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All queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; e-mail: pubrights@worldbank.org Design and layout: ULTRA Designs, Inc. 1 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Table of Contents Acknowledgments 3 3.0 DESIGN 34 Acronyms 4 3.1 Site and external environment 36 About This Guidance 5 3.2 Building design, structure, and materials 39 How This Guidance Is Organized 6 3.3 Building services 43 3.4 Finishes, fixtures and equipment 45 1.0 INTRODUCTION 7 3.5 Construction considerations in design 47 1.1 Background 8 3.6 Operations and maintenance considerations in design 48 1.2 Objectives 8 Case Study: Tambacounda Hospital, Senegal 49 1.3 Intended Audience 10 Case Study: Ng Teng Fong General Hospital / Jurong Community Hospital (NTFGH-JCH), 1.4 Scope of Guidance 10 Singapore 50 1.5 Overview of Key Concepts 12 Case Study: Elbistan State Hospital, Türkiye 51 2.0 PLANNING 16 4.0 OPERATION 52 2.1 Defining value and setting objectives 17 4.1 Commissioning 53 2.2 Considering context, service area, and wider network 18 4.2 Operational policies and plans 55 2.3 Selecting and assessing a site 20 4.3 Monitoring and maintenance 58 2.4 Identifying regulatory requirements 22 Case Study: Health Clinic Upgrades, Togo 60 2.5 Facility master planning and programming 23 Case Study: Kurashiki Central Hospital, Japan 61 2.6 Financial considerations 26 Case Study: Cicendo National Eye Hospital, Indonesia 62 2.7 Preparing for the design phase 28 Case Study: Culebra Community Health Center, Puerto Rico 63 Case Study: Maternal Center of Excellence, Sierra Leone 31 Case Study: Nyarugenge District Hospital, Rwanda 32 5.0 CONCLUSION AND SUMMARY TABLE 64 Case Study: Ghana Infectious Disease Center, Ghana 33 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 2 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation APPENDICES 69 BOXES Appendix A Health Facility Measures 70 Box 1 Applying the World Bank’s GRID Approach to Health Facilities 8 Appendix A.1 Resilience Measures by Hazard Type 71 Box 2 Why invest in resilient, green, and inclusive health facilities? 10 Appendix A.2 Catalog of Green Building Measures 83 Box 3 Who are health facility “users”? 12 Appendix A.3 Catalog of Universal Accessibility Measures 95 Box 4 Five Pillars of Resilient Health Systems 12 Appendix B Tools and Resources 102 Box 5 Resilient health facilities: considerations depending on scale 13 Appendix C Key Questions 104 Box 6 Green health facilities: considerations depending on scale 14 Appendix D Glossary of Terms 110 Box 7 Inclusive health facilities: considerations depending on scale 14 Box 8 Rehabilitation, Adaptation, and Retrofit of Health Facilities to Improve Resilient, References 116 Green and Inclusive Aspects 59 TABLES FIGURES Table 1.1 Types of health facilities covered by the guidance 11 Figure 1.1 Interaction between resilient, green and inclusive approaches for health facilities 9 Table 2.1 Key steps to achieve resilient health facilities 13 Figure 2.1 Value chain framework for delivery of health services 17 Table 5.1 Summary of guidance by implementation phase 66 Figure 3.1 Key design categories for resilient, green and inclusive health facilities 35 Figure 3.2 Munini District Hospital by Mass Design Group 38 Figure 3.3 Tambacounda Hospital in Senegal used locally fabricated brick screens to reduce solar heat gain 39 Figure 4.1 Types of plans for monitoring and maintenance 59 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 3 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Acknowledgments This guidance was developed as part of a global thematic area, This work benefitted from valuable peer review comments from World Bank), Christoph Michael Klaiber (Consultant, World Bank), “Climate and Disaster Risk Management for Health Systems” global experts (in alphabetical order): Clodagh Dodd (Senior Access Gabriel Aguirre Martens (Economist, World Bank), Swati Sachdeva and “Building Regulation for Resilience” under the Global Facility Consultant, O’Herlihy Access Consultancy), Dr. Tetsunori Ikegami (Urban Specialist, World Bank), Fatimah Abubakar Mustapha for Disaster Reduction and Recovery (GFDRR) with support from (Head of Emergency Room, Kurashiki Central Hospital), Jacob (Health Specialist, World Bank), Christine Lao Pena (Senior Human its Japan–World Bank Program for Mainstreaming Disaster Risk McKnight (Senior Researcher, Oxford University), Dr. Atsuhiro Development Economist, World Bank), Salvador Jiao (Consultant, Management in Developing Countries, financed by the Government Nakagawa (Professor, Tohoku University), Annette Ortwein (World World Bank), Nadia Leonova (Consultant, World Bank), Artemis of Japan. The team would like to express gratitude to the Ministry Health Organization), Dr Alex Camacho (Disaster Risk Reduction Ter Sargsyan (Consultant, World Bank), and Peeyush Sekhsaria of Finance, Japan for their continued support and guidance. Chief, Pan American Health Organization), Vita Sanderson (Senior (Consultant, World Bank). In addition, very helpful peer review Consultant, Arup) and Dr. Aki Toriyama (Principal, Design Division, comments were provided by the following World Bank colleagues: This guidance was developed by Katherine Coates (Consultant, Shimizu Corporation; and Director, Japan Institute of Healthcare Xiaohui Hou (Senior Economist, World Bank), Cristian A Herrera World Bank), Rebecca Laberenne (Consultant, World Bank), Keiko Architecture). (Senior Health Specialist, World Bank) and Marilyn Tolosa Martinez Sakoda (Senior Disaster Risk Management Specialist, World (Senior Disaster Risk Management Specialist) through the decision Bank), Mersedeh Tariverdi (Senior Data Scientist, World Bank), The team would like to thank the following World Bank col- meeting co-chaired by Niels Holm-Nielsen (Practice Manager, Ana Campos Garcia (Lead Disaster Risk Management Specialist, leagues for providing valuable inputs through consultations: World Bank) and Magnus Lindelow (Lead Economist, World Bank). World Bank), and Jun Rentschler (Senior Economist, World Bank). Arsala Deane (Operations Officer, World Bank), Wei Han (Senior Lastly, we thank the World Bank’s Global Corporate Solutions Technical inputs were provided by Takahiro Hasumi (Senior Health Health Economist, World Bank), Kari Hurt (Senior Operations Translation and Interpretation Services for editorial assistance, Specialist, World Bank), Vasudevan Kadalayil (Consultant, World Officer, World Bank), Ilhame Ouansaf (Health Specialist, World and Ultra Designs, Inc for graphic design. Bank), Andres Balcazar de la Cruz (Consultant, World Bank), Keita Bank), Mahoko Kamatsuchi (Senior Health Specialist, World Nfaly (Consultant, World Bank) and Barbara Minguez Garcia Bank), Maria Vida A. Gomez (Health Finance Specialist, World (Consultant, World Bank). Bank), Yasuhiro Kawasoe (Disaster Risk Management Specialist, 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 4 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Acronyms AIIR Airborne Infection Isolation Rooms IFC International Finance Corporation ASHRAE American Society of Heating, Refrigerating and Air-Conditioning Engineers IPS Isolated Power Supply BCA Benefit-Cost Analysis ISO International Standards Organization BCP Business Continuity Plan KPI Key Performance Indicator BREEAM Building Research Establishment Environmental Assessment Methodology LCCA Life-Cycle Cost Analysis CBDRM Community Based Disaster Risk Management LED Light-Emitting Diode CEA Cost-Effectiveness Analysis LEED Leadership in Energy and Environmental Design CT Computed Tomography MRI Magnetic Resonance Imaging DRM Disaster Risk Management NGO Nongovernmental Organization EDGE Excellence in Design for Greater Efficiencies NHS National Health Service EIA Environmental Impact Assessment O&M Operations and Maintenance EMS Energy Management System PAHO Pan American Health Organization EMT Emergency Medical Technician PBD Performance-Based Design EPC Engineering Procurement and Construction PBTs Persistent, Bio-accumulative and Toxic chemicals FF&E Furniture, Fittings and Equipment PPE Personal Protective Equipment GBV Gender-Based Violence QR Quick Response (code) GFDRR Global Facility for Disaster Reduction and Recovery SROI Social Return on Investment GHG Greenhouse Gas TVD Target Value Design GRID Green, Resilient and Inclusive Development UPS Uninterruptible Power Supply HCD Human-Centered Design US EPA US Environmental Protection Agency HIA Health Impact Assessment UVC Ultraviolet-C (Germicidal UV) Light HVAC Heating, Ventilation, and Air Conditioning UV Ultraviolet Light ICT Information and Communication Technology WHO World Health Organization ICU Intensive Care Unit WWR Window-to-Wall Ratio IEQ Indoor Environmental Quality 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 5 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation About This This document is intended as a primer to communicate key concepts, strategies and practical measures, supported by case study examples. It is for policy makers, development partners, and health sector practitioners involved in investment in health sector Guidance facilities, including planning, design and operations. Although the guidance includes some technical content related to planning, design and operation of physical infrastructure, it is intended to be accessible to users without expertise in planning, architecture, or engineering. Access to safe and affordable health services is essential for the This guidance document consolidates and conveys key concepts well-being of people, societies, and healthy economies. Climate and measures to promote resilient, green, and inclusive health change and environmental degradation are placing greater demands facilities linked to three key phases of the facility investment life on the health sector by increasing the exposure of many populations cycle: planning, design, and operation. to extreme heat, water insecurity, poor air quality and increased risk The guidance is organized into three main sections according to the R Resilient health facilities maintain functionality and provide ● three macro-phases of the facility investment life cycle: planning, sufficient capacity to reliably deliver essential health services design and operation. Within each phase, subsections organize during and after extreme events such as natural disasters or guidance based on common activities in that phase (for example, epidemics, and despite exposure to chronic stresses, such as selecting a site in the planning phase, or designing building utility demographic pressures on health systems or climate variability. systems in the design phase). Within each subsection, the guidance G ● Green health facilities are designed and operated to reduce covers resilient, green, and inclusive aspects separately, with color resource consumption and minimize negative impacts on the coding to facilitate navigation: environment throughout their life cycle. I ● Inclusive health facilities provide equitable and accessible As investments are made in new and existing health care infrastruc- health care to users of all ages and abilities by considering their ture, it is critical that efforts are made to reduce the carbon footprint diverse needs and addressing potential barriers to access. of health facilities to support global climate mitigation targets, while also improving infrastructure resilience to address the increasing risk and strains on the health sector due to climate change. These interventions must be formulated and implemented equitably, using inclusive principles to meet the needs of all health care users, partic- ularly underserved populations. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 6 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation How This SECTION 2.0 SECTION 3.0 SECTION 4.0 There are three main sections according to the three PLANNING PHASE DESIGN PHASE OPERATION PHASE macro-phases of the facility investment life cycle: Guidance Is GUIDANCE GUIDANCE GUIDANCE planning, design and operation. Within each phase, subsections organize guidance Organized based on common activities in that phase (for example, Planning Operations selecting a site in the planning phase, or designing Design Guidance Guidance for Guidance for building utility systems in the design phase). Within for Resilient Resilient Health Resilient Health each subsection, the guidance covers resilient, green, Health Facilities Facilities Facilities and inclusive aspects separately, with color coding to facilitate navigation. A summary table of the guidance in Sections 2.0 Planning Operations through 4.0 is provided in Section 5.0. The guidance Design Guidance applies to a wide range of types and scales of health Guidance for Guidance for for Green Health facility providing inpatient, outpatient, acute or Green Health Green Health Facilities preventative care in a wide variety of geographical Facilities Facilities contexts: urban, suburban, rural or remote. Due to the broad scope of the guidance, it is often generalized. However, it is supplemented by case studies that illustrate specific concepts and topics across a range Planning Operations of facility scales and geographic and socio-economic Design Guidance Guidance for Guidance for contexts. More detailed information on specific resilient, for Inclusive green and universal accessibility design measures are Inclusive Health Inclusive Health Health Facilities provided in Appendices A.1, A.2 and A.3, and Appendix Facilities Facilities B includes a list of existing tools for deeper investigation into specific topics within the planning, design and operation of health facilities. Appendix C gives a list of key questions and Appendix D a glossary of key terms. Click on any of these boxes to jump to that section 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES Click on this menu to jump to the Table of Contents 7 Chapter 1.0 Introduction 1.1 1.2 1.3 1.4 1.5 Background Objectives  Intended Audience  Scope of Guidance  Overview of Key 8 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Concepts  1.1 BACKGROUND represents a fundamental shift away from a reactive response and toward a deliberate strategy for climate action alongside long- BOX 1  Access to safe, affordable health services is essential for the term sustainable and inclusive development for all. It recognizes APPLYING THE WORLD BANK’S GRID APPROACH TO HEALTH FACILITIES well-being of people, societies, and healthy economies. The that social inequalities, aging populations, health, environmental impact of the recent COVID-19 pandemic on health systems as well impacts, and economic conditions are interdependent (World Bank, Green Promoting solutions that sustain natural capital, mitigate as the growing impact of climate change—increasing the frequency 2021a). climate change, and ensure that today’s decisions do not undermine and intensity of extreme temperatures, flooding, and storms—have tomorrow’s growth. This is particularly important for health facilities, demonstrated the need to enhance the resilience of our health This guidance draws upon and expands upon the concepts in as they are some of the most resource-intensive types of facilities. facilities by reducing the risk of damage and disruption of essential the GRID approach to provide practical guidance on promoting Resilient Investment in resilience and risk management to adapt services. Climate change and environmental degradation are also resilient, green and inclusive qualities in the delivery of health to climate change and prepare for pandemics, natural hazard events, responsible for mounting chronic health problems for vulnerable facilities. and socio-economic and financial shocks. As health facilities provide populations as well as disease outbreaks, underlining the need for essential lifesaving services, investing in their resilience to provide better access to health services. In addition, the World Health Organization (WHO) has recognized continuity of care is a priority. the need for guidance on the qualities of resilient hospitals and There is also growing evidence that the health sector has a what steps are needed to deliver them. According to the WHO Inclusive Supporting solutions that reduce disparities in access to framework, resilient hospitals have the following attributes: they quality health care services and do not leave anyone behind. To provide large environmental impact.1,2 As investments are made in new equitable health care services, facilities must be designed and operated and existing health care infrastructure, it is critical that efforts are safe and sustainable, inclusive, agile, and continuously learning to address the needs of all users including differing genders, ages, are made to reduce the carbon footprint of health facilities, while (PAHO, 2024)—this broadly aligns with the GRID approach. abilities, races, ethnicities, and religions. improving the resilience. Furthermore, to be equitable, these inter- ventions must be conceived of and implemented to meet the needs of all diverse health care users, considering demographic trends 1.2 OBJECTIVES (for example, aging populations) and the needs of vulnerable and underserved groups in societies. The main objective of this guidance is to share key concepts and measures to achieve resilient, green, and inclusive health In line with the Paris Agreement,3 the World Bank has committed facilities linked to three key phases of the facility investment to a green, resilient, and inclusive development (GRID) approach life cycle: planning, design, and operation. These concepts and (see Box 1 illustrating how the general GRID framework applies to measures are further explored in relevant case study examples health facilities). With respect to risk management, this framework throughout the guidance. 1 The National Health Service (NHS) in England calculated that it contributed 25 percent of all public sector emissions (NHS, 2009). 2 A global study showed that the health care sector is responsible for 4.4 percent of global net emissions (29 percent of which result from health facilities and their use of power). If health care were a country, it would be the fifth largest emitter on the planet. (Arup, 2019) 3 Specifically, for this topic, alignment relates to Mitigation (Art. 4), Adaptation (Art. 7) and Loss and Damage (Art. 8) of the Paris Agreement. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 1.1 1.2 1.3 1.4 1.5 Background Objectives  Intended Audience  Scope of Guidance  Overview of Key 9 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Concepts  More specifically, the objectives are: FIGURE 1.1 INTERACTION BETWEEN RESILIENT, GREEN AND INCLUSIVE APPROACHES FOR HEALTH FACILITIES ● To communicate the benefits of investing in green, resilient and univer- sally accessible health care facilities; Wh t m sur s c n nsur th s f t of ll us rs, r rdl ss of nd bilit , whil improvin r sili nc ? ( . . how c n ll ● To introduce key concepts and measures for achieving green, resilient us rs v cu t s f l in dis st r nd wh t continuit of and inclusive health care facilities and understand how these are applied c r is n d d?) depending on the country context, their type, scale and complexity of function; How c n f ciliti s d liv r h lthc r mor quit bl s ● To share how these concepts and measures can be implemented during the dis st r nd clim t ch n imp cts r disproportion t l , planning, design and operations phases of health care facilities, including imp ctin , vuln r bl roups? ( . . f ciliti s m n d to b the roles of key stakeholders; and bl to incr s c p cit nd/or h v mor r dund nt n twork to d liv r c r ) ● To share good global practice through relevant case studies, as well as applicable tools and guidance documents. Although the guidance is separated into resilient, green and inclusive topic areas, we recognize that there may be influences and interdependencies Wh t t p of loc l r sourc s nd among planning, design and operational approaches, the better to achieve cr ftsm nship c n b d plo d RESILIENT INCLUSIVE th t r r sili nt to xp ct d results in each area (See Figure 1.1). In fact, to achieve lasting green and inclu- shocks nd str ss s nd sive benefits and a strong return on investment, the longer-term resilience of ppropri t for th loc l a facility is paramount. nvironm nt to support th communit nd conom ? Wh t t p s of r n buildin m sur s lso h lp improv Wh t consid r tions r n d d GREEN r sili nc to clim t ch n for r n buildin m sur s to b imp cts? ( . .sol r sh din t ilor d for ll us rs? nd r fl ctiv roofs c n ( . .univ rs l cc ss to r n r duc th imp ct of xt rior sp c s, s st m, xtr m h t for buildin op r bilit , d si n, comfort occup nts). r n s, d p ndin on us r t p ). Source: Authors 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 1.1 1.2 1.3 1.4 1.5 Background Objectives  Intended Audience  Scope of Guidance  Overview of Key 10 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Concepts  1.3 INTENDED AUDIENCE Although this guidance has been tailored for the planning and BOX 2 design of new facilities, some concepts, particularly those in the WHY INVEST IN RESILIENT, GREEN, AND INCLUSIVE HEALTH This guidance is intended as a primer to communicate key concepts, planning and operations sections, could be applicable for upgrading FACILITIES? strategies and practical measures to promote resilient, green, and existing facilities (refer to Box 8 in Section 4.0). The construction Access to safe, affordable health care is essential for the well-being of inclusive health facilities to policy makers, development partners and decommissioning phases have been excluded because most people, societies and healthy economies. and health sector practitioners involved in the health sector facility decisions supporting resilience, green building and inclusivity goals investment, planning, design and operations. Although the guidance are made in the planning, design, and operation of facilities. Global trends in many countries are converging to put more pressure includes some technical content related to planning, design and on health systems. These include aging populations, increased risks operation of physical infrastructure, it is intended to be accessible driven by climate change including habitat degradation, natural to users without expertise in planning, architecture, or engineering. disasters and pandemics. Human and economic losses avoided: More resilient health facilities can improve the continuity of care in the face of shocks and stresses. 1.4 SCOPE OF GUIDANCE Less disruption means lives saved, especially in the aftermath of disasters (Yamanouchi, 2017). The guidance applies to a wide range of types and scales of health facilities providing inpatient or outpatient acute and/or preven- Improved well-being and productivity: For example, incorporating tative care (see Table 1.1). These facilities can be located in urban, of natural landscaping or improved natural light and ventilation into health facilities, has been shown to improve the comfort and well- suburban, rural or remote areas. The guidance is not intended to being of patients and the productivity of health care providers (Ackley cover nursing homes and other long-term care facilities. Given that et al., 2024: Van Iperen et al., 2023). the guidance covers concepts at a generalized, high level, the user should evaluate which approaches and measures are most appropri- Lower life-cycle costs: Evaluating costs over the whole building life ate for the context of the health facility project under consideration. cycle can demonstrate that upfront investments in resilience and Selected case studies are provided to give practical applications of green building measures can yield longer-term savings (Multi-Hazard Kerala government family health center in India. © libin jose / iStock. the guidance across a range of facility scales and geographic and Mitigation Council, 2019; Dwaikat and Ali, 2018). socio-economic contexts. Long-term value: A resilient, green, and inclusive approach to health facility design includes building in flexibility to adapt to future demands. This ensures that facilities have enduring value, providing long-term benefits to the populations they serve. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 1.1 1.2 1.3 1.4 1.5 Background Objectives  Intended Audience  Scope of Guidance  Overview of Key 11 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Concepts  TABLE 1.1 TYPES OF HEALTH FACILITIES COVERED BY THE GUIDANCE LEVEL OF CARE PROVIDED PATIENT TYPE(S) COMMON TYPES OF TYPICAL NUMBER LOCATION FACILITIES OF BEDS Primary: Typically the first point of contact Outpatient Health posts, clinics, 0–20 Remote, rural, suburban, urban for patients, often delivered by a general community health centers, Small medical clinic in rural Kenya. practitioner, nurse or pharmacist who can primary care centers handle many basic concerns in an outpatient © Melissa Kopka / iStock. setting. Referrals can be made for more specialist care, if required. Secondary: This type of care can be more Outpatient and District hospitals, “first 5–1,000 Rural, suburban, urban complex and involves specialist input to inpatient referral” facilities, day A small hospital in Uganda, Africa. diagnose and treat a broad range of medical surgery/procedure centers © Delmas Lehman / iStock. conditions, often in a combination of inpatient and outpatient settings. Tertiary: This type of, inpatient care is for Inpatient Specialized hospitals, larger 50–1,000 Urban, suburban patients with more severe diseases or those in national hospitals need of intensive care. Typically, tertiary care is provided in larger, specialized hospitals. Central Hospital in Guinée-. © mtcurado / iStock.com. Source: Adapted from Ahmed et al., 2015; Nah and Osifo-Dawodu, 2007. (*) In addition to these main types of care, there is quaternary care (for rare or complex conditions), emergency care, and long-term care, delivered through hospitals, clinics and other health facilities, which may also be evaluated and supported through the lens of resilient, green, and inclusive interventions, although these are not specifically addressed in this guidance. