The case for taller hospitals

Speaking at FICCI’s recently held Medical Value Travel Conference, NITI Aayog member Prof Vinod K Paul called for industry suggestions on reducing compliance burdens for healthcare facilities. A news release quoted Dr Paul saying, “We are systematically looking at how compliance burden for creation of facilities in cities, towns, and Tier 3 cities can be reduced.”

Reducing the compliance burden is also behind the efforts of NATHEALTH, a consortium of healthcare service providers. Among other issues, the association has been advocating for more clarity and relaxations in the National Building Code (NBC) 2016. More specifically, allowing hospitals to go beyond 45 metres, may be up to 60 m at least.

The association has reportedly submitted a letter to the Director General of Health Services (DGHS), along with a feasibility report on how these specific relaxations/clarifications could allow hospitals to maximise the cost of acquiring land and infrastructure costs by constructing more floors and rooms.

The NATHEATH report titled, Hospital Expansion in Urban India: Ensuring Safety in Vertical Growth, makes the case that vertical expansion of hospitals is the only way forward to mitigate the ever-increasing construction and land cost in urban centres. An annexure to the report suggests amendments to certain clauses in the National Building Code (NBC) 2016, which are a “source of confusion and misinterpretation for hospital building plan approvals.” The report makes the point that hospital buildings should be allowed to go beyond 45 metres; may be up to 60 m at least. This relaxation in height would allow hospitals to expand 3-4 floors beyond the existing norm of 12-15 floors, increasing the number of beds per facility.

Besides relaxing the cap on height, the annexure asks for changes in certain definitions. For instance, the existing NBC code states that ‘all critical patients and those incapable of self-preservation and having physical impairment shall be housed within 30 m height.’ This definition is interpreted as no patient room above 30 m by most states; thereby leaving only 30 m height for hospital planning. The NATHEALTH document points out that locating consultation chambers above 30 m will add to the elevator load. Secondly, it is also a hygiene issue for OPD patients to travel all the way to upper floors, besides becoming a source of outside infection for in-patients. NATHEALTH has suggested that the NBC should be suitably amended to define critical patients as those housed in an ICU or in an operating room.

Siddhartha Bhattacharya, Secretary General, NATHEALTH points out that certain states have already given this flexibility to certain projects. He reasons that if the NBC guidelines themselves are amended to allow higher flexibility, many other states can adopt these practices and this help both public and private, not only private, healthcare facilities to expand vertically.

Ironically, Bhattacharya points out that “hospitals often get outbid by hotels and residential apartments who can go higher. I think for hospitals the land should be the last of the worries, as they should be looking at treating as many patients as possible.”

Obviously, there is a difference between the residents of hospitals and hotels/apartments. Bhattacharya agrees that “hospitals have patients and in the event of a fire, they require speedy evacuation. But the detailed document looks at global examples where hospitals go up far above 30 metres, while ensuring that fire safety norms, patient safety are taken care of.”

The document cites examples such as Medanta Hospital in Gurgaon (60m), HN Reliance Hospital in Mumbai (75m), and the under construction Warangal Hospital Tower (100+ m). Among the global examples cited, the report mentions Guy’s Hospital Tower in London (149m) and Memorial Hermann Tower in Houston (165m), which demonstrate the feasibility of high-rise healthcare infrastructure.

Summarising the benefits, Bhattacharya believes that vertical expansion allows hospitals to maximise the utilisation of land, ultimately bringing down the cost of healthcare delivery. This could be one way for quality affordable expansion of healthcare facilities, both public and private, especially in urban areas, where land is scarce and very expensive.

The NATHEALTH document concludes that the analysis of global best practices, particularly from countries such as Singapore, the UK, the US, Dubai, and Malaysia, demonstrates that hospitals exceeding 45 metres in height must adhere to stringent fire safety measures, zoning protocols, and emergency preparedness standards. The document also cites Telangana’s amendments which introduce comprehensive regulatory provisions, enhancing fire safety, egress planning, and structural integrity for high-rise hospital buildings, pointing out that these reforms align with international best practices and provide a robust framework for the responsible vertical expansion of hospitals in India.

To ensure safe and structured hospital vertical expansion, the NATHEALTH document recommends that a formal working group be established comprising representatives from the Ministry of Health, fire safety experts, urban planners, and hospital administrators. This working group should develop a phased implementation roadmap for vertical hospital expansion, focusing on four aspects:

◆Aligning national building codes (NBC 2016) with National Fire

Protection Association (NFPA) and IBC standards for high-rise

hospital safety.

◆ Encouraging performance-based metrics for vertical

expansion of hospitals while establishing key parameters in

order to ensure alignment with desired outcomes and effective

assessment.

◆Introducing digital compliance tracking for fire safety audits and

inspections.

◆ Developing emergency response training programmes for

hospital staff in coordination with state fire departments.

There is no doubt that these recommendations would go a long way towards increasing the number of hospital beds in India’s urban areas. India requires an additional 2.4 million hospital beds to meet the WHO recommended ratio of three hospital beds per 1,000 people. Policy makers will have to tweak policies to cope with today’s realities of increasing urban populations and escalating costs of healthcare.

But recommendations tend to look better on paper. Reality is a different dimension, as implementation and interpretation could skew the original purpose. Do we have strong enough monitoring mechanisms to check that enhanced safety norms are being followed as hospitals add more floors? Ideally, public sector healthcare facilities should also be able to add extra floors. That would be the real game changer.

Secondly, increasing the number of hospital beds in urban areas might also widen the urban-rural divide. Healthcare facilities in rural areas rarely attract the required number of doctors and para medical staff. Thus, the benefits of taller hospitals might not filter down to a sizable number of ordinary patients unless policy makers put in sufficient checks and balances, and monitoring mechanisms.

VIVEKA ROYCHOWDHURY, Editor

[email protected]

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