The COVID-19 pandemic will serve as a milestone in human history, with everything being divided into three eras: Before COVID-19 (BC), During COVID-19 (DC) and After COVID-19 (AC)
With healthcare facilities as the battleground and India falling way short of hospital beds, there is no doubt that healthcare facilities AC will be very different from BC.
The trend was set at Ground Zero of the SARS-nCoV infection when Chinese authorities reportedly installed a 1,000-bed hospital in 10 days and then topped it with a second one in six days.
Closer home, authorities in Mumbai created a mega-hospital in an exhibition ground. And on July 2, Glocal Healthcare’s HellolyfCX Digital Dispensary won the Public Appreciation Award 2020 at the HIEX – Health Innovation Exchange hosted by UNAIDS and other partners. HellolyfCX is a portable digital clinic which is safe even in a pandemic like COVID19, protected by UV-C light disinfection, positive pressure and an acrylic barrier between the nurse and the patient. It does not require a doctor. Doctors can see the patient remotely on video, conduct examination remotely through the Internet of Things, all tests are done inside within 15 minutes using Point of Care diagnostics, and medicines are dispensed automatically from a machine. (The award movie and the innovation can be seen at https://youtu.be/fGHuhqte500 The Health Innovation can be visited at https://event.healthinnovation.exchange/booth?id=89) It was voted as the top innovation by the maximum number of innovators, health experts, policymakers and other visitors to the exchange.
As the virus spread across continents, it was clear that the new normal called for new approaches in hospital building design and architecture. Or modifying existing concepts to the new requirement for creating isolation and containment zones at high speed.
The buzz words seem to be a modular design. Nejeeb Khan, Country Head India and Design Head MEA, Katerra explains that Katerra’s design philosophy entails transporting standardised precast concrete elements manufactured at Katerra’s factories and assembled onsite, Lego-style.
Akshat Bhatt, Principal Architect, Architecture Discipline suggests recycling sea containers into community medical centres after refurbishing them with the necessary medical technology.
But is there any hope for turning around existing medical facilities? Thankfully yes. In the process of upgrading four government healthcare facilities, Chinmay Patil, Project Head, Healthcare Spaces, Edifice Consultants talks about the challenges of upgrading existing healthcare facilities without stopping usual activities. He also stresses on the need to ensure that such upgrades can be reversed smoothly once the pandemic passes, so that the existing facility can revert back to its original use, without lying vacant.
Mitu Mathur, Director- GPM Architects and Planners too feels the need to actively consider adaptive re-use of under-utilised civic infrastructure, like Mohalla clinics and government dispensaries which are already in place. This strategy can address the rising needs of beds in hospitals and act as an extension of larger hospitals or neighbourhood clinics. This approach will avoid the enormous costs of creating new infrastructure.
The Lego way
California, US-based Katerra actually uses the Lego concept as part of their “sustainable designs and (DfMA) design for manufacturing and assembly. The company “design and offsite manufacture components as repeatable products and streamline field assembly – allowing us to offer improved efficiency to customers. We are building at scale, without sacrificing design freedom by using standardised, configurable components – to design unique products,” says Nejeeb Khan of Katerra India.
“If you have seen complex Lego models or built one, you will notice that many of the pieces are standard but can be used to create different structures. The process of DfMA follows the same philosophy. Designing using this process allows large scale complex projects to be factory manufactured faster and better.”
Khan reveals that during the lockdown, Katerra also designed a 400-bed quarantine hospital that can be built in two weeks, similar to projects that have been built in both China and many European countries.
He explains how the DfMA philosophy was applied to two projects from India: Kovai Medical Center and Hospital (KMCH), Coimbatore and Meitra Hospital, Kozhikode. The company took an existing design and value-engineered them to suit the DfMA philosophy. Both buildings were fully factory automated, manufactured, and assembled on site.
The KMCH Hospital is, in fact, a COVID Centre in India, and Katerra India were building their 1 million sq ft expansion amid the lockdown with special government permissions. He points out that the advantage of the offsite manufacturing model meant that every aspect can be controlled, hence they had no outbreak onsite and construction continued seamlessly during the pandemic.