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 1.1 1.2 1.3 1.4 1.5 Background Objectives  Intended Audience  Scope of Guidance  Overview of Key 12 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Concepts  1.5 OVERVIEW OF KEY CONCEPTS What is a RESILIENT health facility? BOX 4 Resilient health facilities are a key component of resilient health In this section, we define the terms resilient, green, and inclusive, FIVE PILLARS OF RESILIENT HEALTH SYSTEMS systems as defined by the five pillars set out by the World Bank and explain how these characteristics inform the planning, design, in ‘Frontline: Preparing Healthcare Systems for Shocks from This guidance focuses on Pillar 2 but touches upon other related aspects and operation of health facilities. Finally, we look at key stakehold- Disasters to Pandemics’ (World Bank, 2021b) (see Box 4). More from Pillars 1, 3, 4, and 5. ers involved in the delivery process. broadly, resilient systems seek to anticipate and mitigate risks while maintaining adaptive capacity to respond to disruptions and 1. Foundations: health systems that can effectively manage recover from them. Extreme events or acute, sudden shocks can routine demand. Ensure universal access to routine health care BOX 3 by strengthening operational and technical capacity, planning, include disasters caused by cyclonic wind events, earthquakes or WHO ARE HEALTH FACILITY “USERS”? governance; improving information systems; mobilizing financial floods or a sudden or unexpected increase in the number of cases resources, and so forth. Throughout this guidance document, the word “users” is defined as all of a disease. In some cases, health facilities can also take on new people who interact with the physical environment of a health facility or expanded functions and capacity in the aftermath of disaster 2. Resilient health facilities. Ensure adequate capacity and resilience of and/or receive its services. Users include, but are not limited to, patients facilities by upgrading structures, improving facility management, events. Fundamentally, resilient health facilities aim to maintain and their families; health care providers such as doctors, nurses, planning for emergencies, and so forth. their critical functions—and associated services—during and technicians, emergency medical technicians (EMTs), and other personnel; in the aftermath of shocks or stresses. Resilient health facilities 3. Resilient health systems. Integrate individual health facilities into hospital staff including janitors, maintenance workers, administrative achieve this by mitigating risks, incorporating redundancy into a coordinated network and improve cooperation during crises staff; temporary visitors including delivery people; and the communities their design, and displaying the ability to adapt and transform to by using data-driven approaches, improving communication that are served by the health facility. and cooperation, leveraging health care solutions outside health drive service continuity (PAHO, 2024). Operational planning is also facilities, and so forth. required for handling such scenarios in ways that safeguard all users and address stresses on facilities and health professionals 4. Integrated emergency response. Integrate health care into disaster caused by patient surges during emergencies. risk management (DRM) systems by meeting critical needs during crises, coordinating with search and rescue, establishing interagency communication channels for emergencies, defining Resilient health facilities must also be capable of coping with more roles and responsibilities in crisis, improving early warning systems, frequent and chronic stresses. Stresses can range from periodic and so forth. heatwaves, water scarcity, heavy rainfall or localized flooding to loss of services such as electricity blackouts or lack of security in 5. Resilient infrastructure. Ensure the resilience of critical infrastructure systems upon which health facilities depend by conflicted-affected zones. Solutions can include climate adapta- upgrading transport, water, electricity, and telecommunications tions for facility design, secure locations for critical medical sup- assets, strengthening cyber resilience, and mandating risk-informed plies, and backup systems for water and power supplies. infrastructure planning. Lao women leave a public health clinic Muang Ngoi village Northern Laos. Source: (World Bank, 2021b) © Malcolm McDougall Photography / Alamy Stock Photo 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 1.1 1.2 1.3 1.4 1.5 Background Objectives  Intended Audience  Scope of Guidance  Overview of Key 13 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Concepts  This guidance considers the following keys steps to achieve resilient health facilities: BOX 5 RESILIENT HEALTH FACILITIES: CONSIDERATIONS DEPENDING TABLE 2.1 ON SCALE KEY STEPS TO ACHIEVE RESILIENT HEALTH FACILITIES Larger facilities: These facilities often provide specialized or intensive DEFINE IDENTIFY SHOCKS IDENTIFY LEVEL OF IDENTIFY KEY IDENTIFY WAYS MONITOR AND care. They may also serve additional functions during regional VALUE AND SET AND STRESSES EXPOSURE/SITE VULNERABILITIES AND TO REDUCE MANAGE RESILIENCE HAZARDS COSTS OF DISRUPTION VULNERABILITIES emergencies. As such, they require a higher level of consideration in OBJECTIVES AND BUILD ADAPTIVE resilience planning to ensure continuity of service provision. Larger CAPACITY facilities may also have more complex interdependencies than smaller Understanding the To test the resilience The size and scale Vulnerabilities could Measures include Facilities must facilities, and these must be considered in resilience planning. value of the health of a system, shocks of the facility and relate to the physical resilient design of be adequately care facilities and and stresses need the number of building (both structural facilities, backup for maintained, Smaller facilities: In determining the resilience objectives of smaller the services they to be identified, occupants determine and nonstructural essential services, monitored and facilities, it is important to understand which services can be interrupted provide and setting evaluated and its exposure. The elements), power, water, improving reliability managed and in an emergency without serious consequence (for example, emergency resilience objectives prioritized in terms specific levels of and other supplies, or and redundancy, operational patients may be routed to a larger, regional hospital) and which services is the starting point of potential impact. geological and organizational aspects. flexible design for planning must cannot (for example, chronic health care services such as dialysis). to determine how to climatic hazards Evaluating costs of adaptability, and be up to date prioritize investment are linked to site damage and disruption additional resource to respond to and focus efforts. location and are can help prioritize capacity. This could changing needs and often minimized investment. include the wider risks and thereby with appropriate site network. ensure resilience selection. and continuity. Examples of measures to improve resilience for various types of efficiency of buildings and systems, reducing the embodied carbon shocks and stresses are given in Appendix A.1. of construction materials and activities, and incorporating planting into the design, such as green roofs and exterior planting. Green What is a GREEN health facility? building measures can also improve resilience to climate change impacts such as extreme temperatures, water scarcity, heavy rain- Green health facilities are designed to be more resource-efficient fall and the risk of localized flooding. and have a reduced environmental impact throughout their life cycle—from selection of the site, design, and construction to oper- Examples of green buildings measures tailored for health facilities ation, maintenance, renovation, and demolition (US EPA, 2021). are given in Appendix A.2. Flooded hospital at Perumbavoor. © Vishnus00, WikiMedia. Green measures include improving the energy efficiency and water 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 1.1 1.2 1.3 1.4 1.5 Background Objectives  Intended Audience  Scope of Guidance  Overview of Key 14 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Concepts  What is an INCLUSIVE health facility? Universal accessibility is a particularly important element of inclusiv- BOX 6 ity for health facilities, because they provide essential services and Inclusive health facilities promote equitable and effective access to GREEN HEALTH FACILITIES: CONSIDERATIONS DEPENDING ON can have a higher proportion of users with special needs. These include SCALE health services by considering the diverse perspectives and needs persons with disabilities, children, pregnant women, the elderly and of users of all ages and abilities and addressing potential barriers to Larger facilities: These people in a range of psycho-emotional states. Accessibility ensures access. Inclusive measures should be founded upon a human-rights facilities are typically more ease and efficiency of independent approach, entry, evacuation, based approach to health provision, considering the needs and energy- and water-intensive. and/or use of a building and its services by all the building’s potential cultural preferences of marginalized and underrepresented groups, It is recommended that both users with an assurance of safety, dignity, and welfare during those passive and active measures including women and minorities, who are served by the facility or activities (World Bank, 2022 and 2025). be considered to improve work in the facility. energy and water efficiency Although this guidance is primarily focused on how to help health for the buildings, alongside investment in energy and facilities fulfull requirements for universal accessibility, broader water efficient equipment Rooftop garden in Singapore. BOX 7 aspects of social inclusion in the planning and operational phases and measures to reduce © Lim Weixiang - Zeitgeist Photos / iStock. INCLUSIVE HEALTH FACILITIES: CONSIDERATIONS DEPENDING of delivery are also touched upon. resource usage. ON SCALE Smaller facilities: These are Larger facilities: These facilities typically serve a larger catchment area Delivering resilient, green, and inclusive health facilities typically in operation during and may provide a wider range of services for a more diverse range of Key activities in the planning, design and operations phases: fixed daytime hours only and patient and provider needs and conditions. Site accessibility, clear do not serve inpatients. The signage, and communication of wayfinding for more complex functions, Planning includes: energy footprint is lower and fittings, fixtures and equipment for people of all genders, ages and than for larger facilities. abilities are essential, particularly when they are sick or needing medical ● Identification of stakeholders and users, and goal setting, For example, green building care. Typically, these buildings will be multi-story and require accessible including determining capacity, service needs, and the rela- measures may focus design for vertical circulation. tionship of the facility to existing health systems and other on building orientation, physical and social systems; daylighting, natural Rural health center in Kenya. © Elen Marlen / Smaller facilities: Universal accessibility must be addressed for any size iStock. ● Understanding of the context (such as geography, hazards, ventilation, insulation and of facility, but some smaller facilities like clinics and health posts will be less complex than larger hospitals as they typically have less complex climate, regulations, culture); other measures to ensure a that ensure a comfortable temperature within the building as well as the provision of renewable energy. circulation and functions. In some contexts, to reduce complexity and ● Funding and financial planning; cost (for example, the need for elevators) it may be advantageous to ● Master planning and programming; avoid multistory buildings. The use of local materials and construction methods as well as labor for construction, operations and maintenance ● Site assessment and selection; and could be explored to extend the project’s economic benefits to the local ● Preparing for the design stage, including setting the design community. brief and procuring design services. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 1.1 1.2 1.3 1.4 1.5 Background Objectives  Intended Audience  Scope of Guidance  Overview of Key 15 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Concepts  Design includes: Resilient, green, and inclusive objectives can be supported by Key stakeholders across the delivery stages typically include: ● Specifying technical design criteria based upon refined the above activities when the following principles are adhered to design objectives and requirements for the facility; throughout the delivery of the health facility: ● Investors/financing partners/donors; ● Evaluating and selecting measures for resilient, green, and ● Facility operators/owners; 1. Set clear objectives for the facility and track and maintain the inclusive design; ● Facilities management; design intent over the course of delivery of the facility irrespec- ● Estimating costs (including life cycle costing) and value ● Planners and design and construction professionals (see Section tive of any technical, financial, or scheduling challenges; engineering to meet budget and operational requirements; 2.7); 2. Recognize the facility’s context and interdependencies with Medical and nonmedical staff; ● Preparation of design and construction documents and ● existing connected systems; specifications; ● Patients and their families; ● Specifications for equipment, furniture, supplies, and so 3. Use forward thinking over the life cycle of the facility to antici- ● Suppliers and vendors of medical equipment and supplies, utili- forth; and pate and plan for future needs and uncertainties; and ties, or information systems; ● Regulatory approvals. 4. Support inclusive stakeholder engagement and collaboration in ● Health educators/researchers; decision-making. ● National and local government including policy makers, health Operations include: regulators, and building regulators; Key Stakeholders ● Building commissioning; ● Attorneys and legal advisors; Input from key stakeholders at each stage of planning, designing ● Setting operational policies; ● Community groups and organizations including patient support and operating health facilities will shape a clear, shared understand- ● Emergency and business continuity planning related to groups; and ing of the service offering and target population for any proposed facilities management; Local residents and communities. health facility. The input will ensure that the design of the facility ● ● Training and capacity building activities for facilities and its operational practices meet the needs of service users and management; providers. Particularly for smaller scale, rural health facilities, ● Periodic risk assessments and performance evaluations; community engagement in the delivery of the facility will elicit key ● Ongoing maintenance; inputs, identify potential barriers to implementation, and cultivate long-term local engagement and investment in maintaining the ● Expansion, renovation and/or retrofit of facilities; and facility. ● Community engagement in the above activities. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 16 Chapter 2.0 Planning Key Activities in the Planning Phase Defining value and setting objectives (Section 2.1) Considering context, service area and wider network (Section 2.2) Selecting and assessing a site (Section 2.3) Identifying regulatory requirements (Section 2.4) Facility master planning and programming (Section 2.5) Financial considerations (Section 2.6) Preparing for the design phase (Section 2.7) 2.1 2.2 2.3 2.4 2.5 2.6 2.7 Value and objectives Context, service area Site Selection  Regulatory Master planning and Financial Design phase prep 17 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation and wider network  requirements  programming  considerations  preparation 2.1 Defining value and setting objectives Aligning stakeholders on the strategic goals for the value that the health facility delivers (services Summary Points in the Planning phase provided, functions, other wider co-benefits) and related objectives in the planning phase sets the direction for further decision-making during delivery. Identifying key stakeholders and facilitating The facility’s value—its intended impact—explicitly aligned with meeting resilient, green their engagement is essential at the start of the delivery process (refer to Section 1.0). Initially, the and inclusive goals, should be set in the planning phase and integrated into facility master delivery team must define priorities for the functions and services of the health facility and its capac- planning and programming. ity, typically based on a needs assessment of the service catchment area (WHO, 1996) as well as anticipated future needs. Understanding the context, service area and how the facility will fit into the wider network strongly informs the ultimate resilient, green and inclusive design criteria for the facility as How value is defined for the facility will influence and interact with the resilient, green, and inclusive well as the scope of service needs. objectives for the facility. These strategic goals and related objectives will be refined during different elements of the planning process as described in Sections 2.2 - 2.6. For example, for the resilience Appropriate site selection can minimize hazards that may impact the facility and assessment, potential vulnerabilities and solutions to add redundancy and recovery strategies can be maximize accessibility and other community benefits. identified by analyzing steps in the value chain. Facility regulatory requirements and the quality and comprehensiveness of regulations for resilient, green and inclusive aspects in the jurisdiction should be evaluated early in the FIGURE 2.1 planning phase. VALUE CHAIN FRAMEWORK FOR DELIVERY OF HEALTH SERVICES It is important to assess the longer-term financial benefits of resilient, green and inclusive health facilities to motivate decision-makers and other key stakeholders to invest in them. Administration Communication and IT Support functions The planning phase offers an important opportunity to influence the resilient, green, and inclusive Marketing/PR benefits of a health facility. In this phase, key decisions are made around the goals and objectives Procurement (of medication) of the facility, its required capacity and programming needs, and where it is located. Stakeholder engagement during the planning phase ensures that the voices of patients and their families, doctors, Admission Diagnosis Treatment Discharge Post- nurses, staff, community leaders and local policy makers are heard and meaningfully integrated into treatment Patient flow care delivery. The planning phase also requires developing an understanding of the context (physical, social, environmental, and so forth) into which the new facility will be integrated. Accurately assessing the investments and long-term benefits of resilient, green, and inclusive features is crucial for their inclu- sion in the facility’s funding and financing. Source: adapted from: Porter, Michael E., “Competitive Advantage”. 1985, Ch. 1, pp 11–15. The Free Press. New York. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 2.1 2.2 2.3 2.4 2.5 2.6 2.7 Value and objectives Context, service area Site Selection  Regulatory Master planning and Financial Design phase 18 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation and wider network  requirements  programming  considerations  preparation 2.2 Considering context, service area, and wider network RESILIENT-SPECIFIC GUIDANCE Identifying shocks and stresses: Identify the types of shocks, such as disasters caused by earth- Acquiring an understanding of the context in which a new facility will be located is fundamental to quakes, storms, flooding or other events that could impact the facility. Identify stresses that validating and refining objectives and developing a plan to deliver the facility. The geographic, climatic, might impact the facility such as extreme heat, water scarcity, conflict, seasonal diseases, and demographic, health, socio-economic and cultural context must be evaluated for the area that will demographic trends. Risk trends may need to be considered (for example, how future climate or be served by the facility. The systems and networks to which the facility will connect should also be demographic trends can affect risk levels). mapped, including the wider regional health care network and infrastructure systems. Consultation with stakeholders as part of this process is valuable for gaining deeper insights into priorities. Assessing vulnerabilities: Assess the vulnerabilities in the surrounding population and built envi- ronment that could increase the risk to these hazards and might influence health care (for exam- Key areas to be agreed and determined in the planning phase to support resilient, green, and inclusive ple existing aging population, population without health insurance, and so forth). Vulnerabilities benefits include: should be considered for both normal operations as well as in the aftermath of disasters. For example, approximately 20 percent of the population age five or older in the 10 parishes ● The role of the health facility in the community, the region and the wider network of health facil- of New Orleans affected by Hurricane Katrina in 2005 had a pre-existing disability of some ities and health resources (including mobile units, virtual health care and so forth) during normal type, and tens of thousands of those affected had cancer (Mensah et al., 2005). operation and in emergencies. ● The service catchment area for the facility and the health needs of the users within the catch- Role in the wider network: How the facility and its services fit into the wider network should be ment (for example, demographics, cultural practices, epidemiology, risk factors, relevant health considered when setting resilience objectives. For example, the facility may provide essential ser- behaviors). vices that are not available elsewhere in the region. Conversely, if certain services were disrupted ● Anticipated future trends (for example, shocks and stresses of increasing frequency and severity or there was a surge in capacity, demand could potentially be served by other facilities in the due to climate change impacts, aging population, need for added capacity, changing health needs, health network or by mobile units. In the event of a regional disaster or an epidemic, changes in and so forth). service needs and demand for care should be evaluated, including how the facility would cope as part of a wider network, and whether there are opportunities to divert patients to other facilities. ● The extent to which the facility design can provide other benefits to the community, beyond health service provision (such as additional green space, accommodation for staff, children’s play areas). Reliance on wider infrastructure systems: Connection to and reliance on essential wider infra- structure systems should be assessed (for example, power, water, telecommunications, trans- Case study connection: The Tambacounda Hospital in Senegal integrated a playground—the port) and as well as their level of reliability and resilience when experiencing a shock or stress. city’s first—for the children of visiting families as well as for the surrounding community into Depending on resilience objectives, this can inform the types and capacities of backup systems the design of the site. This served to accommodate the local cultural practice of having family needed. members of patients on hospital premises. Overall, it is important to specify in the planning phase levels of acceptable service disruption or reduced service provision for different functions in the face of defined, plausible shock and stress scenarios. The consequences of disruption may be more serious for certain functions, like 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 2.1 2.2 2.3 2.4 2.5 2.6 2.7 Value and objectives Context, service area Site Selection  Regulatory Master planning and Financial Design phase 19 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation and wider network  requirements  programming  considerations  preparation intensive care, than others like pediatric primary care, so different targets can be set for each. For example, in Tanzania, where solar photovoltaic systems were installed at health clinics For example, it will be important after a disaster for smaller health facilities, such as health posts to provide lighting and refrigeration of vaccines, local students were trained to maintain the or primary care facilities, to maintain basic services, if possible, not least to reduce the stress on systems (WHO, 2009). larger hospitals (while avoiding further diminution of access to care). Key questions: Resilience objectives should also consider the intended role of the facility in emergency or disas- ● What are the climatic conditions in the region? Which types of green building measures ter scenarios—for example, if it will serve different or expanded purposes to support the broader are appropriate for the climatic conditions? community’s resilience goals. Together, these objectives will guide the development of the techni- ● Depending on the local construction environment and available resources, which types cal design and operational planning of the facility. of construction, materials and green building measures and systems will be feasible and Key questions: appropriate to implement? ● What are the shocks and stresses that can affect the current and future service delivery and/or demand needs as well as disrupt or damage the health facility? INCLUSIVE-SPECIFIC GUIDANCE ● For resilience objectives, what level of disruption to service delivery is acceptable in Universal accessibility needs: Assess the special needs of potential users that will influence uni- different types of shock or stress scenarios? versal accessibility. This should include considerations for the elderly, children, people with disabil- ● How do the facility and its services fit into the wider health network and how does this ities, and other marginalized or disadvantaged groups within the service catchment area. affect resilience objectives? ● How are the facility functions reliant on wider infrastructure systems? How can this Wider considerations for inclusion: Cultural or traditional practices of potential users—especially inform requirements for backup systems? around birth, death and caring for loved ones—are important needs that should be understood, considered and accommodated during the early planning stages. Facility impact on local communities: Potential negative impacts from the new facility on local GREEN-SPECIFIC GUIDANCE communities resulting from the delivery of the facility should be considered along with strategies The climate of the region: Assess it (for example, temperate, tropical, dry, and so forth). This will to minimize these impacts in the planning phase (for example, increased traffic congestion, lack determine which green building strategies are appropriate to consider and how they influence the of adequate parking, light pollution). form, orientation and materials of buildings. Also see Section 3.2 for further guidance. Case study connection: The Maternal Center of Excellence in Sierra Leone was planned Local construction environment and resources: Evaluate the capacity of the local construction with generous courtyards and gardens for family members who often accompany patients sector, types of local material available well as the capabilities and funding available for operating to support their basic care and nonmedical needs. and maintaining building services. This can broadly inform which green building strategies are appropriate (for example, passive vs. active energy efficiency measures, or a combination of both, Positive impact on local economies: The planning phase should consider if local construction appropriate types of technology and equipment, ease of use and maintenance, and so forth). skills and labor can be used for the project and how local communities could be involved in the management or maintenance of the facility over the longer term. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 2.1 2.2 2.3 2.4 2.5 2.6 2.7 Value and objectives Context, service area Site Selection  Regulatory Master planning and Financial Design phase 20 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation and wider network  requirements  programming  considerations  preparation Key questions ● If there is more than one site under consideration, conduct a site option comparison using multicriteria decision analysis that captures the advantages and disadvantages of each location ● What types of universal accessibility needs are anticipated for the facility based on across the life of the facility. services provided and user types? ● What types of cultural practices need to be considered in the planning and design of the facility? RESILIENT-SPECIFIC GUIDANCE ● How can any potential negative impacts of the facility be mitigated? ● How can the facility have a positive impact on the local economy Identifying site specific hazards: For example, the risk of landslide, other soil instability, flooding, ● How can broader community investment in maintaining the facility be encouraged? strong winds, sea level rise and other hazards can be assessed for the site. In some cases, as part of the planning process, hazard and risk maps at appropriate scale are available but site-specific hazards such as landslide, soil instability, or localized flood events often need site-specific investi- 2.3 Selecting and assessing a site gations such as geotechnical investigations, landslide risk assessments, or flood risk assessment. It may be necessary to engage disaster risk experts for advice to address these considerations Selecting a site and understanding the context are strongly linked. As such, many of the considerations and conduct necessary assessments in the early stages of the planning phase. identified in Section 2.2 influence the final selection of a site. These include the site’s relationship to the wider health care network, environmental considerations, relevant shock and stress scenarios Consider if alternate sites are available that would avoid or significantly reduce exposure to cer- and accessibility of the site relative to the service area. Additional considerations in selecting and tain hazards altogether (for example, sites at a higher elevation outside of floodable areas, or sites assessing a potential site include the following: located farther from landslide-prone hillsides). In general, it is much more cost-effective to miti- gate natural hazard risk through careful site selection than through engineering or nature-based measures (Moradian et al., 2017). General: For example, in New South Wales, numerous sites were considered for the construction of ● Where are the gaps in health care coverage in the targeted area? A mapping exercise can help to a new Tweed Valley Hospital. Ultimately a site with an elevation above the probable max- identify potential areas for new facilities or expansions to existing facilities. imum flood level (and limited flood risk in access routes to all population centers served) ● What is the service catchment area for the site? How accessible is the site to users? Is it affordable was selected because the cost of flood mitigation infrastructure at other more exposed for users to travel to the site? sites would have significantly impacted the remaining budget for the facility itself. (NSW ● Is the size of the site adequate for current needs as well as potential future needs for expansion? Government, 2018). ● What planning regulatory requirements need to be met from land-use and zoning perspectives? For each site under consideration, see which risks can be mitigated through civil engineering (for example, retaining structures, ground improvement techniques, flood defense systems). Consider Case study connection: The Ghana Infectious Disease Center was built in just 100 days in which risks must be mitigated in the design of the building (for example earthquake-resistant response to the COVID-19 pandemic. To facilitate zoning approvals and reduce the need for new structural design, foundation design, floodproofing). utility infrastructure, a site within the grounds of an existing hospital was selected with existing connection the national electric grid. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 2.1 2.2 2.3 2.4 2.5 2.6 2.7 Value and objectives Context, service area Site Selection  Regulatory Master planning and Financial Design phase 21 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation and wider network  requirements  programming  considerations  preparation Case study connection: Because it was not feasible to relocate the Kurashiki Central landscaping, natural breezes, plentiful natural light) and which should be mitigated (for Hospital in Japan out of the floodplain to ensure accessibility of health services to citizens, example potential heat-island effects)? administrators decided instead to invest in a flood protection barrier around the perimeter ● What natural and environmental resources in the immediate area should be protected of the facility. or preserved? What potential environmental impacts from the new facility must be mitigated? Assess whether risks will change over the useful life of the facility. For example, in coastal zones, ● Is the site served by public utilities? If not, will utility networks be expanded to provide sea level rise might need to be factored into flood risk assessments. service, or will off-grid solutions be necessary (for example renewable sources such as geothermal energy, solar power arrays, and so forth)? Evaluate sites to understand if the public utilities serving the site are reliable, or if backup systems ● Can the site be accessed through lower-emission forms of transport (for example, are needed (for example, generator, fuel storage on site). walking, biking or public transport)? Evaluate the redundancy and vulnerability of the relevant road network: could the site become inaccessible after a disaster? INCLUSIVE-SPECIFIC GUIDANCE Key questions: Information gathered from the local community can inform site selection and planning. Local peo- ● For the selected site(s), what are the potential site hazards? ple can highlight risks or inefficiencies in the proposed site, for example, and judge the accessibility ● Can these be mitigated, or are alternative sites available that are less exposed to such of the site for the range of users, including disadvantaged groups. hazards? ● Does the selected site have adequate connection to public utilities, transport networks Key questions or roads for normal operations and in the aftermath of disasters? ● How can communities be engaged in selecting and assessing the site? ● How far is the facility from residential areas and other related health and public facilities? GREEN-SPECIFIC GUIDANCE ● How will users access the facility in normal circumstances? Are there affordable, safe At this stage, local climatic conditions can be evaluated and potential options for green building and efficient transport options that are appropriate for all types of users of the health measures refined. In addition, local environmental and natural resources at the site and in the facility? surrounding area can be assessed. ● Is the site exposed to loud noises, vibrations from nearby activities, or other nearby hazardous facilities that could negatively affect patients? Case study connection: The buildings of the new Nyarugenge District Hospital in Rwanda ● Is the site or surrounding area currently used by the community? Does it have cultural were oriented on the site according to wind patterns to maximize natural ventilation. significance? If so, how will the new health facility be sensitive to existing uses? Key questions: ● What local climatic conditions should be considered in master planning and building design? Which ones should be leveraged (for example, rainfall capture for watering 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 2.1 2.2 2.3 2.4 2.5 2.6 2.7 Value and objectives Context, service area Site Selection  Regulatory Master planning and Financial Design phase 22 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation and wider network  requirements  programming  considerations  preparation stringent design checks ahead of approval, and they are subject to increased monitoring and inspec- tion during construction (HCAI, 2024). Special planning permits and studies (for example, environmental impact assessments or EIAs) may be required before the site and scale of building development can be approved. Regulatory require- ments for health facility design can often span different agencies and different levels of government. The requirements are often covered by national building design codes and standards, but may also be issued by (national or regional) health ministries or other regulatory bodies. Health facilities, as they provide vital community services (assigned to the category of higher importance buildings), are often held to more stringent building control procedures, involving plan checks, building permits, and inspections, as required by local or regional authorities. If a country or region has gaps in its building regulatory framework, other international codes and standards may be referred to and/or adapted for the local context. Because these shortcomings could prevent the facility from meeting a certain targeted outcomes, the facility owner may decide to spec- ify compliance with an internationally recognized standard or certification program. July 2018 flooding in Mabi, Kurashiki City, Japan. © Kurashiki City Fire Department. RESILIENT-SPECIFIC GUIDANCE: 2.4 Identifying regulatory requirements Understand how well applicable planning and design regulations capture local hazard and risks: In some cases, the applicable building code will have insufficient or outdated hazard criteria for the Health facilities are often subject to strict design and construction regulations as they are considered purposes of design. In these situations, planning and design teams may choose to consult exist- higher importance facilities. It is important to review the building regulatory framework for the juris- ing hazard datasets or bring in additional expert support to perform site-specific studies. More diction of the facility in the early stages of planning to confirm minimum requirements that might advanced building codes from other neighboring countries or other international standards can impact planning decisions and need to be factored into later stages of design and construction. act as reference standards where there are gaps in structural analysis and regulatory oversight of design, but care must be taken to ensure these are appropriate for the local context.5 For example, in the State of California, USA, the design and construction of hospital buildings is reg- ulated by the Department of Health Care Access and Information.4 The department requires hospital design to meet higher building performance requirements related to seismic resilience, fire safety, and healthy indoor environments as compared with nonhospital buildings, as well as for them to adhere to 5 Refer to Code Checklist tools for Green Buildings (World Bank, 2023), Structural Resilience (World Bank, 2024) and Universal Accessibility (World Bank, 2025) for further details on evaluating the completeness of regulations on these topics and considerations for adopting international 4 Formerly known as the Office of Statewide Health Planning and Development (OSHPD). standards. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 2.1 2.2 2.3 2.4 2.5 2.6 2.7 Value and objectives Context, service area Site Selection  Regulatory Master planning and Financial Design phase prep 23 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation and wider network  requirements  programming  considerations  preparation For example, because of the COVID-19 pandemic, the importance of design guidance on INCLUSIVE-SPECIFIC GUIDANCE: reducing airborne disease transmission in health facilities was heightened, leading to the Universal accessibility standards tend to be the primary means for improving inclusivity through development of new standards for indoor air quality. building regulation. In situations where jurisdictions lack universal accessibility requirements, Also, refer to Section 2.6 for a discussion of the benefits of designing a facility that exceeds min- international sources such as ISO 21542:2021 may be referenced or adapted for the design of the imum code performance requirements. facility. Regional sources may also be consulted. Key questions: For example, the Universal Accessibility Built Environment Guidelines of Saudi Arabia (Prince Salman Center for Disability Research, 2010) has provisions relevant for the wider region ● Do current planning requirements and building design and construction codes capture that are not included in other international standards such as specific provisions for ablution expected hazards and risks? If not, what other regional and/or international regulations spaces. or standards could be used? Key questions ● Is there a universal accessibility standard in place in the relevant jurisdiction? GREEN-SPECIFIC GUIDANCE: ● If there is no standard or if gaps exist in the current standard, what other regional or Where green building codes and standards are not available within a country or region, the plan- international universal accessibility standards could be used? ning and design team may refer to international standards or certification systems to define facil- ity requirements. These might include aligning to a green building standard according to various 2.5 Facility master planning and programming green building certification programs (for example, Leadership in Energy and Environmental Design (LEED) Building Research Establishment Environmental Assessment Methodology (BREEAM), the Facility master planning shapes the layout and interaction of buildings on the site and key services. It International Finance Corporation’s IFC’s Excellence in Design for Greater Efficiencies (EDGE) and should include considerations for phases of development, and future expansion and adaptation of the so forth) or defining acceptable ranges for indoor environmental quality for the facility. facility. Facility programming determines the size of interior and exterior spaces within the facility, Case study connection: The Ng Teng Fong General Hospital and Jurong Community their configuration, and flow within and between them (adjacencies). Multiple options are frequently Hospital in Singapore was designed and built to comply with the Platinum level of studied to determine the one that best meets the overall objectives. Singapore’s Green Mark Certification. Master planning and programming are informed by the studies conducted and information collected Key questions: to answer some of the questions posed in Sections 2.2, 2.3 and 2.4. These studies include surveys, environmental and social impact assessments, risk assessments, and site-specific investigations ● Do green building requirements exist in the applicable building codes/certification conducted once a site has been selected. Master planning is also influenced by other information such schemes? Are the provisions mandatory, voluntary or a mix of both? as site boundaries, land titles, and governing regulations and should include considerations for phases ● If there is no standard or if gaps exist in the current standard, what other green building of development and any future expansion and adaptation of the facility. regulations or certification schemes could be used? 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 2.1 2.2 2.3 2.4 2.5 2.6 2.7 Value and objectives Context, service area Site Selection  Regulatory Master planning and Financial Design phase 24 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation and wider network  requirements  programming  considerations  preparation Key stakeholders should be engaged in master planning to ensure that solutions target their needs For example, it may be advantageous to plan for larger floor-to-ceiling dimensions to allow while opportunities to enhance resilient, green, and inclusive benefits are maximized. Human-centered for greater depth of ceiling plenum (the cavity between the structural ceiling and the dropped design (HCD) is an approach to problem-solving that involves the human perspective in the design ceiling where heating, ventilation, and air conditioning—HVAC—and other equipment runs) process. In planning a health facility, HCD takes a holistic approach to understand stakeholder experi- to allow for future flexibility for changes to building utilities and equipment. ences and needs as the starting point for developing design solutions. For example, one HCD approach Additionally, for buildings targeting resilient, green, and inclusive outcomes, the following additional develops “personas” of patients to explore how best the facilities can meet their needs. topics should be considered in master planning and programming: The following general considerations capture some of the key aspects for the master planning and programming of a new health facility: RESILIENT-SPECIFIC GUIDANCE: ● Target amounts of medical care provided (for example, number of patients per day, number of Programmatic needs for emergency and disaster scenarios (for example, additional surge surgeries per year); capacity, additional health services, triage spaces, and so forth), such as: ● Number of staff by job type and working hours; ● Parking and strategy for emergency vehicle staging, including potential need for helicopter ● Main building functions and types/sizes of spaces required, general layout, and how spaces are landing area in emergency conditions. accessed and interact in terms of patient flow, circulation routes, and so forth; Following the Great East Japan Earthquake in 2011, the designated helicopter landing area ● Structural grid, modular design; on the site at the Ishinomaki Red Cross Hospital was at risk of being unusable due to flooding ● Building mass, shape, and height; (Ishii, 2011). ● Strategy for building utilities (for example, connected to municipal infrastructure, off-grid, existing ● On-site overnight accommodation and/or nap areas for staff and/or volunteers in the case of infrastructure on the site, and so forth); emergency events. ● Strategy for integration of digital technologies; ● Requirements for infectious disease control including circulation flow and containment. ● Space requirements for deliveries and loading or unloading; Case study connection: The patient circulation routes of the Ghana Infectious Disease ● Waste disposal plan and need for incinerators; Center, which was built to fight and manage COVID-19 and other infectious diseases, were ● Phasing and site requirements during construction (access, storage of materials, and so forth); carefully planned to reduce airborne disease transmission and complemented by UVC ● Views of the facility—from the exterior; conversely, looking out from the interior—and arrange- lighting and HVAC system controls. ment of buildings to allow for views (for example, from patient wards); ● Site perimeter safety and access strategies; and Requirements (including physical space) for backup systems in the event of a disruption to central ● Future needs and adaptability related to utilities, services, technologies to avoid obsolescence (for power or water supply: example, modular design strategies, adaptable layouts, overflow design) and to avoid disruption of ● Minimum storage requirements (including physical space) of critical supplies, particularly service provision during future renovations or expansions. for emergency situations (for example, medical equipment, food, medicine, fuel, gases). 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 2.1 2.2 2.3 2.4 2.5 2.6 2.7 Value and objectives Context, service area Site Selection  Regulatory Master planning and Financial Design phase 25 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation and wider network  requirements  programming  considerations  preparation ● Considering issues of accessibility on upper floors in the event of power outages. GREEN-SPECIFIC GUIDANCE: Considerations for risk mitigation strategies: The following are key areas relating to green building measures that should be considered as part of master planning: ● Site topography and any proposed changes to site levels, soil improvements. ● Percentage of built-up area on the site, stormwater runoff studies and space to manage ● Building orientation for energy efficiency and daylighting; drainage (such as retention ponds). ● Consideration of local landscape and climate conditions; ● Consideration of climate adaptation needs to address potential changes to climate and ● Opportunities for separate zoning of building services and the use of natural ventilation, hazard over the useful life of the facility (for example, flood risk, sea level rises). including identifying which spaces require stricter indoor environmental quality controls ● Location of critical utilities and exposure to potential hazards such as flooding, wind and through mechanical ventilation (for example, surgical suites, isolation rooms). Design of landslides. natural ventilation and mechanical systems to exchange and clean air should also consider ● Fire protection and emergency evacuation strategy. measures needed for reduced transmission of airborne disease; and ● Exterior spaces, landscaping and approaches to integration of green infrastructure on Business continuity planning for the health facility and coordination plan with other health facil- buildings, including solar shading and/or rain protection needs in some climates. ities in the same region, to consider: Case study connection: The Nyarugenge District Hospital in Rwanda has trellis structures ● Continued access to essential health services during disasters and other emergencies. on the building façade to encourage native climbing vines and help to reduce temperatures ● Coordination of facility requirements with the regional business continuity plan (BCP), in the building while providing shade and privacy. including understanding supply chains for drugs, medical supplies and equipment, oxygen supplies, food, water, fuel, and so forth. ● Allocating space for renewable energy generation onsite. For specific resilience measures related to managing different types of risk—including flooding, ● Integrating green spaces to support in reducing the impacts of extreme heat, including heat- strong winds, earthquakes, soil instability, extreme heat, drought, and pandemics—refer to island effects, particularly in urban contexts. Appendix A.1. ● Preservation of existing trees or other natural features on the site. Key questions: Case study connection: The Ng Teng Fong General Hospital and Jurong Community Hospital in Singapore have a publicly accessible park on site for use by local city residents. ● Does the master planning and programming phase take sufficient account of resilience considerations that reduce the risk from key hazards, and enable the facility to adapt Key questions: and recover with only limited disruption of critical services? ● Have opportunities to incorporate green building measures for the facility been fully explored in the master planning and programming phase? 