health institutions.- Present utilisation.

X6 - Present staffing.B Existing Conditions

- The present layout of the complex.- Existing zoning of activities.- The date of construction of the different buildings.- The distributioll of departments in the buildings with gross areas.- Layout of mains services and drainage reticulations.- Departments which are badly located in relationship to other departments/ functions.- Departments which fuLnction well.- Departments which function badly.- Condition of key building elements: roofs, external walls, doors and windows,

internal partitions, floors, sanitary installations, water and drainage, and electricalinstallations.

- Buildings wliclh should be renovated as a matter of urgency.- Buildings which should be demolished.

C Issues- What is the predicted fiuture use and occupancy of the facilities?- Which provision norms are applicable?- Which priorities should be used for determining the sequence of future steps?

D Future Proposals- Areas of the site for fu-ture constructioll.- Future zoning of activities.- Proposed traffic / circulation routes / ways.- Future layout plan to provide for expected requirements in 1 5-years time.- Proposed phasing of activities.

E Budget- Estimates for realising the individual projects shown in the plan.- Annual budgets for capital works to realise the Masterplan.- Development plan budgets.

Appendix MOther Sources of Information

Little material on health facility planning has been published in the Southern AfricaRegion in recent years. Publications from other parts of the world are unfortunatelynot always entirely appropriate to the region's needs.

For the chapter on Planning of Health Equipment, several publications have been consulted.These are:

Manpower Development for a Health Care Technical Service, WHO 1990, Report Nr.WHO/ SHS/NHP/90.4. z

Bloom G. and others, The Right Equipment.. .In Working Order, World Health Forum, Vol.10, 1, page 3-27.

WHO Global Action Plan on Managemiienlt, Maintenance and Repair of Health Care Equipment. Ca

Bloom G., and Temple-Bird C., Medical Equipment in Sub-Saharan Africa, IDS, ResearchReport, WHO(Rrl9).

The South African CSIR has published various memoranda and reports dealing wvith technicalissues related to building construction, building specifications, aspects of internal climatecontrol in buildings (and some specific health-building issues). CSIR undertakes, fosters andmanages broadly-based market -driven research and development and technology transfer insupport of its clients in both the public and private sectors, and to meet the community needsand improve the quality of life of all South Africa in a cost-effective and ethical manner.

The CSIR can be contacted for more information on their publications at

CSIRPretoriaRepublic of South Africa.tel: 27-21-887 5101fax: 27-21-887 5142WVorld Wide Web: http://csir.co.za/

http://x-vw.ctcc .gov.za/business/education .htmle-mail: [email protected]

The World Health Organisation

The Organisation frequently publishes reports and discussion papers on many aspects of serviceprovision and management. These are particularly relevant wvhen dealing with investment projectsin the health sector. In the 80s, WHO published a series of reports on building for primary healthservices. The World Health Organisation can be contacted for more information on its publicationsthrough its field offices, regional offices or head quarters.

Headquarters Regional Office for AfricaWorld Health Organization WHO - AFROOffice of Publications B.P. 620, Avenue Appia BrazzavilleCH-1211 Geneva, CongoSwitzerland tel: 242-839111

Tel: 41-22-791 2111 flax: 242-242-839410Fax: 41-22-791 0746 / 791 4150World Wide Web: http://wwNAv who.ch/e-mail: libraryvwho.ch or:publications@vho .ch

The World Bank

Important information on employing consultants and contractors and on aspects on thetendering process can be obtained from the World Bank's publications on Procurement.

This publication wsill be available on the World Wide Web: http:// -wvw-worldbank.org/htlm/afr/healthb

The World Bank can be contacted for more information on its publications at:

Resident Missions

or:

World Bank BookstoreWorld Bank1818 H Street, N.W.Washington, D.C. 20433U.S.A.

tel: 1-202-473 2941World Wide Web: http://wwxAv.worldbank.orgE-mail: [email protected]

The wNeb site has information on local distributors, publications and prices. Customers outside theUnited States must place their orders thl-rough their local distributor. The World Bank has established thispolicy to provide efficient service at a fair local price. Customers benefit because their orders can beprocessed quickly and their purchases can be made in local currency. They also avoid the additionalshipping and handling charges that can considerably increase the cost of direct orders from the UnitedStates. If no distributor is listed for your country, you may order directly from the World Bank in theUnited States. Payment may be made by credit card or by US dollar check drawn on a US bank payableto the World Bank. Please note the order number and price of the items you wNish to purchase. Theorder number and price are listed in the bibliographic information of each abstract.