The building also features Katerra’s prefabricated modular bathroom pods manufactured entirely with all fittings, finishes, and MEP at the Katerra India pod factory and transported to the site for instant plug and use.
Speaking about the MEITRA Hospital, Khan says it was their first healthcare project, designed with patient care pathway as a focus. The 4 lakh sq ft. 500-bed super-specialty tertiary hospital which was constructed in 18 months, was designed to ensure maximum repeatability of elements. Every aspect of the hospital was planned before manufacturing, which ensured just-in-time production and seamless delivery and assembly. “Utilising DfMA was critical in bringing both production and cost efficiency to the project. With MEITRA, we successfully bridged the gap between architecture, engineering, and technology while reducing time considerably.”
Khan reveals that they are also constructing a new medical centre for GKNM Hospital, Coimbatore, Tamil Nadu, for treating women and children. All buildings built by Katerra come with an 80-year build warranty and require minimum to little maintenance.
Recycling sea containers as community medical centres
Akshat Bhatt of Architecture Discipline suggests using the same principle of prefabricated modular design at the primary healthcare level. His firm’s Life Community Medical Facility (CMF) uses prefabricated pods made from refurbished sea containers, which can be designed, built and transported to rural areas or disaster zones for almost immediate deployment.
The idea is rooted in the firm’s philosophy that “design is about reduction and optimisation. Hence, there is a strong need to revisit the essence of design and start removing all the unnecessary embellishments that result in waste and clutter.”
Reflecting on the present healthcare model in our country, he points on that it’s an easy realisation that the primary healthcare services are fairly inconsistent and while no country in the world can actually be fully prepared to handle an emergency like this, the time is ripe to push the agenda and re-invigorate primary healthcare as a critical public service.
As he explains, “Life CMF is an initiative that is conceived to address prevailing disparities brought to light by the current crisis aimed at ensuring accessibility, the immediacy of care, economical deployability, affordability, and a socially-integrative approach to health and well-being of individuals, families, and communities.
Life CMF also scores on the recycling front. “By using shipping containers as structural units, it revolutionises the speed of construction, opens up newer avenues for recycling and expands the availability of healthcare from cities to towns and villages and to all segments of our population.”
The Life CMF is modelled to provide community-oriented and patient-directed installation; to deliver comprehensive and high-quality primary healthcare services while eliminating economic, geographic and cultural barriers.
Listing the key features, Bhatt says that Life CMFs are designed to be modular and flexible, adaptable and durable and finally, to be easily installed during emergencies.
The design allows Life CMF to be delivered as prefabricated, ready to operate pods that are modular and expandable to cater to various needs. Each pod is flexible to be configured singularly or in a combination of two or more containers to function as a primary care unit, critical care unit, surgical suite, trauma/emergency unit, isolation or recovery pod and support functions such as pharma unit, screening unit, or diagnostic labs, or any other medical as well as administrative space as needed by the clients.
The adaptability and durability come from the fact that since the pods are made from steel shipping containers with R-19 insulation and temperature control devices, they can withstand extreme weather conditions, earthquakes, harsh terrain and security threats.
According to Bhatt, the interiors of the Life pods adhere to all healthcare standards, the finishes and material palette is of optimum hospital grade. In addition, they are fitted with bactericidal, fungicidal and virucidal solutions. The LED lighting and air-conditioning systems used are all rated Green Technology, utilising the sun as a renewable energy source.
The ease of installation during emergencies is a key factor, as the use of containers as a structural element allows the CMFs to be easily deployed anywhere in the world, even remote regions, according to Bhatt. With the clinic already assembled within the container, they can be operational within days of deployment, thus being able to set up emergency care facilities for COVID-19 patients and primary healthcare centres. It can be set upon a site measuring as small as 96’ x 96’ and can be completely dismantled and moved to a different place for reuse.
Bhatt has that they have currently envisaged more than 14 spatial arrangements possible within the units from single patient care to staff quarters to the administrative support areas. These could be further modified as per requirements.