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 2.1 2.2 2.3 2.4 2.5 2.6 2.7 Value and objectives Context, service area Site Selection  Regulatory Master planning and Financial Design phase 26 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation and wider network  requirements  programming  considerations  preparation INCLUSIVE-SPECIFIC GUIDANCE: the investment for decision-makers by demonstrating significant returns (Multi-Hazard Mitigation Council, 2019). Universal accessibility considerations for master planning, such as: ● In certain contexts, to limit the cost and complexity of meeting universal accessibility Furthermore, resilient, green, and inclusive health facilities can provide higher quality, more reliable requirements, one-story buildings may be preferable to avoid the need for elevators. health care environments and services to more people, including those with the greatest needs, lead- ● Specific service functions, such as outpatient clinics and emergency wards, should ing to greater overall community health benefits and social returns. Identifying resilient, green, and preferably be located on the ground floor to improve speed and ease of accessibility for inclusive objectives and strategies early in the planning phase can be beneficial financially as well patients. because it allows for more integrated—and therefore cost-effective—design solutions that achieve ● Consideration for how different user groups will access the site (from roads, on foot, public multiple objectives simultaneously. transportation) and any barriers that might be present. ● Cultural heritage features or considerations related to site development. To understand the full range of costs and/or benefits that a resilient, green, and inclusive health facility ● Special programmatic requirements to accommodate the needs of specific groups will have relative to a more traditional facility and to demonstrate the case for investment, several including marginalized or underserved populations (for example, on-site childcare facilities, approaches can be used: facility requirements tailored for cultural practices around birth, illness and death, or accommodations for accompanying family members). ● Life-cycle cost analysis (LCCA): This approach considers the costs over the whole building life cycle including initial costs (purchase, land acquisition, design, and construction costs), opera- Case study connection: The Tambacounda Hospital in Senegal provides communal areas tional, maintenance and repair costs, end-of-life costs (resale, salvage, demolition and disposal and courtyards for visiting family members of patients (who take care of nonmedical needs costs) and financing costs (for example, loan interest). If a facility is damaged beyond repair, the of patients like food preparation and clothes washing). These communal areas are visible analysis can take into consideration replacement/reconstruction costs. Health facilities often and accessible from open balconies of the maternity ward rooms. house expensive contents, such as specialized medical equipment; investments to protect it from shocks and stresses can yield longer term benefits. In addition, the costs of disruption in the event Key questions: of a shock or stress should be considered. Because LCCAs account for operational savings over the ● Have universal accessibility needs and broader inclusive considerations been taken into life cycle of the building as well as avoided losses from downtime or disruption, they are useful for account in the master planning and programming phase?  justifying green and resilient investments. ● Payback period: Payback period, one metric used in an LCCA, is the length of time required to recover initial costs of an investment. For example, a survey of 19 countries in 2018 found that 2.6 Financial considerations although 74 percent of respondents reported that incorporating green building measures in new buildings cost more upfront, 36 percent reported a payback period of 1–5 years and 43 percent Although investing in resilient, green, and inclusive health facilities may incur higher upfront capital reported a payback period of 6–10 years (Dodge Data & Analytics, 2018). costs, a careful evaluation of the financial and economic benefits over the life cycle of the facility, including reduced energy consumption, maintenance costs, and service disruptions, can help justify ● Benefit-cost analysis (BCA): Benefit-cost analyses compare all costs and benefits for different investment options for a facility over a set time period in standardized monetary terms, including 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 2.1 2.2 2.3 2.4 2.5 2.6 2.7 Value and objectives Context, service area Site Selection  Regulatory Master planning and Financial Design phase 27 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation and wider network  requirements  programming  considerations  preparation both upfront capital costs and longer-term operational costs, as well as any short- and long-term robustness, and so forth) can reduce the risk of damage and service disruption, including deaths health and nonhealth benefits that can be quantified monetarily. BCAs can be expressed as a ratio and poor quality health outcomes for patients unable to access care in the aftermath of a disaster of benefits-to-costs (B/C) or as net benefits (B – C) (NSW Health, 2018). (defined as secondary losses). A life-cycle cost analysis or a benefit-cost analysis that considers the financial benefits of avoided damage and operational disruption can be used to justify the Case study connection: Administrators at the Kurashiki Central Hospital in Japan, which increased upfront costs of such resilience measures. serves as a disaster base hospital for the region, determined that it was unacceptable for services at the hospital to be disrupted in the event of riverine flooding and made the decision For health facilities with highly specialized and expensive medical equipment (for example, CT to invest in flood protection measures. Potential damage, loss as well as level of service and MRI equipment), the monetary benefits of protecting buildings and their contents from dam- disruption for the region was estimated, and a benefit-cost analysis was carried out to identify age by incorporating resilience measures can be particularly significant. the optimum investment option. For example, one study of a hospital in China demonstrated that use of seismic base iso- lation devices increased upfront costs by one percent but reduced direct losses from an ● Cost-effectiveness analysis (CEA) is another variation on similar BCA concepts that is useful in earthquake by 37 percent compared to a fixed-base building (Dang et al., 2015). comparing options to determine the most optimal one for achieving a particular target objective. It typically does not include broader social benefits (Brent, 2023). Inspection and maintenance requirements of systems supporting resilience (for example, costs ● Health impact assessments (HIA) and Social Return on Investment (SROI) are additional methods of deployable flood barriers, including training, drills, storage space) must be considered in opera- that can be used to demonstrate the return on investment for a health facility, focusing on the tional budgeting for the facility to ensure they are viable in the long run. social benefits of improvements to public health and well-being, which can be broadened when inclusive planning approaches are taken (Ashton et al., 2020). GREEN-SPECIFIC GUIDANCE: ● Target Value Design (TVD) is another approach that can be used to deliver a resilient, green, and inclusive health facility. TVD establishes a cost target and then seeks to maximize the value that A life-cycle cost analysis can demonstrate the financial viability of green measures through cost can be delivered for that target (Miron et al., 2015). This approach may be particularly applicable savings over the lifespan of a facility due to reduced operational costs, even if capital costs may in contexts where resources are limited, and the facility is seeking to maximize resilient, green and be higher for sustainable construction materials and building systems. inclusive qualities within a tightly constrained budget. For example, the 350-bed Central Hospital of Jaipur, India, was able to reduce its total The following are additional considerations related to the costs and benefits of resilient, green, and 2005–2008 energy bill by half through energy conservation measures, including installation inclusive health facilities. of solar water heaters and lighting (WHO, 2009). Benefit-cost analysis can help justify the use of green building measures by accounting for benefits RESILIENT-SPECIFIC GUIDANCE: such as flood and extreme heat risk reduction, improved biodiversity, better air quality, enhanced Facilities designed to building code minimum requirements typically limit loss of life and injury well-being from access to green space, and so forth. in the event of an extreme event but may be uneconomic to repair after a disaster, leading to It is important to factor specialized operational needs (for example, staffing or materials) includ- serious disruption and secondary losses. Resilience measures (redundancy, enhanced physical ing operational budget requirements for green building systems (for example, green roofs and 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 2.1 2.2 2.3 2.4 2.5 2.6 2.7 Value and objectives Context, service area Site Selection  Regulatory Master planning and Financial Design phase 28 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation and wider network  requirements  programming  considerations  preparation walls, exterior planting) in the planning phase to ensure that proposed approaches are feasible, 2.7 Preparing for the design phase and sustainable, in the long term. Following facility master planning and other studies in the planning phase, the services of a design team are procured to provide design and construction documents for the facility. Key outputs from the INCLUSIVE-SPECIFIC GUIDANCE: planning phase, including facility goals, objectives and requirements (both mandatory and voluntary), programmatic requirements, overall construction budget, regulatory approval processes and so forth Although little work has been done to quantify the financial benefits of design for universal acces- are summarized in a design brief, which is an important component of the procurement materials for sibility (Terashima & Clark, 2021), qualitative benefits include reaching more types of patients design services. and supporting health to ensure societal contribution from people of all ages and abilities. Benefit-cost analysis can be used to quantify social benefits provided by an inclusively planned Design and construction requirements in a design brief may be specified as either prescriptive or per- and designed facility (for example, improved health outcomes like reduced morbidity and mortality formance-based, or using a hybrid approach. Prescriptive requirements give prescriptive rules or pro- rates for target populations, reduced health disparities, community and economic development cedures for how aspects should be designed and built (for example, a regulation on daylighting might and job creation). require 30 percent glazing for certain occupancy types). Performance-based requirements identify the performance objective the facility is aiming to achieve and leave flexibility for the design team to Noncapital, ongoing costs of inclusive measures (for example, staff training, community out- develop a solution that meets these objectives (for example, daylighting performance metrics such as reach) need to be factored into the operating budget. daylighting factors—percentage of sunlight brought indoors—may be specified as verified through a Retrofitting facilities for universal access is typically more expensive and complex than includ- daylighting computer simulation). ing these considerations in the initial planning of a new facility. The following information informed by the earlier planning activities should be considered in the design For example, retrofitting an existing building to accommodate wheelchair use requires the brief to ensure that the design intent related to the facility’s anticipated resilient, green, and inclusive potential widening of corridors and doors and the addition of ramps and elevators, signifi- benefits is well documented and conveyed to the design team for effective implementation: cantly impacting usable space for health care delivery. Key questions: RESILIENT-SPECIFIC GUIDANCE: ● What information (for example, costs, quantitative and qualitative benefits) is needed ● Resilience goals and objectives for anticipated shocks and stresses (for example, how quickly to assess the value of investments for options to achieve a resilient, green and inclusive various functions and spaces must recover in the event of various hazard scenarios); health facility? ● Site risk mitigation strategies—devised in the planning phase—for any residual site risks; ● What tools and approaches could be used to communicate the value of investments ● Backup and emergency systems required to limit disruption to services; to achieve a resilient, green and inclusive health facility (both qualitative and ● Compliance with any design and construction standards that exceed or supplement current quantitative)? regulations in force; 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 2.1 2.2 2.3 2.4 2.5 2.6 2.7 Value and objectives Context, service area Site Selection  Regulatory Master planning and Financial Design phase 29 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation and wider network  requirements  programming  considerations  preparation ● Programmatic requirements and functions in normal operating conditions and in emergency INCLUSIVE GUIDANCE: conditions; Inclusive goals and objectives, including target populations should be given. ● Intentions for future climate adaptation; ● Other key findings or conclusions from master planning related to resilience requirements; More specific goals related to universal accessibility might include: and ● Design considerations for critical equipment (building utility systems and medical ● Outputs from assessments performed in the planning phase to understand the needs of equipment). users; ● Regulations and supplementary standards to be met to ensure universal accessibility for Key questions: users of all ages and abilities; ● Any cultural practices or needs of specific groups in the service catchment area that need ● Does the design brief clearly set goals, design criteria and other requirements related to to be accommodated within the design of the facility; resilience? ● Requirements related to use of local building materials or construction techniques; ● Has the relevant expertise needed in the design team to address the resilience aspects in ● Requirements for community and stakeholder engagement; and the brief been identified? ● Other key findings or conclusions from master planning related to inclusive considerations identified. GREEN-SPECIFIC GUIDANCE: Key questions: ● Green building goals, objectives and related performance requirements; ● Alignment with a green building certification program (for example, LEED or IFC’s EDGE) or ● Does the design brief clearly set goals, design criteria and other requirements related to with any green standards that exceed or supplement minimum regulatory requirements; universal accessibility and inclusive design for the facility? ● Intentions for future expansion needs; ● Has the relevant expertise needed in the design team to address inclusive aspects in the ● Programmatic requirements for outdoor spaces, external planting and other spaces essential brief been identified? to green building systems; and ● Other key findings or conclusions from master planning related to green requirements. Procurement documents for the design stage will also specify design team requirements. Required design team expertise will depend on the size and complexity of the facility, but common expertise Key questions: needed for the delivery of resilient, green, and inclusive facilities includes: ● Does the design brief clearly set goals, design criteria and other requirements related to incorporating green building measures into the facility? ● Architects (including those specialized in health care); ● Has the relevant expertise needed in the design team to address green building aspects ● Health care facility planners; in the brief been identified? ● Financial planners; ● Engineers (civil, geotechnical, structural, mechanical, electrical, plumbing); ● Hazard and risk expertise (in seismic risk, flood risk, fire protection, and so forth); 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 2.1 2.2 2.3 2.4 2.5 2.6 2.7 Value and objectives Context, service area Site Selection  Regulatory Master planning and Financial Design phase 30 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation and wider network  requirements  programming  considerations  preparation ● Green building experts (these can sometimes be mechan- ical engineers); ● IT/communication system specialists; ● Security specialists; ● Medical equipment procurement specialists; ● Landscape architects; ● Interior designers; ● Facilitators for stakeholder engagement; ● Ergonomics and patient safety experts to consider flow of patients and potential harms; ● Infection control specialists and other specialists, par- ticularly for design of acute care facilities with highly controlled indoor environments; ● Input from key clinical staff and hospital management in charge of business continuity planning; and ● Community representatives and patient representa- tives, particularly those who have conditions targeted by the new facility. Onagawa hospital located on a hill top was damaged by Tsunami 11th March 2011. © Hideo Kurihara / Alamy Stock Photo 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 5.0 SUMMARY 31 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation CASE STUDY Maternal Center of Excellence, Sierra Leone G I The Maternal Center of Excellence will provide much needed access new, sustainably designed facility focused on equity-minded maternal to maternal and family health care in a new green facility embedded and family health care. in local culture and planned with the needs of women and children in mind. The new facility, which is expected to open in 2024, was conceived and implemented with the engagement of women and the needs of women Featured qualities: Green (energy efficiency, natural ventilation, local in mind. The 166-bed inpatient facility and accredited national teaching materials and labor), Inclusive (sensitive to women’s and children’s hospital for maternal health care will have a neonatal intensive care needs, local materials and labor) unit (ICU), surgical suite, blood bank, outpatient clinic for prevention of mother-to-child HIV transmission, adolescent health services, sexual Kono district has one of the world’s highest rates of maternal mortal- health, and care for victims of gender-based violence (GBV), mental ity with one in 20 women dying in pregnancy or childbirth, five times health counseling, routine pre- and post-natal care, childhood vaccina- the global average. In Kono, 10 percent of children die before their fifth tion, family planning, gynecology and oncology (Partners in Health, n.d.; birthday (Partners in Health, n.d. and n.d.1). A public–private partnership BHI, n.d.1). Key features of the project are: between the Ministry of Health and Sanitation and two international NGOs aimed to reduce strain on the Koida Government Hospital, the only ● Culturally sensitive planning: The new facility was conceived with Construction workers on the construction site. © Topia Salone/The Guardian. one in the district, by expanding its capacity and service offerings in this a sensitivity to local customs through community engagement, offering a blueprint for future, equity-minded health care facilities ● Local materials and labor: Building materials and construction in the country. Programming of the new facility addressed deficien- systems were chosen to facilitate exclusive use of local material and cies in care that were identified as contributing to maternal, fetal labor to support the local economy. The single-story buildings have and neonatal mortality, including the need for increased capacity reinforced concrete block masonry walls with roofs constructed from for cesareans and 24-hour electricity to perform cesareans (Fallon, either cast-in-place reinforced concrete slabs or sheet metal on steel 2023). The new one-story buildings are oriented to allow generous trusses that were welded together on site (Partners in Health, 2023, circulation spaces, outdoor courtyards and gardens for patients, and n.d.). A co-benefit of the project has been its ability to attract a staff, and visitors, including family members assisting in care provi- local female workforce in its construction, allowing them to gain skills sion (BHI, n.d.). Dormitories are available for staff as well as high-risk and greater economic independence. At its peak, 60 percent of the expectant mothers who live far from the hospital (and their children), construction workforce on site was female (Fallon, 2023). The first so the mothers can be monitored as necessary in the weeks prior to female construction worker joined in 2022 as a tool depot manager delivery (Fallon, 2023). (Duggan and Velazquez, 2023). She then brought in other women, and by early 2023 as many as 25 women were busy welding, bricklaying, ● Energy efficiency: The buildings employ passive strategies for cool- and training other workers to read construction blueprints (Duggan ing and lighting to reduce electricity consumption, and they manage and Velazquez, 2023; Fallon, 2023). Construction of Maternal Center of Excellence Sierra Leone. © Good News, WikiMedia. energy use with sensors (Partners in Health, n.d.). 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 3.0 OPERATION 4.0 DESIGNING 5.0 SUMMARY APPENDICES 32 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation CASE STUDY Nyarugenge District Hospital, Rwanda R G I The Nyarugenge District Hospital is one of 30 new hospitals in of Nyarugenge District Hospital in Kigali (120 beds) was completed in underground and used for toilets and watering gardens to reduce Rwanda whose design is driven by national standards that pro- 2020, comprising two main buildings with an emergency department, water usage in this drought-prone region; mote sustainability, resilience and accessibility while allowing high-dependency unit, operation rooms, labor and delivery, neonatal ● The structure of the buildings was designed with reinforced concrete for adaptation to address local needs. intensive care unit, adult and pediatric medicine, outpatient clinic, phar- shear walls to provide appropriate seismic resistance for the moder- macy, diagnostic imaging, and dentistry. The second phase will add 180 ate seismicity of the region. Featured qualities: Resilient (heavy rainfall, earthquakes), Green (natural beds, operation theaters, trauma wards, intensive care, mental health ventilation, green infrastructure, local materials and labor), Inclusive and ophthalmological services (MASS, 2020). The first phase includes Inclusive features: (universal accessibility, sensitive to women’s needs, local materials and numerous green, resilient, and inclusive features conceived through In addition to incorporating design features sensitive to expectant labor) community engagement in the design process. mothers as described above, the main entrance to the hospital includes a wide ramp and large signage to enhance accessibility (MASS, 2020). Green features (MASS, 2020): Another District Hospital, the Munini District Hospital, built to the same ● The two buildings were positioned according to wind patterns on the design standards in a more rural area where patients arrive from long site to maximize natural ventilation and reduce the operational costs distances on foot or by public transport, includes a large open-air garden and environmental impact of air conditioning; with seating at the entrance to allow visitors to rest following their jour- ● The complex has many outdoor waiting areas and gardens, including ney (MASS, 2022). These types of responsive, inclusive features reflect an early labor walking garden to decrease the discomfort of expect- the involvement of the community in the planning and design phases of ant mothers in labor; these projects. ● Trellis structures on the building façade encourage native climbing vines and help to reduce temperatures in the buildings while providing Nyarugenge District Hospital. shade and privacy; © Benji1909, ● Patient wards were positioned to maximize views of surrounding WikiMedia. landscapes. Patient rooms also include terraces that provide access to the gardens to support improved health outcomes; Nyarugenge District Hospital. © Benji1909, WikiMedia. ● Solar panels power outdoor lighting to reduce energy consumption; and ● To support the local economy and reduce embodied carbon, locally As part of a decades-long effort by the Rwandan government to rebuild fabricated compressed stabilized earth blocks (CSEBs) were used for the country’s health system and expand health care access to rural com- the nonstructural walls of the buildings. munities following the 1994 civil war, the Ministry of Health announced a plan in 2012 to construct new hospitals in 30 underserved districts. Resilience features (MASS, 2020): To facilitate consistent, high quality and cost-efficient construction, the ● Green infrastructure and permeable paving help to manage storm- Ministry of Health developed a set of District Hospital Design Standards water during heavy rainfall. The water is captured, filtered, stored to guide these projects (MASS, 2014). The first phase of construction 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 33 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation CASE STUDY Ghana Infectious Disease Center, Ghana R G I The Ghana Infectious Disease Center was rapidly yet effectively The Ghana Infectious Disease Center, a 100-bed facility in Accra, was the national electric grid. A modular panel system was used for the built in response to the COVID-19 pandemic with specific atten- built in just 100 days between April and July 2020, to function as the hospital’s structural walls to hasten construction (expanded polysty- tion to disease control, green building and use of local resources country’s leading national public health institute, isolation, and treat- rene sandwiched with welded wire mesh and steel diagonal elements, in the design. ment center to fight and manage COVID-19 (Essah, 2021). The US $7.5 sprayed with concrete on site using a shotcrete pump). In addition to million project was part of an ambitious plan to improve health care being designed to withstand wind and seismic loading, these panels Featured qualities: Resilient (pandemics); Green (water efficiency, infrastructure in the country and manage the crisis that included the also provide high thermal insulation, supporting the project’s energy energy efficiency, local materials and labor); Inclusive (local materials construction of six regional hospitals in places lacking regional facilities, efficiency goals (Sam-Awortwi, 2021). and labor) 88 hospitals with 100 beds in districts lacking district-level facilities, and three new infectious disease con- ● Resource efficiency and design for airborne disease control: In trol centers (Sam-Awortwi, 2021) addition to the insulated walls and roof, the building includes ener- (Ghana Ministry of Health, 2020). gy-efficient lighting and air conditioning (air-cooled chillers), low-flow The public–private initiative, funded plumbing fixtures, and water-efficient landscaping (EDGE, 2020). by the Ghana COVID-19 National Studies showed that operational savings from the project’s green Trust Fund and the Ghana COVID- features would cover the additional upfront costs incurred in less 19 Private Sector Fund, achieved than one year, allowing future savings to support enhanced care for IFC EDGE Level 1 Certification for its patients (EDGE, 2020). The design also considered ways to reduce green features that provide 23 per- airborne disease transmission through patient circulation routes, cent in energy savings, 28 percent antimicrobial paints, UVC lighting and filtration, and HVAC system in water savings and 31 percent less control (Sam-Awortwi, 2021). Designers also referenced a set of embodied energy in building materi- simple-to-use spatial and engineering guidelines developed by the als compared to a building without Association of Ethiopian Architects for COVID-19 quarantine and green building features (EDGE, treatment centers to design circulation paths with one-way traffic 2020). Key elements of the project (Sam-Awortwi, 2021). included: ● Use of local resources: Project materials were sourced by a Ghana- ● Construction efficiency: Project based construction company, serving as a demonstration of pro- decision-making prioritized effi- posed “local content laws” for the construction sector in Ghana by ciency. For example, a site within highlighting the cost savings and economic development advantages the existing Ga East Municipal of sourcing goods and services locally (Essah, 2021). In addition to Hospital was selected to facilitate sourcing materials locally, the project employed 536 Ghanaian work- zoning approvals and take advan- ers, working in alternating shifts to allow a continuous construction tage of an existing connection to schedule over the short period of construction (GhanaWeb, 2020). View of the Ghana Infectious Disease Center, Accra, Ghana. © EDGE Green Buildings Program, IFC. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 34 Chapter 3.0 Design Key Activities in the Design Phase Site and external environment (Section 3.1) Building design, structure and materials (Section 3.2) Building services (Section 3.3) Finishes, fixtures and equipment (Section 3.4) Construction considerations (Section 3.5) Operations and maintenance considerations (Section 3.6) 3.1 3.2 3.3 3.4 3.5 3.6 Site and external Building design, Building services  Finishes, fixtures and Construction Operations and maintenance 35 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation environment structure and materials  equipment  considerations  considerations  During this process, it is important to protect the facility’s goals and intended outcomes (for example, design intent) despite challenges to technical feasibility or cost-cutting needs that may arise. Selecting design options on upfront cost estimates alone without factoring in which option best achieves the Summary Points in the Design phase longer term resilient, green, and inclusive objectives will risk eroding the potential benefits delivered by the facility. Close coordination is required among a multidisciplinary design team in combination with consultation with wider stakeholders to deliver a design with the maximum resilient, green FIGURE 3.1 and inclusive facility benefits. KEY DESIGN CATEGORIES FOR RESILIENT, GREEN AND INCLUSIVE HEALTH FACILITIES The definition of the value of the facility and related resilient, green and inclusive objectives and goals are further refined in the design phase. Resilient facility design Resilient, green and inclusive facility features rely on the performance of the structural elements and nonstructural elements (for example, services, finishes, fixtures and Site Structural Resilience of Selection of Design of back Design for Design selection resilience non-structural fixtures, fittings up systems for flexibility and considerations equipment) of the building. components and equipment essential future for emergency services adaptability planning If resources are constrained, prioritization for the final design can be facilitated by further evacuation evaluation of the benefits (quantitative and qualitative) of different design options. Green facility design Construction considerations as well as facility operations and maintenance requirements should be taken into account throughout the design phase. Site and Energy Water Building Construction Occupant Solid waste context efficiency efficiency materials safety, health, management and comfort In the design phase, design solutions that meet facility goals and requirements are explored by a mul- tidisciplinary design team in consultation with other key stakeholders. The main outputs for this phase are design and construction documents and related technical specifications. In earlier design stages, Facility design for universal accessibility design options can be evaluated and compared to assess which provide best value to meet service and facility performance needs. The value that the facility provides, and resilience objectives should be revisited in the design stage, along with more detailed risk assessments to understand potential External Entrances, Horizontal & Building Building Evacuation environment doors and vertical access & facilities fixtures and & safe hazards, vulnerabilities, level of exposure and how the design can increase reliability, redundancies and lobbies circulation fittings egress adaptative capacity to reduce risks, limit disruption and improve recovery times. Source: Green and universal accessibility topics were adapted from World Bank 2023, and 2025. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 3.1 3.2 3.3 3.4 3.5 3.6 Site and external Building design, Building services  Finishes, fixtures and Construction Operations and maintenance 36 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation environment structure and materials  equipment  considerations  considerations  Figure 3.1 summarizes the main categories of design measures for resilient, green, and accessible (removable) flood protection barriers were designed to be integrated into the perimeter of health facilities. The following sections provide guidance and specific examples, grouped broadly by the site to seal off the entire complex in the event of a flood. design topic and design disciplines involved. Additional resources related to design are provided in Appendices A.1, A.2 and A.3. The site within the wider network: An understanding of dependencies and interdependencies between the facility and the systems into which it will be placed—including connections to exist- ing transport infrastructure, utilities and other services and requirements for backup systems 3.1 Site and external environment should be refined based on the initial assessments performed in the planning stage (see Sections 2.2, 2.3 and 2.5). Building on the master planning outputs in the planning phase, more detailed site plans will be devel- Mitigating risk from site hazards: in the design phase, specific strategies are studied to deter- oped that include consideration of the external environment. These plans involve refining land-use mine how to mitigate site hazards and improve recovery times to meet wider resilience objectives plans, site boundaries and other restrictions, setting the layout and form of buildings, consideration and intended outcomes specified in the design brief. of building orientation, open spaces with landscaping, utility connections, and pedestrian and vehicle access and circulation. Site plans should be informed by the master plan to take into account require- Site hazards may include flooding, landslides, other types of soil instability or soil contamination ments and needs for future modifications, flexibility and additional capacity. Site planning typically and past underground constructions. For example, in the case of flooding, site measures to miti- requires input from planners, architects, landscape architects, a multidisciplinary engineering team, gate risk can include adequate drainage systems, overflow basins or wetland landscaped zones, and sustainability and resilience specialists. Community engagement and input are vital at this stage reduction of hardscaping to increase permeability, llocating occupied spaces above the design to maximize benefits for users, including regeneration opportunities, while ensuring environmental flood level, and physical flood barriers. Also refer to Appendix A.1 for other types of resilience protection and connections to contiguous development. measures related to the site. Emergency planning: The site design should consider the need for potential evacuation of the RESILIENT-SPECIFIC GUIDANCE: facility including accessible evacuation routes, evacuation assembly points, as well as signage and emergency lighting. In addition, the site plan must consider how the facility will function in The design of the site and the exterior environment—including landscaping and civil engineering emergency or disaster conditions. In emergencies, the facility may need to respond to a surge in measures—must address a range of shocks and stresses identified through a risk assessment, users, for example, the need for triage space in open areas. Space may also be needed for emer- typically initially conducted in the planning phase as part of site selection (see Section 2.3). A gency generators, fuel and water storage. site is ideally selected to avoid or significantly reduce exposure to current and future risks; how- ever, sometimes this is not feasible and mitigation measures to reduce residual site risks are Site security: General site security measures must also be provided for in the design. Depending necessary. on the context, these might include access control, security personnel, surveillance systems, alarm systems, perimeter security, visitor management systems and reliable communication systems Case study connection: The Kurashiki Central Hospital in Japan is located in a floodplain in facilities and to the wider network. In some cases, design measures to reduce the risk of blast with significant exposure to flood risk. Relocation was not considered a feasible option may be appropriate. because the hospital was a tertiary care provider for the region. Instead, deployable 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 3.1 3.2 3.3 3.4 3.5 3.6 Site and external Building design, Building services  Finishes, fixtures and Construction Operations and maintenance 37 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation environment structure and materials  equipment  considerations  considerations  Designing for future needs: Site design should also address needs for future growth or adaptation Integrating nature: Evidence is growing that experiencing a connection to nature—through views identified in the planning phase to accommodate changing needs while minimizing disruption to or access to green spaces or water features—can reduce stress for patients and staff and improve health care services. For example, open space on the site might be allocated for expansion. health outcomes (Franklin, 2012). Through site and landscape design (for example, exterior plant- ing), there are opportunities to enhance green benefits for users of the facility as well as sur- Case study connection: The Tambacounda Hospital in Senegal used a flexible, modular rounding communities. Consider providing publicly accessible (or access-controlled) areas such as design for the buildings on site to facilitate future programmatic changes, including the healing and rest areas for patients, and exterior seating areas for staff. Such measures can also future addition of staff dormitories to attract additional doctors from the city. support natural habitat restoration and biodiversity as well as reduce heat-island effects and reduce energy demands for active cooling. Key questions: Case study connection: The Ng Teng Fong General Hospital and Jurong Community ● What other infrastructure systems does the facility depend on to function (for example, Hospital in Singapore integrated green roofs and exterior planting into the design of the energy, communications, transport, waste and water infrastructure)? facility for use by patients and staff. Two years into operation, a survey found that 90 ● To reduce vulnerabilities, what backup systems are required, and have they been percent of patients surveyed stated that the design helped them to recover faster. considered in the site plans? ● Have more refined risk assessments related to the site been performed? Have Water efficient measures: Strategies to reduce water consumption and facilitate water reuse appropriate measures to mitigate risks been incorporated into site planning? can be integrated into the site design. Rainwater harvesting systems with storage tanks or under- ● Have site security and emergency planning and related site requirements been ground reservoirs can be employed to collect rainwater from building roofs and store it for use in considered? landscape irrigation, toilets, and building HVAC systems like cooling towers. These systems are ● Can the site plans accommodate future needs and options for expansion/change of use? particularly valuable in climates that experience intense periods of rain followed by drought. In drought-prone areas and to minimize water use from irrigation, drought-tolerant, native species can be used in landscaping designs. GREEN-SPECIFIC GUIDANCE: Energy-Efficient Facilities: As part of both resilient and green strategies, health facilities may Understanding the context of the building, the existing natural environment and the effect that utilize microgrid systems, powered by renewable energy sources such as solar or wind energy or the building has on the site and its surroundings is the starting point for implementing measures fuel cells. The space required for the equipment and infrastructure for these systems must be that support sustainability. If an environmental and social impact assessment was conducted considered in site design. in the planning phase, the potential negative environmental impacts of the site development and facility operation will have been identified (for example, natural habitat loss, heat-island Key questions: effects, stormwater impacts, increased traffic, light, noise and air pollution) alongside strategies ● Does the site plan make the most of opportunities to incorporate green spaces, and are to address them. In the design phases, these strategies are further explored through design and some accessible for patients, staff and visitors? analysis and decisions are made as to which approach(es) to implement. In addition, the site plan ● If rainwater harvesting is used, is the related infrastructure accommodated and included needs to consider the green building measures that the project will incorporate. in the site plan? 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 3.1 3.2 3.3 3.4 3.5 3.6 Site and external Building design, Building services  Finishes, fixtures and Construction Operations and maintenance 38 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation environment structure and materials  equipment  considerations  considerations  ● If on-site renewable energy systems are used, is adequate space allocated in the site Emergency evacuation: The design of external circulation routes must reflect how users of all plan for them, any related equipment and grid connections? ages and abilities will need to evacuate in an emergency. Key questions: INCLUSIVE-SPECIFIC GUIDANCE: ● Does the site design ensure facilities are accessible for users of all ages and abilities as well as accommodate the needs of specific vulnerable user groups? Site design for accessibility: Equitable access to the site in normal and emergency situations ● Has consultation with users taken place to test accessible design features for the site with respect to existing transport networks should be addressed in the selection of the site in the and its immediate environs? planning phase (see Sections 2.2 and 2.3). In the design stage, principles of universal accessibility ● Have users of all ages and abilities been considered in relation to the site design for are integrated into the site design. The site should be barrier-free, accessible, and welcoming for emergency evacuation? users of all ages and abilities, allowing them to arrive and safely access the health facility. Design of the external environment should consider the need for pedestrian access; vehicular drop-off areas; off-street parking; level, sloped, ramped, or stepped access routes; handrails; external lighting to create safe, well-lit public spaces; signage; and places to rest. Beyond typical univer- FIGURE 3.2 sal accessibility considerations, in some contexts, the site plan may need to accommodate user MUNINI DISTRICT HOSPITAL BY MASS DESIGN GROUP groups with other special needs. For example, site design may need to incorporate access via separate, confidential entrances for people seeking care after suffering from domestic violence. The Munini District Hospital in Rwanda provides seating in a large, open-air garden at the entrance to the hospital to allow visitors who have travelled long distances on foot to rest before entering the facility (see Figure 3.2). Inclusive engagement: Including intended users of the facility in the design phase can help to identify and overcome unintended barriers through thoughtful design approaches to the external built environment, with a focus on understanding how people will interact with the environment and design features in practice. Case study connection: Local organizations for persons with disabilities who guided the planning, design and implementation of accessibility upgrades to the Cicendo National Eye Hospital in Indonesia identified lack of understanding of the purpose of some building accessibility features as a barrier to accessibility (for example, wheelchair ramps blocked with motorbikes or potted plants). © Rosemarie Goldrick. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 3.1 3.2 3.3 3.4 3.5 3.6 Site and external Building design, Building services  Finishes, fixtures and Construction Operations and maintenance 39 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation environment structure and materials  equipment  considerations  considerations  3.2 Building design, structure, and materials Decisions about the materials of the building envelope (for example, amount of insulation, or U-values provided) and cladding (including solar shading devices) will influence the design of the building’s HVAC In the design phase, the architecture team and consultants build upon the master plan and design system (in essence, how hard it needs to work to meet indoor temperature requirements). brief to study more detailed strategies for the facility’s building(s). A building’s architectural form and configuration are often influenced by planning and zoning regulations. They are also inherently tied to RESILIENT-SPECIFIC GUIDANCE: its construction materials and structural system. Programmatic needs during emergencies or disasters: The spatial design of the building, includ- The selection and specification of building materials and structural systems are an important part of the ing its size and number of levels, is influenced by the architectural program of spaces, service design phase because this level of detail is required to begin to determine the sizing, configuration, and delivery functions, and adjacency requirements; therefore, many of the resilience considerations details of building systems and components. For example, certain structural systems require different relevant to master planning in Section 2.5 apply here as well such as considerations for increased column grid spacing and sizing than others, and that will in turn influence the allocation and planning of capacity or changes to function during emergency and disaster scenarios. For example, in the interior spaces. Decisions to prioritize local construction materials may also influence the building design. event of transport networks being disrupted in a disaster, staff may not be able to return home, so temporary staff accommodations may be needed. In a pandemic, isolation spaces for patients Case study connection: The design of the Tambacounda Hospital in Senegal was heavily and staff may be necessary. Designing spaces for flexibility to be able to serve multiple functions influenced by a desire to integrate indigenous craftsmanship into the project. All construction goods can also be useful to provide resilience should unexpected events occur or to provide seasonal and services were sourced within the region, including 50,000 custom bricks (see Figure 3.3). or recurring surge capacity (for example, malaria or cholera). During the design phase it is also important to consider what storage is needed for stockpiled supplies for use in emergencies or in FIGURE 3.3 the case of supply chain disruption. TAMBACOUNDA HOSPITAL IN SENEGAL USED LOCALLY FABRICATED BRICK SCREENS TO REDUCE SOLAR HEAT GAIN Case study connection: The circulation paths of the Ghana Infectious Disease Center were designed to allow for one-way traffic flow to reduce airborne disease transmission. Evacuation planning: Facility design should consider safe building evacuation routes for patients and staff of all ages, abilities, and health conditions, including in the event of an elevator shut down due to loss of power. For facilities with patients who cannot be moved without being carried or who use wheelchairs or any other moving devices, multiple fireproof areas on the same floor may be necessary to allow for horizontal evacuation in the event of a fire. Structural system design: In the design phase, the structural engineer will specify the design basis for the facility’s structural system based on the current building code in force and other proj- ect requirements, including serviceability requirements (for example, vibration control for special Lattice bricks allow air into the wards. medical equipment) as well as design loading criteria including those related to relevant hazards © Oliver Wainwright, The Guardian. (derived either from the building code or from site-specific studies). Health facilities are typically 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 3.1 3.2 3.3 3.4 3.5 3.6 Site and external Building design, Building services  Finishes, fixtures and Construction Operations and maintenance 40 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation environment structure and materials  equipment  considerations  considerations  assigned a higher importance factor in building codes for wind and seismic design than other types Case study connection: Resilience upgrades were made to the Culebra Community Health of less critical building, to reduce the risk of structural and nonstructural damage in the event of Center in Puerto Rico prior to Hurricanes Maria and Irma in 2017, allowing it to resist strong a strong windstorm or earthquake, and thereby limit disruption. In some cases, advanced design winds with little damage. Both structural and nonstructural improvements were made, methods—performance-based design—are used to validate the structural design and confirm it including the installation of hurricane clips and straps for the roof, tie-downs for mechanical meets the design performance objectives to limit or prevent service disruption for certain levels of equipment and hurricane-resistant windows and shutters (FEMA, 2018). design event. Refer to the Building Code Checklist for Structural Resilience (World Bank, 2024) for additional information on structural safety and resilience design provisions. Adaptability: Overall, the design should consider flexibility needed for different scenarios and future adaptability, including for expansion. For the structure of the facility, the use of systems Case study connection: The Elbistan State Hospital in Türkiye was designed with a that allow for greater flexibility in the placement of wall partitions (for example, steel or con- seismic base isolation system to reduce the impact of earthquake events on the structure crete frames) is advisable when future adaptability of layout may be needed to ensure long-term and contents of the hospital buildings. The seismically isolated hospital building performed usability. well in the 2023 Türkiye–Syria earthquakes and remained operational so it could provide uninterrupted delivery of health care services. Hazard specific building design resilience measures: For specific resilience measures related to different types of hazards—for flooding, strong winds, earthquakes, soil instability, extreme heat, Structural system and material selection should also consider the local construction environment. and water scarcity—refer to Appendix A.1. Some measures, for example resilience measures to The complexity of the build should align with the level of local construction capacity. reduce the impact of extreme heat or water scarcity, will have co-benefits in terms of improving energy and water efficiency. Structural system materials: Poor material quality in the main load-carrying structural ele- ments of a building can be a leading contributor to vulnerability. For this reason, construction Key questions: materials, particularly those used in the structural systems of buildings, must typically meet ● Does the design consider what will be required during emergencies or disasters (for or exceed certain minimum requirements for strength that are specified by governing building example, ability to adapt spaces to increase capacity, isolate patients, accommodate codes or regulations. Material testing is often required to confirm material properties of concrete, staff, store emergency supplies)? masonry, steel, and other structural materials. This is particularly important for health facilities ● Does the design consider evacuation needs for users of all ages, abilities and health located in high seismic areas or exposed to strong wind events. conditions? Nonstructural elements: In addition to ensuring that the building structure is designed for antic- ● Do the structural system and materials selected meet architectural design needs (for ipated loads from hazards loads from hazards such as earthquakes and strong winds, it is also example, for flexibility, modular design, clear span distances) including for future expansion? important to design and detail nonstructural elements such as partition walls, hanging ceiling ● Do the structural systems and nonstructural components meet required performance panels, and the exterior cladding of buildings to withstand the types of movements, vibrations objectives per design regulations, or to meet resilience objectives to limit disruption and forces they might be subjected to during these events as they move with the structure of the which may be above the minimum code requirements (for example, for the earthquake building. design level, or wind design level)? ● Are the materials selected locally available or imported? Are they durable and easy to maintain? 