They have two cluster variants; the white variant to function as the neighbourhood health facility and the green variant which is specific for deployment in the emergency zones – affected by natural calamities like floods, earthquakes, warzones, refugee settlements.
Prices vary from Rs 3.5 lakhs for the smallest upcycled module unit of size 20’ X 7’ X 8.2’ (6 X 2.1 X 2.5 M) to as high as Rs 25 lakhs depending on the services being integrated within the pod.
Admitting that they are currently not executing any projects along with the Life CMF concept, Bhatt estimates that once an order has been placed, it would take about a week to finish the smallest module whereas the full facility can be erected onsite within 14 to 18 days.
Repurposing for and beyond COVID-19
Even while COVID-19 overshadows the near future, we will have to ensure that facilities built for COVID-19 can be repurposed for other situations and do not lie unutilised once cases subside.
Making this point, Chinmay Patil of Edifice Consultants says, “The fact that we will have to learn to live with COVID-19 and such diseases are going to be recurring in the future, needs to be accepted by the Government and private entities. Strategies will need to be developed in the handling of such diseases beyond the current scope of the being specific during monsoons. At the same time, a careful balance would need to be maintained to ensure that we don’t build such facilities which lie under or unutilised leading to wastage of critical resources like trained staff, medical equipment and money.”
Edifice has developed a design for a prefabricated engineered facility for COVID-19 positive patients needing dedicated care, which can be developed in the time frame of three months and has a life of 10 years.
Describing the details, Patil says, “It consists of a 100-bed facility capable of providing with a 64 beds Inpatient Care Centre and Critical Care through Intensive Care and High Dependency Units of 36 beds along with demarcated areas for triage, screening and discharge of patients. It also consists of support areas for diagnostics, laboratory, CSSD, kitchen, laundry, stores, mortuary etc. The design of the facility is complete with all required air-conditioning, ventilation, humidity control, electrical, plumbing and fire prevention and fighting measures. Strategies for modular water, fire and sewage treatment plants are also in place for their quick installation.”
He mentions that the facility is also planned in different modules providing with the required flexibility to add functions later without hampering the sanctity and functioning of the already constructed facility. Patil mentions that Edifice is currently in talks with entities in the non-profit and government sectors on the implementation of these plans.
Edifice has had a long association with the Tata Group and over its 30 years of existence of late has been working closely with Tata Trusts in developing cancer hospitals for them across the country. In fact, Edifice is currently in the final stages of completing and handing over a Tata Trusts’ project to upgrade four government hospital buildings, two in Uttar Pradesh and two in Maharashtra, into Covid-19 Care Centres.
As the hospitals selected for conversion into a COVID -19 Care centres are all existing hospitals and delivering healthcare to the local population, each facility came with its own advantages and disadvantages.
Giving more details, Patil narrates how a few of the facilities were ageing and had to be retrofitted with the essential structural and Mechanical, Electrical and Plumbing (MEP) services to be fit for usage. Other services like medical gas pipe system – essential for providing care to critical patients – kitchen, laundry, general and pharmacy stores had to be added to these facilities to make them comprehensive in existence. Places, where such services existed, had to be augmented to meet the additional requirements of a COVID-19 Care Centre.
Since the hospitals are already existing, the most challenging aspect was to create a flow for the patients, staff and material within the given parameters to ensure absolute sterility and operational efficiency. At some locations, the rooms had to be altered to accommodate additional diagnostic modalities like X-Rays, USG machines and CT scanners without affecting the planning and functioning of the hospital.
Another aspect to be considered was that the upgradations had to be done in a way which would still allow the hospitals to be able to revert to its original intent of use with a smooth transition and minimal interventions.
Other hospital projects listed on the Edifice Consulting site are AMRI Hospitals, Bhubhaneshwar, Odisha, AMRI Women and Children Hospital, Mukundpur, Kolkata and the Zimlib War Memorial Hospital Project, Zimbabwe.
Tactical adaptive re-use of defunct structures
Mitu Mathur of GPM Architects and Planners explains that to fight the pandemic in the long run, we need an advanced and extensive network of accessible, available and affordable hospital-like facilities. Thus, locally available healthcare facility centres should be redeveloped to serve as health facilities which can address the rising needs of beds in hospitals and act as an extension of larger hospitals or neighbourhood clinics. Coupled with similar protocols of screening and treatment infrastructure, these facilities can prove to be an asset to the communities.
Another concept she believes in is design interventions that adhere to local contexts. “In the long run, while addressing the challenges faced by the existing hospital setups, the health care facility centres or institutions must adopt a new design template for the future designs, which are culture and climate-sensitive. A shift from monolithic single block building to a hybrid prototype, which offers courtyards and outdoor interaction will be prevalent. The focus should be on improving the sustainability of these buildings that traditionally have high energy consumption.”
As a case in point, she explains the design of their project, the Aayush Hospital at Panchkula. Listing the plus points, she says, “The built environment of the project integrates climate-sensitive design allowing natural ventilation for self-cleansing of air, interaction with green outdoors for natural light intake and thereby creating a positive recovery environment for the patients. The passive energy strategies employed through design interventions help reduce the maintenance cost with less dependency on air conditioning and artificial lighting.”
Besides the National Institute of Ayurveda, Panchkula, GMP has designed the HCG Mangalam Hospital, Jaipur, National Institute of Unani Medicine, Ghaziabad, Akaash Hospital, New Delhi and Balaji Nairogdham, New Delhi
No quick fixes
Seven months after the first cases of the novel coronavirus were first revealed, it is now clear that the virus is not going to be so easy to shake off. Therefore quick fixes like turning exhibition grounds, malls, workspaces, and hotels, into hospitals are not long term measures and are not as effective in any case.
The conversion of existing buildings into ICUs out of necessity is common wartime practise, points out, Khan. This practice gives governments the advantage of expanding capacities in critical medical times rapidly at a minimal cost.
But he cautions that these structures are not designed to be hospitals; hence, there is severe pressure on the medical staff to follow stringent protocols to avoid infectious spreads.
For example, he points out many of these structures don’t have adequate washrooms; they have toilets but no bathrooms. Their lifts and stairwells are not designed for the movement of stretchers and hospital equipment. The AC ducts and vents are built as per hospital protocol. Patient pathways, isolation room facilities are all makeshift, putting healthcare staff and support staff in these hospitals at significant risk.
Thus if we have to live with the virus indefinitely, we will have to think of more long term measures.
During the lockdown, Katerra designed a 400-bed quarantine hospital that can be built in two weeks, showcasing that building with speed and quality is possible in India as well.
Khan says their supply chain mimics the ‘hub and spoke’ model with two types of factories: mega factory campuses and mobile factories. The company has two mega factories in India (Hyderabad and Tamil Nadu), which cater to all of south India. Their mobile factories are movable units which are set up around a large project. Once the project is complete, the factory is moved to the next site. The model helps the company cater to projects anywhere in India.
On the cost front, Khan says, “The exciting part about the plug and play model is that the larger the project, the better the cost value. We take a very industrialised approach to construction – for example, the cost of building one car or mobile phone is very high, but economies of scale can drive prices down considerably. The cost of plug and play is in line with A grade traditional construction in India. Quality and Sustainability is critical to us, and we always prioritise this in any project.”
According to The National Health Profile 2019, India has around 7,13,986 beds, just 0.55 beds per 1000 people, way below the WHO recommendations. But getting to this number will need resources.
In a broader sense, Khan feels that “COVID-19 will transform both design and material used in all spaces. We have always advocated for a holistic model with high-quality material – placing quality first. New design projects will hopefully adopt this approach. Covid-19 has made the world aware of the threat of large-scale infectious diseases, and the crippling effect it can have on our lives, and this should lead to better design in places we live, work and entertain.”
He predicts that the use of technology and AI to map people’s movement, density, and building usage while designing spaces will also gain prominence. According to him, Katerra is already using AI software for design and mapping, and they believe that this will gain more traction in the years to come.