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 3.1 3.2 3.3 3.4 3.5 3.6 Site and external Building design, Building services  Finishes, fixtures and Construction Operations and maintenance 41 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation environment structure and materials  equipment  considerations  considerations  ● Is the local construction industry familiar with the selected structural systems, Note that the structural and architectural design (for example, floor to floor height, layout of the architectural components and materials? floor structure) needs to be coordinated with services design to accommodate active systems, ● Depending on the local hazards, which hazard-specific resilience measures can be such as HVAC systems, and associated mechanical equipment. The loads associated with solar considered for incorporation into the design? shading systems, renewable energy systems such as solar panels, and green roofs and walls needs to be considered in design. Case study connection: The floor plans of the patient wards of the Ng Teng Fong General GREEN-SPECIFIC GUIDANCE: Hospital and Jurong Community Hospital in Singapore are narrow and fan-shaped to Appropriate selection of green building measures will depend on climatic conditions. For example, minimize the distance between windows on opposite faces of the building for improved air buildings in tropical climates will benefit from passive measures such as designing to maximize flow. The ventilation standards achieved only by natural ventilation are higher than the natural ventilation, or to reduce solar heat gain by selecting lower thermal mass materials (as standards for typical patient rooms in the United States. buildings cool down less at night). Building Materials: The selection of building materials provides one of the greatest opportunities The following green building measures relate to the main building components, the building form, to improve the green qualities of the facility. orientation and cladding: ● Specification of materials with low embodied energy such as steel with recycled content or ● Daylighting: The location of buildings and building orientation on the site, as well as the size those with carbon sequestration properties such as certain timber products from sustainably and placement of windows may be influenced by daylighting, a strategy to optimize the use managed forests can reduce the carbon footprint of the building. Alternative cementitious of natural sunlight to light interior spaces, reduce energy consumption and create healthy materials and recycled aggregates can also be specified for concrete to reduce its significant indoor environments. carbon footprint. ● Solar shading: Architectural elements or devices (for example, overhangs, screens, louvers) ● Alternatives to modern building materials that are locally available or leverage local can be used to control the amount of sunlight—and solar heat gain—entering a building, as craftsmanship—such as the use of locally fabricated mud brick or locally quarried stone— well as minimize glare and enhance occupant comfort and energy efficiency. not only have low embodied energy, but also effective insulating properties, and their use in ● Wall and roof insulation: Building materials with high thermal resistance (R-Value) or low construction supports local economies and can be more cost-effective. thermal transmittance (U-Value) may be used in exterior walls, floors, and roofs to help regulate indoor temperatures and minimize energy loss. Case study connection: Tambacounda Hospital in Senegal is an inspirational example ● Reflective walls and roofs (for example cool walls and roofs) can minimize heat gain inside maximizing natural ventilation by employing vernacular architectural materials and the building and reduce the need to cool the building with active systems. designs in harmony with local culture, society and climate (the operating suites did require ● Natural ventilation: Building shape and building orientation and the position of operable mechanical systems, using air conditioning via a zoning approach). windows and louvers in buildings can promote cross-ventilation and stack ventilation (for example, chimney effect) to reduce or eliminate mechanical cooling requirements for some ● The durability of building materials, particularly relative to the climate—as well as the ability health facility spaces. to maintain them with local resources— are also important considerations for ensuring that the facility is sustainable in the long term. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 3.1 3.2 3.3 3.4 3.5 3.6 Site and external Building design, Building services  Finishes, fixtures and Construction Operations and maintenance 42 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation environment structure and materials  equipment  considerations  considerations  ● The use of construction materials with higher thermal mass such as concrete, masonry and away in the facility, rooms designed for family members to spend the night with patients, earth can regulate indoor temperatures in hot and/or cold climates by absorbing and storing and other facilities tailored to accommodate Māori spiritual and healing practices (Morris, heat during the day and releasing it at night. 2021). ● Materials should be selected to reduce the release of persistent, bio-accumulative and toxic The architectural design of health facilities should translate goals and design intent for inclusivity— chemicals (PBTs) associated with the life cycle of the building materials. such as equitable use of space, barrier-free access to services, independent use of space and For more detail on individual green building measures for health facilities, refer to Appendix A.2. ergonomically suitable spaces—into physical approaches for construction. Examples of strategies Additional guidance is also provided in the Building Code Checklist for Green Buildings (World and considerations include: Bank, 2023), IFC’s EDGE tool and the Institution of Structural Engineers (IStructE) carbon calcu- Accessible entrances, doors and lobbies: These should remain independently accessible and lator tool in Appendix B. obstruction-free, both physically and otherwise, regardless of the user’s language, knowledge, Key questions: sensory condition, disability or level of concentration. This may include step-free transitions; doors of adequate width to accommodate wheelchairs, mobility scooters or stretchers; auto- ● What are the climatic conditions for the site location? mated doors; clear layout of the space to identify reception or the main circulation route; and a ● Are there opportunities to maximize the use of passive green building measures such as lower reception desk to allow communication with wheelchair users. natural ventilation (even if active measures are also needed)? ● What is the embodied energy of different material options and are there ways to reduce Horizontal circulation: Circulation should provide independent access within the building. Some the embodied energy for the design? considerations include the following: ● Inpatient circulation on each floor within a building should be clear and easy to navigate for all users; INCLUSIVE-SPECIFIC GUIDANCE: ● Adequate space in corridors should allow all users to maneuver and pass one another, The use of patient-centered design ensures that facilities are designed with user experiences in including those on stretchers or in wheelchairs; and mind, providing easy access to a range of services in environments that ensure user dignity and ● Floor coverings and thresholds should be designed not to cause difficulty for wheelchair users privacy while supporting well-being and positive health outcomes. This might include integrat- or tripping hazards for people with limited mobility or sight. ing certain services within the same facility or nearby to encourage a continuum of care that is Vertical circulation: Stairs, ramps and elevators provide essential access to floors in multistory focused on maintaining or improving health rather than just treating the acute illness. It might buildings. Vertical features should be closely integrated with elements of the horizontal circulation to point to the inclusion of nonclinical spaces for companions or dependents of patients to wait, provide a logical and convenient means of moving through an entire building. For smaller health clinics, access to faith practices and indigenous healers in the facility, or provision of overnight accom- it can sometimes be more cost-effective to keep buildings to one story to avoid any need for elevators. modation for patients and families who live far from the facility. Emergency room access: Emergency drop-off areas should allow for a clearly visible, direct, bar- Based on a cultural impact assessment and co-design process, the New Dunedin Hospital rier-free access path into the emergency room unit of the health care facility. Circulation spaces in New Zealand will consider Māori cultural practices around healing, birth and death. These should be large enough for triage and transfer of patients in stretchers to the emergency room. include dedicated weaving spaces for volunteers to weave items for babies that have passed 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 3.1 3.2 3.3 3.4 3.5 3.6 Site and external Building design, Building services  Finishes, fixtures and Construction Operations and maintenance 43 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation environment structure and materials  equipment  considerations  considerations  Waiting areas: Quiet waiting areas should be provided as well as places to rest using mixed seat- RESILIENT-SPECIFIC GUIDANCE ing options to accommodate a range of user needs, including those with wheelchairs, mobility Considerations related to natural hazard events, pandemics and climate adaptation should inform aids, service dogs or accompanying children. Designing waiting areas with windows to allow for the design of building services. natural light and an outdoor view is also desirable. Physically resilient building services design: In addition to ensuring that the building’s struc- Communication and wayfinding: Communication and wayfinding aids can include visual as well tural and nonstructural elements such as partitions and cladding will withstand extreme events as audio announcements, braille signage and contrasting color signage. Also see Section 3.4. Pre- with limited damage (see Section 3.2), engineers must also ensure that a building’s mechanical, visitor information can be useful for users to explain how to reach the building, where to go and electrical, plumbing and ICT systems can withstand the types of relative movements, vibrations, how to get to reception or other relevant destinations. or other effects caused by extreme temperatures, earthquakes, strong wind and rain, or floods. Facilities for patients and staff: In addition to basic facilities such as sanitary facilities, these can For example, critical services and equipment required for operation should be located away from range from the provision of primary care with waiting areas and examination rooms to complex areas of the building more at risk from flooding. hospitals with specialized treatment facilities, inpatient accommodation, cafeterias and waiting In some cases, strategies that reduce vulnerability to one hazard may increase vulnerability to areas. The facilities provided should be safe, accessible and useable by the widest range of people, another, so a multihazard approach to design that considers the range of plausible scenarios is where practicable, and should encourage active participation by all users. Facilities should also important. For example, constructing a heavy roof to resist uplift from strong winds or locating take into account cultural practices. critical equipment on a roof to reduce flood damage would increase the seismic forces that the Great discomfort and loss of dignity can be caused for users if the sanitary facilities (toilets and building would need to resist in an earthquake. hand-washing facilities) do not meet the requirements in terms of access and use. Redundancy and backup systems: Where a health facility relies upon central utilities for power, Key questions water supply and telecommunications, redundancy should be built into the design in case of cen- tralized service disruption. This could include provision of an isolated power supply (IPS) to iso- ● What was learned from stakeholder engagement in terms of types of users and their late the equipment from power disturbances such as blackouts, an uninterruptible power supply needs and cultural practices that are relevant for the design of health facilities? (UPS) to provide a temporary power source, and on-site backup generators (located in elevated ● How can each key aspect of inclusive building design respond to these needs? locations, with sufficient fuel supply) to supply power over longer periods, backup water storage systems (which could include cisterns for rainwater harvesting), and alternative communication systems (for example, satellite phones or two-way radios). For health clinics in countries with 3.3 Building services limited power supply networks, off-grid solar power can support operations and protect critical supplies such as vaccines or other medicines that need refrigeration. Inverter systems can also be This section focuses on opportunities to enhance the resilient, green, and inclusive qualities of health specified to ensure continuity of power to life-critical systems without power dropping during the facilities through the design of the mechanical (heating, ventilation, air conditioning, HVAC), plumbing, switchover to backup power systems. electrical, information and communications technology (ICT), and waste disposal systems. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 3.1 3.2 3.3 3.4 3.5 3.6 Site and external Building design, Building services  Finishes, fixtures and Construction Operations and maintenance 44 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation environment structure and materials  equipment  considerations  considerations  Case study connection: Upgrades to health clinics in the Kara region of Togo were aimed Energy efficiency: Passive methods such as natural ventilation, daylighting, and insulation, dis- at improving access to basic services like power and water. Most upgrades included the cussed in the above sections, are effective in reducing energy demands on HVAC and electrical introduction of new solar power systems as well as boreholes where access to municipal systems and may be more cost-effective and achievable for small scale facilities. More energy-effi- water supply was not possible. These upgrades were not only green but also inherently cient HVAC systems with heat recovery (for example, heat pumps, radiant heating/cooling, chilled resilient, allowing the facilities to function effectively off-grid. beam systems) can also be specified to reduce the energy usage of active systems for moderating indoor environmental quality. Renewable energy, such as solar power, can supply a portion of the Infectious disease control: Building HVAC systems should also be designed to minimize the spread power needed by these systems. To reduce energy consumption related to the provision of hot of disease including airborne pathogens. Airborne Infection Isolation Rooms (AIIR) use negative water needed for disinfection and health care needs, energy-efficient hot water systems can be pressure relative to adjacent spaces to help contain pathogens. Air filtration and UV light systems specified such as air source heat pumps and solar water heaters. More energy-efficient ancillary can also be deployed for infection control. Monitoring systems and operational procedures for equipment like motors, pumps, fans, compressed air systems may also be selected. air quality should also be in place. To address the risk from COVID-19 and other airborne patho- gens, the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) Water efficiency: Water efficiency can be improved by integrating rainwater harvesting and recy- has developed a pathogen mitigation standard which is at the forefront of indoor air quality and cling/treating of greywater (for example, wastewater, including condensate recovery from HVAC infection control (ASHRAE, n.d.). Standards such as this could be implemented in future health systems) into building plumbing systems. These on-site sources of water can be used for nonpo- care facilities. table purposes such as watering external planting, toilet flushing and laundry, or in the cooling towers of HVAC systems. More water-efficient equipment could include air-cooled rather than For additional resilience measures related to the design of services, refer to Appendix A.1. water-cooled refrigeration systems, or medical equipment that uses recirculated water. Key questions: Sustainable waste management: Measures to reduce and sustainably manage routinely gen- erated wastewater and solid waste should also be factored into the design. Internationally rec- ● Has the design of services considered the potential vulnerabilities to relevant hazards ognized best practices for medical waste management include reducing the generation of waste and related mitigation measures? (such as hazardous medical waste), segregating waste, reusing as much as possible (that is, reuse ● Has the design considered adding redundancy and backup systems? after high-temperature treatment), promoting recycling, and appropriate disposal methods (Lee ● How effective is the services design to reduce the spread of airborne pathogens and are & Lee, 2022). Planning for proper containment, treatment, and disposal of hazardous or infectious isolation rooms provided (if required)? solid waste, as well as radioactive wastewater and medical gases, is also important for preventing the spread of disease and protecting the environment. This became a pressing issue during the COVID-19 pandemic, when solid waste (such as personal protective equipment, PPE) was in some GREEN-SPECIFIC GUIDANCE: cases generated faster than it could be safely disposed of. Where incineration systems are used, The design of the HVAC, electrical and plumbing systems and specification of equipment provides efforts should be made to reduce their environmental impact. one of the best opportunities to enhance energy and water efficiency. This is particularly the case for resource-intensive health facility types, such as those that require strict controls on air quality and temperature, include water-intensive equipment and activities and have inpatient facilities (US EIA, 2017). 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 3.1 3.2 3.3 3.4 3.5 3.6 Site and external Building design, Building services  Finishes, fixtures and Construction Operations and maintenance 45 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation environment structure and materials  equipment  considerations  considerations  Key questions: RESILIENT-SPECIFIC GUIDANCE: ● Have a range of active energy efficiency measures been explored for the facility (this can Physically resilient finishes, fixtures and equipment: For health facilities located in high seismic be in combination with passive measures)? zones or areas exposed to high wind speeds, it is important to design building components, fix- ● Have a range of water efficiency measures been explored? tures, and equipment to resist necessary forces and accommodate movement or vibration with- ● Have measures for sustainable waste management been explored and how is waste out failure. Even if the structure of a hospital is damage-free following a natural hazard event, management connected into the wider network? the facility may not be able to function as intended if finishes, fixtures or equipment is damaged or has fallen and compromised the use of spaces. Suspending elements like light fixtures, HVAC ductwork, sprinkler heads, ceiling panels and other components might require anchorage or brac- INCLUSIVE-RESILIENT GUIDANCE: ing. Equipment may require seismic anchorage and resistance to uplift from wind forces. Indoor environmental and comfort: The design of building services is essential in determining Protecting sensitive medical equipment: In the design phase, coordination is required between factors such as air quality, temperature, odors, lighting, and sound, which create the indoor envi- the structural engineering team, the architects and the suppliers of high-value, sensitive medical ronment experienced by users. Users of all ages and abilities and their needs should be considered equipment (for example, CT or MRI equipment) to ensure that its placement and the detailing of during design of these systems and their controls. For example, people with head injuries or neu- its supporting structure provide for limitation of exposure to vibration (for example, caused by rological conditions may be very sensitive to light and noise. Where possible, build in adjustability human-induced movements on floor systems) or loading or deflection (for example, caused by and opportunities for patients to control their indoor environment (for example, adjustable ther- wind or seismic movement) that might impact its performance. mostats, ventilation controls, and so forth). Built-in redundancy in equipment provision: For medical equipment, additional equipment may Key questions be needed during surge periods or backup equipment could be considered in case critical items are damaged or inaccessible. ● Does the services design for control of indoor environmental quality and comfort meet user needs? Key questions: ● Can users control some aspects of the indoor environment? ● Have relevant loading and allowable movements—including from design-level hazard cases—been considered for the performance of finishes, fixtures and equipment? ● Is equipment located to reduce the risk of damage for different design-level hazard 3.4 Finishes, fixtures and equipment types? ● Is an appropriate level of redundancy built into the provision of medical equipment for Finishes, fixtures, and equipment are the main elements of building(s) with which users come into direct critical functions? contact. It is therefore important to ensure that the products specified in the design phase support the facility’s resilient, green, and inclusive objectives. In addition to equipment related to building services, health facilities often contain high- value medical equipment, which ideally should be protected from damage to ensure continuity of health services provision. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 3.1 3.2 3.3 3.4 3.5 3.6 Site and external Building design, Building services  Finishes, fixtures and Construction Operations and maintenance 46 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation environment structure and materials  equipment  considerations  considerations  GREEN-SPECIFIC GUIDANCE: INCLUSIVE-SPECIFIC GUIDANCE: Energy- and water-efficient fixtures: Inpatient health facilities are one of the most water-inten- The selection of finishes, fixtures and equipment should ensure that facilities are safe, accessible, sive types of buildings (comparable to hotels, for example) and require water for medical equipment, and usable by the widest range of people, where practicable, and should encourage active partic- HVAC systems, food preparation and sanitation. Outpatient facilities have less intensive water ipation by all users. requirements that are more comparable to office building requirements (EIA, 2017). In addition Accessible equipment: Medical equipment should be specified with the needs and abilities of all to the strategies in Section 3.3 to address water supply, demand for water can be reduced with users in mind. For example, height adjusted examination tables, patient lifting equipment, spe- water-efficient fixtures. Similarly, energy consumption can be reduced with more energy-efficient cial scales for wheelchair users, adjustable medical equipment for x-rays, and so forth, and beds lighting, energy-efficient HVAC equipment and other appliances (see Section 3.3), and energy adapted for patients with limited mobility. management systems (EMS) that automatically monitor, control, and optimize energy use. Barrier-free furniture, fixtures, and fittings: Furniture, fixtures, and fittings in health facilities Cool roofs and walls: These support energy efficiency goals and reduce the impacts of extreme must be usable by people of all ages and abilities. Some examples include universally accessible heat. Highly reflective finishes on the roofs or walls of buildings, such as white or light-colored lighting and service controls (including touchless sensors), highly visible electrical outlets, and paint, will reflect a significant portion of the sun’s solar radiation back into the atmosphere rather adjustable/adaptable furniture to accommodate a range of needs. Handrails and guiding blocks than absorbing it as heat. As a result, less heat is transferred to the building, helping to keep should be integrated into corridors. Ensuring safe and independent usage is also important, par- indoor temperatures down, and imposing lower demands on HVAC systems (that is, improving ticularly for sanitary facilities. Great discomfort and loss of dignity can be caused for users if building comfort through passive regulation of temperature). toilets and hand-washing facilities do not meet requirements in terms of access and use. For Sustainable materials: Interior finishes, furnishings, and other materials should be sustainably example, if a door handle is too high, or if a door is too heavy for a frail or elderly person to open, sourced and low-embodied energy products where possible, maximizing the use of recycled mate- then a toilet becomes inaccessible. rials and reducing the release of persistent, bio-accumulative, and toxic chemicals (PBTs) over User-friendly finishes: A building’s interior wall, floor and ceiling finishes must be considered when their life cycle. Also see Section 3.2. ensuring health facilities are barrier-free and accessible. The level of slip resistance of walking Key questions: surfaces, the acoustic properties of finishes, and the color of corridors and rooms are important features enabling a comfortable user experience. ● When specifying finishes, fixtures and fittings, have energy- and water-efficient options and strategies been explored, where applicable? Case study connection: Upgrades to health clinics in Togo included details such as the ● For finishes and furniture, have sustainably sourced and low- emitting materials been use of bright colors and reflective strips to indicate electric outlets and switches and for selected? wayfinding. Wayfinding: Wayfinding is an important means of ensuring health facilities are inclusive and independently accessible by those with physical or cognitive disabilities. Human-centered design approaches can be useful in developing effective wayfinding strategies to accommodate intended users. Accessible wayfinding measures include signage in multiple languages, with lettering, 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 3.1 3.2 3.3 3.4 3.5 3.6 Site and external Building design, Building services  Finishes, fixtures and Construction Operations and maintenance 47 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation environment structure and materials  equipment  considerations  considerations  symbols, and colors appropriate for nonreaders or those with low vision or color blindness; use which construction types and nonstructural finishes are economical and easy to maintain. Also of audible and tactile information; and maps, diagrams, or digital wayfinding to help patients see Section 3.2. navigate to their destination. With mobile technologies, a user may scan a QR-code upon arrival Construction contingency planning: The construction plan must consider exposure to relevant and select a destination. A route is then generated in a web browser (similar to the interface in risks at the site over the duration of the construction period. Contingencies for disruptions to an app such as Google Maps). These tools can also provide patients with other information, such supply chains or human resources should also be integrated into the plan, as well as monitor- as departmental working hours, what they will need for their appointment, and special routes for ing approaches to readily identify and address emerging conditions or risks. To safeguard the disabled patients. resilience measures designed into the facility, construction quality control and assurance mech- Key questions anisms should also be built into delivery, particularly in contexts where building regulations are poorly enforced. ● Are fixtures, fittings and medical equipment provided suitable or adaptable for different types of user needs? Key questions: ● Are finishes user friendly for all types of users? ● Has the local context and construction environment been considered when designing the ● Are wayfinding methods provided for users of all types? facility, including the selection of structural and nonstructural elements and the level of complexity of the build? ● Have construction contingency plans been formulated in the design stage and are they reflected in the construction procurement documents? 