Khan of Katerra India concedes that significant investment will be needed to make a change, but believes that costs can be substantially lowered with a DFMA led offsite hospital building approach. “We have witnessed other countries achieving this, and it is something India can achieve. However, to meet this requirement, DfMA and offsite construction will be the go-to technology in the years ahead. Industrialised construction can deliver 12 per cent to 15 per cent cost efficiency and over 50 per cent saving on time. We need a public-private partnership alongside industrialised construction to provide the healthcare system India needs.”
Harking back to the philosophy of Architectural Design, Bhatt reiterates, “We believe that good architecture is a quest for space and that it must embrace the people and communities it serves because it belongs to them. Our projects are, therefore, guided by a sense of culture, climate, and place and act as canvases that reflect contemporary lives. They take roots from innovation to create modern expressions for the built environment and propagate sustainability as a culture rather than an added layer.
Adding to this, he says,” I also believe that as a civilisation, we need to be appropriate in what we build and not just build for the sake of building. This is going to be the century of recuperation; preservation is the path forward. And therefore, I see immense potential in the existing building stock in our cities. Most uninhabitable spaces can yet be transformed into habitable ones.”
Moving forward, Patil of Edifice Consultants believes that hospitals will have to devise strategies of segregating the infectious and non-infectious patients. This would mean developing two separate infrastructures within the hospital with separate entries to the building, separate diagnostic services like radiology equipment, laboratory, distinct surgery suites and inpatient services including Critical Care Units. Also, importance must be given to the upgradation / development of the building MEP services ensuring that apt airflow is maintained with optimum humidity levels inside the building at all times
Obviously drawing from the experience of refurbishing four government hospitals for the Tata Trusts project, he underlines the fact that “Government hospitals should be developed or modified with such strategies in place as they continue to provide healthcare services for the majority of the population in terms of accessibility and cost. The added measures will lead to increased construction areas and higher emphasis on the engineering services leading to higher capital and operational expenditure. However, implementation of these measures apart from ensuring the safety of the staff, patients and their relatives, also ensures the continuing functioning of the facility despite an epidemic/pandemic and be able to cater to the people which is far more important than the economics at such times.”
Currently, the primary health centres lack infrastructure, medical equipment and supplies, and most importantly sufficient and trained manpower. Hopefully, this pandemic should act as a warning to correct the defective infrastructure and policies to strengthen them. During epidemics or a medical emergency caused by natural or man-made disasters, these primary healthcare centres should be the first responders and act as a liaison with the IDC Centres in the initial reporting, creating awareness about the diseases and most importantly reporting the response of the community to the treatment and policies along with any recurrence of diseases as a means of creating a robust base for the healthcare delivery process. At the same time, an effective mechanism needs to be developed through policies, logistics and staff training in linking the primary health centres to the IDC Centres for a quick and seamless transition of a patient needing care.
Mathur of GPM Architects and Planners believes that “preparedness is prevention” and therefore they are researching ways in which existing hospital buildings are preparing themselves for fighting pandemic and maintain operations for other critical patients at the same time.
Secondly, she points out there will be an integration of technology with digital infrastructure. Tools such as crowd detection, thermal scanning are essential for identifying critical spots and segregate potential disease carriers. Also, with use of video calls and conferencing, virtual contact can be established between patients in quarantine, isolation or Intensive care with nurses, doctors and their loved ones, to minimise contact yet create comfort.
As Mathur sums up, “The motive is to move towards a system where health facilities become a catalyst for better health and promote healthy habits and well-being amongst communities. A nexus of healthcare infrastructure which enables resilience in the society. Therefore, the outbreak is an opportunity to identify gaps and catalyse positive changes in our built environment.”
These different architectural approaches against a common enemy only go to prove that there is no one right solution to tackle a pandemic. None the least when the ground reality is different in every state, city and neighbourhood. Just as a medical strategy which works in an urban slum-like Dharavi in Mumbai cannot be copy-pasted to the rest of the country, so also healthcare facility design has adapted to local needs.