3.5 Construction considerations in design Although the construction phase is short compared to the useful life of a health facility, it presents opportunities to contribute to a facility’s resilient, green, and inclusive qualities. Consideration of con- GREEN-SPECIFIC GUIDANCE: struction in the design phase can mitigate risks and negative impacts and should be documented in the Construction waste: Measures should be considered to reduce the amount of solid waste gener- construction documents procurement package. The scope of this guidance excludes the construction ated during construction (for example, recycling and salvaging materials) and to control air, water phase, but selected considerations related to construction in the design phase have been identified. and noise pollution during site activities. Green construction materials: Refer to Section 3.2 on green building materials as related deci- RESILIENT-SPECIFIC GUIDANCE: sions are made in the design phase. Construction environment: In the design phase, the local capabilities and capacity of the con- Local materials: See Inclusive section below. Sourcing local materials can, in some cases, reduce struction environment should be considered, including available materials, quality of materials, the carbon footprint of the facility, as energy expended on transport of materials will be lower. ability to perform geotechnical works (for example, in some cases, deep foundations may not be feasible), and skills, experience in certain types and levels of complexity of construction, and 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 3.1 3.2 3.3 3.4 3.5 3.6 Site and external Building design, Building services  Finishes, fixtures and Construction Operations and maintenance 48 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation environment structure and materials  equipment  considerations  considerations  Key questions: Key questions ● Does the design consider how to reduce waste during construction or incorporate ● Does the design incorporate local materials? recycled or salvaged materials? ● Does the construction type allow for local labor to be involved in building the facility? ● Have efforts been made to incorporate local materials, and materials with green credentials (for example, sustainably grown timber)? 3.6 Operations and maintenance considerations in design The operational needs identified in Section 4.0—and associated required operational budget—must be INCLUSIVE-SPECIFIC GUIDANCE: considered in the design phase as they may influence the programming, spatial design, building sys- Local sourcing: Sourcing construction materials and labor locally is an effective way of engaging tems, or construction materials and equipment. Furthermore, monitoring systems needed to ensure the local community and building community support—an investment in the long-term success proper operation and functioning of building systems and equipment during the operational phase of the facility. Such stipulations should be considered during design for inclusion in construction must also be integrated into the design. procurement materials. Depending upon the anticipated financial and human resource availability for operations and main- Case study connection: The Ghana Infectious Disease Center sourced all project materials tenance, certain design options may be less viable for longer term functionality of the facility. For locally, serving as a demonstration of proposed “local content laws” for the construction example, for a health facility maintained by a local community with fewer resources for operations sector in Ghana by highlighting the cost savings and economic development advantages of and maintenance, it may be better to use more durable, easily maintained materials (for example, sourcing goods and services locally. masonry or reinforced concrete walls rather than imported, lightweight partitions). This decision could be a deciding factor in the selection of the main structural system and wall layout. Case study connection: Tendering for the construction work related to upgrades to existing health centers in Togo weighted ‘local proximity to the construction site’ most heavily for contractor selection. To distribute work across as many local contractors as possible—to build capacity—each contractor was allowed to win only one site. In some cases, construction firms are engaged to provide both detailed design and construction services (sometimes referred to as design-build, engineering-procurement-construction—EPC— or turnkey contracting). In such cases, it is essential that the design intent related to the facility’s resilient, green, and inclusive features are included in procurement materials and a system for monitoring, evaluation and accountability is implemented by the owner. These measures are nec- essary to ensure that these key qualities are not removed due to budget constraints or a failure to realize their longer-term benefits. Refer to Section 2.7 for more information. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 49 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation CASE STUDY Tambacounda Hospital, Senegal R G I The extension to the Tambacounda Hospital was planned to re- $2.5 million (Morris-Jansen, 2021), was conceived to address the needs is provided only in the operating suites. Other green features used to spond to the needs of women and their families. It employs local of local women and families, leverage local resources and knowledge in naturally cool the building include a perforated, concrete and corru- indigenous architecture and passive ventilation to naturally cool the design process, and distribute social and economic benefits from the gated metal vaulted roof that acts as a thermal chimney, drawing hot the facility, despite extreme heat conditions in the region. project to the surrounding community. Key features are: air upwards to create a breeze, as well as ceiling fans (Wainwright, 2021). The exterior of the roof is painted white to reflect solar energy Featured qualities: Resilient (extreme heat), Green (natural ventilation, ● Community engagement in programming and concept design: Prior (Wainwright, 2021). local materials and labor), Inclusive (sensitive to women’s and children’s to developing a design concept, the architect met with doctors and needs, local materials and labor) staff at the facility to understand their needs. The design was then ● Local sourcing: In the early stages of design, the architect met shared with the local community for input (Bell, 2022). This process with local fabricators to integrate indigenous craftsmanship into The only hospital in Tambacounda—one of the hottest cities in the revealed that a key programmatic need was increased space for the project. As a result, all construction goods and services were world—was overstretched to serve the needs of the 100,000 city res- socialization for visiting families and children. In this part of Senegal, sourced within the region, including 50,000 custom bricks shaped idents and more than one million people living in surrounding regions, it is common for patients to come to the hospital with as many as from a single mold, and metal windows (Wainwright, 2021). Use of including in adjacent Mali (Manuel Herz Architects, 2021). Le Korsa, five family members who take care of basic, nonmedical needs, such indigenous construction approaches not only kept the investment a Senegalese NGO, led a project to triple the capacity of the regional as washing clothes or preparing food, as well as children (Wainwright, within the region but also allows the facility owners to sustainably hospital to 150 beds and add a maternity ward and pediatric clinic. The 2021). The design therefore includes a new two-story building manage future construction and maintenance work, without relying hospital expansion, which was completed in 2021, at a total cost of US winding around the existing circular hospital buildings and trees on on imported materials or expertise. the site (Manuel Herz Architects, 2021). The spatial configuration between the new and existing buildings creates communal areas and ● Flexibility for future needs: A flexible, modular design was used to courtyards for visiting families (Stathaki, 2022). Rooms in the upper facilitate incremental future programmatic changes. For example, maternity wards of the new building have open balconies overlooking the hospital plans in the future to build staff quarters to attract these communal spaces, which include a playground, the first and additional doctors from the city. (ArchDaily, 2022). only one in the city (Wainwright, 2021). ● Sustainable design in extreme heat: A primary focus of the design was limiting indoor air temperatures in the wards during extreme heat conditions (often greater than 40°C) through passive design techniques. The width of the new building was limited to encourage Maternity and Paediatric Hospital cross-ventilation. Covered walkways screened by perforated red clay in Tambacounda, brick walls run the length of the new building and connect it to the old te and buildings (Bell, 2022) Senegal, by Manuel buildings (Manuel Herz Architects, 2024). The screens, referencing Herz. © Iwan Baan 2021. Courtesy of local indigenous architecture, filter sunlight and reduce solar heat the Josef and Anni Maternity and Paediatric Hospital in Tambacounda, Senegal, by Manuel Herz. © Iwan gain inside the buildings (Bell, 2022) (Stathaki, 2022). Air conditioning Albers Foundation Baan 2021. Courtesy of the Josef and Anni Albers Foundation and Le Korsa. and Le Korsa. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 50 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation CASE STUDY Ng Teng Fong General Hospital Ng Teng Fong General Hospital / Jurong Community Hospital (NTFGH-JCH), Singapore and Jurong Community Hospital. © HOK and Rory Daniel Photography. R G The Ng Teng Fong General Hospital and neighboring Jurong Com- energy than a typical hospital in Singapore, and 40 percent less potable square meter than a munity Hospital (NTFGH-JCH) use green design to support the water (NTFGH, n.d.). The project was awarded a Platinum rating from typical hospital in the health and well-being of patients and staff. Green building fea- Singapore’s Green Mark certification scheme (Horwitz-Bennett, 2017). United States (Horwitz- tures also reduce energy and water consumption despite Singa- Bennett, 2017). Savings pore’s tropical climate. Key design features include: come from energy-ef- ficient air conditioning; Featured qualities: Resilient (extreme heat); Green (water efficiency, ● Indoor environmental quality and natural ventilation: The building’s solar panels supplying energy efficiency, renewable energy, green infrastructure, natural ven- siting and design respond to solar orientation and prevailing breezes. power to landscape lighting; and photo and occupancy sensor-control tilation, daylighting) The architectural design includes narrow, sawtooth fan-shaped wards lighting (Horwitz-Bennett, 2017). Potable water efficiency is achieved to minimize the distance between windows on opposite faces of the through water-efficient fittings, rainwater harvesting of exterior veg- Completed in 2015 following an international design competition, the building for improved air flow and natural light. Each patient has a etation and green roofs, and use of treated greywater in the cooling NTFGH-JCH medical campus operated by the Singapore Ministry of Health dedicated operable window. Passive cooling and natural ventilation towers of the air-conditioning system (Horwitz-Bennett, 2017). All provides continuing care from outpatient to post-acute care. The facility, are used in 82 percent of inpatient areas, providing higher ventilation hot water is supplied by solar thermal collectors (NTFGH, n.d.). Total which cost US$461 million to build (Horwitz-Bennett, 2017), includes a standards than typical patient rooms in the United States (NTFGH, carbon emissions for the building are estimated to be 97.5 lbs/CO2/ 707-bed general hospital for acute care and a 396-bed community hos- n.d.; Blahut, 2017). To confirm patient comfort levels and control the sq ft (Blahut, 2017). pital for rehabilitative and palliative care. The building design features spread of infection, airflow was analyzed using computational fluid passive cooling, dynamics models (Horwitz-Bennett, 2017). Energy-efficient mechan- In a survey following two years of operation, 90 percent of patients sur- natural ventilation, ical ventilation, using heat recovery, heat pumps and recycled grey veyed found the temperature and relative humidity in the patient floors and green roof veg- water in cooling towers is provided in operating rooms and other crit- to be acceptable and stated that the design helped them to recover etation to provide ical care areas. If wildfire smoke is present in the region, the operable faster. Ninety percent of staff surveyed said that the hospital design heat resilience windows close, and the central air-conditioning filtration system is made them more productive (Horwitz-Bennett, 2017). benefits in the trop- activated. ical, urban setting. The project used ● Solar shading, exterior planting and green walls: Key architectural performance-based features are the large concrete floor overhangs at each level that add design approaches thermal mass to cool the buildings and provide shading. The overhangs to comply with also support vertical vegetation on the façade that shades patients resource efficiency and cools air through evapotranspiration. The vegetation extends to and indoor environ- green roofs and gardens that function as rest areas and park space. mental quality (IEQ) Ng Teng Fong General Hospital and targets (Blahut, Jurong Community Hospital. ● Energy and water efficiency: Energy use is monitored through a © HOK and Rory Daniel Ng Teng Fong General Hospital and Jurong Community 2017). The buildings building management system. Energy use is 69 percent less per Photography. Hospital. © HOK and Rory Daniel Photography. use 38 percent less 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 51 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation CASE STUDY Elbistan State Hospital, Türkiye R The Elbistan State Hospital, rebuilt in 2017 with seismic base using flexible bearings, concentrating the movements from ground One base-isolated hospital did suffer significant damage, however, isolation, remained fully operational during the February 2023 shaking in the isolators, while limiting the accelerations and displace- because the isolation gap or “moat” at the ground level that allows earthquakes in Türkiye. ments experienced by the building. As a result, base isolated buildings movement between the ground and the building was filled with gravel, perform better in earthquakes, with the building and its contents largely instead of being left empty, causing seismic forces to be transferred to Featured qualities: Resilient (earthquakes) protected from damage, allowing them to be operational immediately upper levels of the building (Qu et al, 2023). This event starkly underlines after an event. Designing hospitals to be operational following a major the importance of ensuring that those involved in construction, oper- In 2013, to enhance the seismic resilience of Türkiye’s health care infra- earthquake not only allows basic health care services to continue but ations and maintenance in health care facilities fully understand such structure, the Ministry of Health issued a regulation that new hospitals also permits the facilities to serve other emergency functions necessary critical features and that works truly comply with the design intent. located in high seismic zones with more than 100 beds must be base to provide life-saving support for communities during response and isolated (Erdik et al, 2015). Base isolation is a method of seismic pro- recovery phases. Base isolation is often a solution used for hospitals in tection where the building structure is isolated from the foundation zones of moderate to high seismicity because the risk reduction benefits justify the typical 10–15 percent increase in construction cost (Daily Sabah, 2023). Minimizing building damage also supports sustainability goals by reducing the chance that the facility will need to be demolished and reconstructed or substantially retrofitted following a major seismic event. Since 2013, numerous new base isolated hospitals have been built in Türkiye, including the Elbistan State Hospital located in Kahramanmaraş, at a total cost of US $45 million (Prota, 2023). The 378-bed state and regional hospital has two buildings: a three-story front building and a nine-story rear building with the isolation layer located between the basement and ground floors (Elbistan State Hospital, 2022). It is one of 12 hospitals located in the region affected by the M7.8 and M7.5 February 2023 earthquakes that caused nearly 60,000 deaths in Türkiye and Syria. Five of these hospitals were base isolated, and four of the five performed to targeted “immediate occupancy” levels (Qu et al, Aerial view of the Elbistan State Hospital in Elbistan, Türkiye (Qu, 2023) 2023). Ground motion sensors indicate that several of these hospitals withstood ground motions that were more than twice their building code design levels, highlighting the absorptive capacity and resilience that base isolation systems can deliver (idem). The operational hospital being inspected after the earthquake events. © Jose Flores Ruiz, Degenkolb Engineers. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 52 Chapter 4.0 Operation Key Activities in the Operations Phase Building commissioning (Section 4.1) Operational policies and plans (Section 4.2) Monitoring and maintenance (Section 4.3) 4.1 4.2 4.3 53 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Building commissioning Operational policies and plans Monitoring and maintenance Key challenges for health facilities during the operations phase related to a facility’s buildings and equipment include maintaining critical functions during and after emergencies, ensuring smooth oper- ation of complex equipment and systems by staff, and planning and implementing capital investments Summary Points in the Operations phase to adapt to future needs while maintaining critical functions. After construction is complete, building commissioning must be carried out to ensure the facility performs adequately to fulfill its resilient, green and inclusive objectives. 4.1 Commissioning Operational policies and plans are required for facilities including Business Continuity Building commissioning is the process of ensuring that a new building’s systems and components Plans, emergency response and recovery plans, sustainability plans, and plans for periodic conform to design requirements.6 While the process begins in the planning stage, it continues into con- accessibility audits. struction with the testing and verification of systems and equipment, and ultimately into the opera- tions phase with ongoing monitoring and maintenance requirements. Commissioning helps to identify Plans should be in place for monitoring and maintenance of health facilities, along with and correct deficiencies and optimize performance. It often includes training for building operators adequate human and financial resources to execute them. and maintenance staff to establish protocols and ensure proper use, monitoring, and maintenance of building systems and equipment. Consideration is needed for how feasible it is to locally monitor and maintain the building, systems and equipment. The operational phase of a health facility includes commissioning, operational planning, and ongoing monitoring and maintenance. For a facility that has been planned and designed to provide resilient, green, and inclusive benefits, it is important to ensure that planning and implementation during the operational phase is coordinated with the facility’s design intent. For facilities that have not been con- ceived specifically with these objectives in mind, there are still many opportunities in the operational phase to work with the existing facility to enhance the resilient, green, and inclusive benefits it delivers. This may be achieved through operational policies and plans and/or building rehabilitation or retrofits of buildings and infrastructure. Engineers Discussing Facility Commissioning. © Dragonimages / Dreamstime.com 6 Please note that the relevant guidance mostly focusses on technical commissioning, for example, the testing of building components, equipment and systems. Aspects of wider operational readiness, such as staff onboarding, are not covered. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 4.1 4.2 4.3 54 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Building commissioning Operational policies and plans Monitoring and maintenance RESILIENT-SPECIFIC GUIDANCE: INCLUSIVE-SPECIFIC GUIDANCE: Building commissioning supports a facility’s resilience objectives by ensuring reliable performance The commissioning process for building systems and equipment can be used to verify that the of a building’s systems and equipment needed for operation. Commissioning helps to identify and universal accessibility features designed into them function properly. Training associated with the mitigate risks. It also helps to ensure that a building’s protective and emergency systems, such as commissioning process also provides an opportunity to educate staff about accessibility features fire protection systems and alarms, function properly. built into the facility. Post-occupancy evaluations may also be conducted to confirm the effec- tiveness of accessible elements of the facility. Key questions: Key questions ● How can the commissioning process be designed to identify potential failures in the system, such as arising from interdependencies that need to be considered during ● Does the commissioning process include testing systems and equipment related to operations? universal accessibility? ● Does the commissioning process measure the redundancy of systems? ● What staff training for universal accessibility features is needed ahead of operating the ● Does the commissioning process include testing of backup systems (for example, water, facility? power, ICT)? GREEN-SPECIFIC GUIDANCE: An important benefit of commissioning is ensuring that the performance requirements for energy efficiency and other green benefits are realized during the operation of the facility, including by verifying the tightness of the building envelope, performance of HVAC systems, energy-efficient lighting controls, and monitoring indoor air temperature and air quality. Key questions: ● Does the commissioning process include testing that the green building performance targets set in the design phase are met (for example, through pre-functional checklists, functional tests and reporting)? ● How can the commissioning results inform current facility requirements as well as a strategy for operations and maintenance? Inspector working on solar panel system maintenance on the roof of building. © Basilico Studio Stock/ iStock. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 4.1 4.2 4.3 55 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Building commissioning Operational policies and plans Monitoring and maintenance 4.2 Operational policies and plans RESILIENT-SPECIFIC GUIDANCE: Supporting the resilience goals of a health facility is a continual process. Operational plans for Operational policies at a facility level provide a framework to capture key information regarding service disasters, emergencies and business continuity should be periodically updated. Updates can delivery and service arrangements. Performance targets, functions, and monitoring requirements for capture changing user needs, resilience goals, and changes in hazards and risks. This information resilient, green, and inclusive facilities should be integrated into operational policies, including estab- can also inform critical capital improvement needs that influence capital planning and budgeting. lishing key performance indicators (KPIs) that can be measured over time. Operational plans and pro- cedures, including business continuity planning, emergency preparedness planning, and sustainability The business continuity plan (BCP) starts with a risk assessment of a facility’s physical and planning are some of the mechanisms by which these policies are implemented. Business continuity operational vulnerabilities to anticipated shocks and stresses. It also evaluates available redun- and emergency plans must be formulated not only for a health facility itself but for the wider health dancies including the backup infrastructure for water, energy, and information systems that are care network and community or region in which it operates. Emergency preparedness planning can be critical to sustain key functions and services of a health facility. The BCP also sets the level of enhanced by linking to early warning systems, for example for strong wind events or flooding. priorities for different functions and related recovery times. Backup information systems for patient medical records, including cloud technologies, are particularly important for health facilities that may be disrupted by damage to physical patient records or loss of access to servers. Business continuity plans may be linked to monitoring systems such as extreme weather fore- casting or early warning alerts for other natural hazard events. Training and regular drills for users are vital to enable them to respond to crises as set out in the BCP protocols. Business continuity planning often requires coordination with and training of partners and col- leagues in the wider region, to keep a regional health system intact. A critical element of this coordination is planning for patient information sharing across different facilities in an emergency. Emergency Preparedness Planning: Emergency planning is focused on preparing for potential emer- gency situations such as fires, security threats or medical emergencies, with a focus on protecting life, health, and property. For health facilities, planning for evacuation, including regular evacuation drills, is a crucial component of emergency planning. Evacuation protocols, including safe evacuation routes, emergency assembly points, and roles and responsibilities should be established with rele- vant stakeholders including the staff and community. For facilities that conduct surgical operations, protocols related to the termination of surgeries should be established based on the severity of the emergency event, and surgeons and staff should be trained accordingly. Scenario planning can be an effective way of promoting preparedness for a range of crisis situations. Planning can include specific Hospital staff having a meeting. © skynesher/ iStock.com. plans for disease outbreaks, intake of mass casualties and mass fatalities scenarios. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 4.1 4.2 4.3 56 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Building commissioning Operational policies and plans Monitoring and maintenance Case study connection: As part of resilience planning for the Kurashiki Central Hospital Stanford Emergency Department tested the use of hospital parking lots as drive-through in Japan, hospital staff are coordinating with Kurashiki City to develop information testing facilities. © Stanford University. sharing protocols and engage in joint disaster drills. Together with other stakeholders, they are developing a regional business continuity plan with the aim of providing continuous health care—including the transfer of patients between facilities—in the event of a future emergency. Response and Recovery Planning: While business continuity and emergency planning support disaster preparedness, planning for response and recovery to a range of potential shocks or stresses is also important for comprehensive disaster management. These plans should consider requirements for adequate medical supplies and equipment and staffing needs and mobilization plans. These efforts should be done in collaboration with the community, including mental health support, medical care for injuries, and rehabilitation services. In addition, plans for information sharing within the health care network and with patients seeking care in the aftermath of a disaster are important. It may also require broader outreach and coordination across a regional Emergency Planning in Action: In 2009, the Stanford Emergency Department tested the health care system. Hospitals are often at the center of post-disaster operations, and planning use of hospital parking lots as drive-through testing facilities in the event of a pandemic for response and recovery at a systems level can lead to greater efficiency. For communities in (Berger, to 2010). When COVID-19 struck in 2020, the hospital began screening and testing remote areas, plans should be in place for how to provide care after a disaster. These could include patients using the drive-through model, which proved to be efficient, allowing for mass specific community buildings designed to be more resilient after disasters from which care can be evaluations while limiting exposure (Flynn et al., 2020). delivered and/or mobile response units. Community-based disaster risk management (CBDRM) is an effective strategy for ensuring local communities are engaged in resilience planning efforts. Key questions: GREEN-RESILIENT GUIDANCE: ● Is a Business Continuity Plan in place, with fixed requirements for regular updates (for Sustainability planning: Operational aspects of sustainability policies and plans may build upon example, a yearly plan update)? the green design features of a new health facility or be developed to enhance an existing facility. ● Is there an Emergency/Disaster Response and Preparedness Plan in place? A sustainability plan (see graphic) outlines strategies for integrating green and other sustain- ● Are the roles and responsibilities for business continuity and emergency planning clearly able practices into a health facility’s operations, facility management, and health service delivery set? processes to reduce environmental impacts and promote health and well-being. Common green ● Are protocols and resources in place for the training of the staff and other key features include strategies to enhance energy efficiency and reduce energy consumption, to bet- stakeholders who will implement those plans if and when necessary? ter manage and conserve water, to reduce waste and improve recycling and composting, and to improve the environmental impact of supply chains. Solid waste management for health care 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 4.1 4.2 4.3 57 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Building commissioning Operational policies and plans Monitoring and maintenance facilities often requires a system-wide approach with coordination across multiple facilities in a evacuation. Community-based disaster risk management (CBDRM) can support the identifica- geographic area for medical waste transfer and disposal. tion of specialized emergency management approaches necessary to meet the unique needs of community users. Key questions: Key questions ● Is a sustainability plan in place for operations? ● Are there clearly defined roles and responsibilities for delivery of the plan? ● Are there plans and requirements to carry out periodic accessibility audits? ● Is training in place to ensure staff treat patients and each other equitably, including those with disabilities and/or other accessibility challenges? INCLUSIVE-RESILIENT GUIDANCE: ● Does the evacuation plan accommodate the needs of different staff and patients of all ages and abilities? Accessibility audits: Management should periodically conduct audits of the facility’s infrastruc- ture and practices to identify any new accessibility needs, deficiencies, or areas of noncompli- ance with accessibility standards that might limit users from accessing a facility’s services—and develop actions to address these. This may require community engagement to assess the types of user needs. Case study connection: As part of the Inclusive System for Effective Eyecare (I-SEE) pilot program in Indonesia, an accessibility audit was conducted of the Cicendo National Eye Hospital to identify barriers to disability-inclusive health care and reflect wider user needs in the design. Staff training on user needs: To offer more equitable care, hospital staff should be trained in disability health equity to better understand the range of disabilities they might engage with, including less widely appreciated cognitive, sensory, and developmental disabilities. They should also be trained in disability etiquette to support respectful interactions with disabled patients. Emergency evacuation for all: Due to the nature of hospitals, it is likely that in an emergency, a high concentration of people with temporary or long-term disabilities or health impairments may need assistance to evacuate the facility. These special needs and related aspects of facility design (for example, an emergency alarm system with both visual and audio signals) must be considered as part of a wider plan that defines the scale of evacuation, stages of evacuation, zoning of facilities, internal and external communications and prioritization of patients and staff by vulnerability level. For example, a hospital may require different zones for fire containment and Emergency evacuation chair. © Wike Sandra / iStock. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 4.1 4.2 4.3 58 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Building commissioning Operational policies and plans Monitoring and maintenance 4.3 Monitoring and maintenance ● Are there requirements to routinely monitor function and test backup systems and/or systems that provide additional capacity during surges (for example, in O&M manuals)? Routine monitoring is a critical element for maintaining and improving resilient, green, and inclusive ● Are staff adequately trained to operate and deploy backup systems and other system health facilities through capital investment over time. It can also limit disruption, improve functioning components that may be needed in an emergency? of equipment and systems and provide a safer working environment (PAHO, 2024). Effective periodic, preventative maintenance, with adequate budget and human resources allocated for it, ensures that these intended benefits do not erode over the lifetime of a facility. The cost of maintenance and nec- GREEN-SPECIFIC GUIDANCE: essary capital improvements will be highly dependent on the scale of the facility, the types of services As part of a sustainability plan, established metrics related to energy and water efficiency can be provided, the type of construction and the age of the facility. One study of over 3,500 hospitals in monitored during a facility’s operation. For example, data related to a building’s energy consump- the USA found that, on average, capital improvement costs (including equipment) were four percent tion can be collected from utility bills, meter readings, or a building’s automated energy manage- of total operating costs, while building maintenance and repairs were just under one percent of total ment systems. These data can be converted to an estimation of direct or indirect greenhouse gas operating costs (Bai and Zare, 2020). Guidance to facility managers and users on maintaining facili- emissions (GHG) over a specific time period. ties can be provided in the form of Operations and Maintenance (O&M) Manuals (for use during normal operations and in post-disaster situations alike) (see Figure 4.2 for examples of types of monitoring Key questions: and maintenance plans). ● Are maintenance and capital improvements and related budget allocation for equipment, systems and green building features included? RESILIENT-SPECIFIC GUIDANCE: ● Are staff allocated and trained to carry out necessary monitoring and maintenance of green building components and systems? Routine monitoring and preventative maintenance underpin the quality and physical resilience of health facilities over the long-term. Financial and human resources must be allocated for these critical activities. Clear protocols, timelines for activities, and roles and responsibilities should be INCLUSIVE-SPECIFIC GUIDANCE: established, alongside staff training. Backup systems for power, water and so forth must be regu- larly tested and maintained. Unfortunately, in an emergency, it is not unusual to discover that the In some contexts, engaging local communities in the maintenance and planned capital improve- backup system is not fully functional because it has not been routinely tested, or because staff ments of health facilities such as small-scale clinics can support long-term viability and sus- are not adequately trained (unfamiliar with operating systems). Routine monitoring and mainte- tainability of the facility. They may also contribute to monitoring activities related to potential nance, including regular drills and trainings, not only ensure that critical systems and equipment exposure to shocks or stresses and protocols to mitigate them. More community involvement with can perform as intended in an emergency but also reduce the risk of unexpected asset failure that health services can have the added benefits of improving equitable access to care, better uptake could result in costly unplanned downtime. in services, and increased self-reliance and local skills development (Mubyazi and Hutton, 2003). Key questions: Case study connection: To determine the scope of upgrades to health centers across the Kara region of Togo, local communities were engaged in conducting site and existing ● Is there a plan and allocated budget for building maintenance and capital improvements building assessments using a standardized tool developed by the lead nonprofit organization for the facility? 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 4.1 4.2 4.3 59 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Building commissioning Operational policies and plans Monitoring and maintenance in collaboration with the Ministry of Health. A key aim of community engagement in planning the upgrades was to build local capacity to manage future infrastructure needs for BOX 8 the clinics. REHABILITATION, ADAPTATION, AND RETROFIT OF HEALTH FACILITIES TO IMPROVE RESILIENT, GREEN AND INCLUSIVE ASPECTS Key questions The guidance in this document is tailored for planning, design and operation of new health facilities. Although ● Are there opportunities to engage local communities to help maintain and monitor the many of its concepts and strategies can be applied to existing facilities, there are additional considerations that are not covered. For example, a few high level considerations include: health facility or help determine planning for capital improvements? ● Are the facility’s materials, systems and equipment cost effective to be maintained ● For existing facilities, the starting point would be to assess the current site planning and hazards, physical locally? infrastructure, service delivery and organizational aspects. These types of assessments require specialized methodologies and approaches. ● If a facility is located on a site at risk from natural hazards (for example, with a high risk of landslide or flood- ing), it may not be feasible to completely mitigate the site hazards. Either accepting the risk or constructing a FIGURE 4.1 new facility on a safer site may be the only options. TYPES OF PLANS FOR MONITORING AND MAINTENANCE ● Future modifications, adaption and retrofits are constrained by the current configuration and construction of the existing buildings. Existing layouts may preclude implementing a more flexible, modular layout. Or, for example, it may not be economically feasible to seismically retrofit certain buildings to limit damage and service disruption after a major earthquake. Similarly, it can often be more expensive to adapt building for universal accessibility requirements as compared to including them in a new building from the start. Plan for Plan for Plan for Plans for Plans for Plan for monitoring and monitoring and monitoring and monitoring quality assessing the monitoring ● There are high levels of uncertainty when dealing with existing buildings and sites. When performing soil maintenance of maintenance of maintenance of of environment for sustainability for maintenance and investigations, hazardous conditions may be discovered. The condition of existing materials and construction energy efficiency on-site energy water usage/water facilities users waste transfer and functionality of performance generation such as air quality, disposal facilities’ may not be what was originally expected. These types of issues can introduce complexity into the design and building operations accessibility increase costs and program lengths. temperature features ranges, access to ● In many cases, partial health facility operations may need to continue during the works. Factors such as daylighting, green length of disruption, the need for incremental works, staff and patient safety, noise, pollution, and logistics spaces, and so forth can strongly influence the approach for modifications to an existing health facility. ● Adapting an existing facility or building will frequently be a more sustainable, low-carbon solution. Other Source: Authors. sustainability considerations specific to existing buildings include limiting the amount of construction waste generated, and taking measures to ensure that building materials are recycled. ● Care must be taken to involve community stakeholders and gather feedback on proposed modifications. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 60 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation CASE STUDY Health Clinic Upgrades, Togo R G I The Ministry of Health is implementing a campaign to upgrade meeting minimum standards for coverage. Construction for Change the comfort, safety and inclusivity of existing public health (CfC), who appointed a female Togolese engineer as project manager, led clinics in the Kara region to improve health services for women the planning process on behalf of the Ministry of Health, and Integrate and children. Health, the NGO that funded the effort (Construction for Change, n.d.) (Integrate Health, 2021). They engaged the local community in conducting Featured qualities: Resilient (extreme heat, strong winds), Green (nat- assessments of each site, defining needs, and establishing project goals. ural ventilation, daylighting, renewable energy, green infrastructure, local materials and labor), Inclusive (universal accessibility, sensitive to In most clinics, electricity was provided by new solar power systems women’s and children’s needs, local materials and labor, training) (Construction for Change, n.d.). With no air conditioning in most clinics, building improvements focused on improving natural ventilation, includ- In Togo, the maternal mortality rate is approximately 50 times that of ing adding louvers to roofs with wind-powered turbines to extract hot most developed countries (WHO, 2023); the Ministry of Health, in part- air. The amount of natural light was also improved in the clinics, and nership with two US NGOs based in Togo, aims to improve health care for reduced the need for artificial lighting. Boreholes were dug for facilities women and children by renovating and expanding existing public health without access to the municipal water supply. Construction techniques clinics in the Kara region. 25 clinics were renovated between 2016 and used local materials and labor, including local stones to insulate and 2023 (Attisso, 2023).  decorate the buildings (Attisso, 2023). To select clinics for intervention, the project team considered available In addition to promoting improved natural ventilation to control indoor data on existing coverage levels and health care needs, with the aim of temperatures in extreme heat, the renovations considered ways to improve the physical resilience of the clinics to strong winds. In some cases, the roofs of the clinics were redesigned based on predominant wind direction and wind speed, using shapes more resistant to strong Construction site (top) and completed clinic (bottom). © Construction for Change / Integrate Health. winds (for example, shed or hip roofs as opposed to flatter configura- tions) Trees were planted near the clinics to provide shade and shield the buildings from strong winds (Attisso, 2023). experience. To distribute the work across as many contractors as possi- ble, to build capacity, each contractor was allowed to win only one site. Accessibility upgrades to the clinics included adding ramps with hand- Supervisory firms were also hired to oversee construction in lots of two rails at the entrances; widening doors for wheelchairs; and using bright or three sites, with additional oversight provided by CfC. With construc- colors and reflective strips for wayfinding and to indicate electric out- tion now complete at more than 25 clinics, CfC is working with some lets and switches. Accessible sanitary blocks were also added. Tendering clinics to write maintenance plans that will engage the local community, of the construction work was planned to prioritize local contractors including women, in the ongoing upkeep of the facilities (Attisso, 2023). Completed health clinic upgrade in Kara Region, Togo. © Construction for Change / by weighting local proximity first, followed by technical capacity and Integrate Health. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 61 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation CASE STUDY Kurashiki Central Hospital, Japan R I Substantial damage and disruption to the operations of medical by a group of experts convened by the hospital indicated that if a major flood response plan, staff would install the removable flood barriers facilities in Kurashiki City, due to riverine flooding in 2018 served flood event were to occur, the facility would be closed for two years while to seal off the complex and use pumps to discharge any rainwater or as the impetus for nearby Kurashiki Central Hospital, located in being rehabilitated. As Kurashiki Central Hospital is one of the region’s floodwater that intrudes. the same floodplain, to invest in flood risk reduction measures few disaster base hospitals, the prospect of it being inoperable for two and operational preparedness planning. years was not acceptable (Ready For, 2023). The study also showed that The 2018 floods also highlighted the need for improved preparedness recovery costs from a possible flood event would total 20 billion yen planning, at both a hospital and a regional level. The flood response plan Featured qualities: Resilient (riverine flooding, heavy rainfall, earth- (approximately US $137 million) (Kurashiki Central Hospital, 2023a). developed for the Kurashiki Central Hospital involves monitoring of river quakes); Inclusive (considerations for elderly populations and patients By contrast, the flood risk reduction measures selected by the hospital water levels to determine when to install the barriers. Disaster drills are with limited mobility) were estimated to cost 1.5 billion yen (approximately US $10 million) used to train staff in emergency preparedness and disaster response (Kurashiki Central Hospital, 2023a) and considered to be an advisable operations (Kurashiki Central Hospital, 2024). Hospital staff also Kurashiki City, situated in a floodplain along the Takahashi River was investment in risk mitigation. For a self-financing private hospital, the coordinate with Kurashiki City to share information and conduct joint until recently adequately protected by a flood protection system built total investment cost was not trivial, and a portion of the funding for disaster drills. Under the leadership of a local medical association and approximately 100 years ago (Kurashiki Central Hospital, 2023a). the flood resilience improvements was crowdsourced (Kurashiki Central with expert help, medical personnel from regional hospitals, clinics, care In July 2018, heavy rainfall caused the collapse of a tributary river’s Hospital, 2023a). facilities, and homecare providers in the region have also been working embankments, leading to the worst flooding in the region in 30 years. together to develop a regional business continuity plan (BCP). The BCP Many people lost power and water, and approximately two million peo- The expert team studied the feasibility, costs, and benefits of several will ensure efficient and effective coordination to facilitate continuous ple, many elderly, were evacuated (NBC News, 2018; Inaba et al, 2020). flood resilience measures to protect the complex in the event of a future health care and timely and appropriate transfer of patients in the event Among other medical facilities heavily damaged in the region, the Mabi large-scale flood event (Kurashiki Central Hospital, 2023b, 2024): of future emergencies (Kurashiki Central Hospital, 2024). Memorial Hospital complex, one of the region’s few emergency care facilities, was flooded up to the floor of its second story. The hospital ● Relocating the existing hospital out of the floodplain was not consid- lost water and sewage services as well as power, as its generators were ered a viable strategy due to the hospital’s central location and size; located in the basement. Without power, the hospital lost access to all ● Relocating critical electrical systems and medical equipment from electronic patient records, elevator service, and air conditioning and lower to higher levels of the buildings was deemed too costly and ventilation (Inaba, 2020). disruptive to ongoing medical services; ● Individually floodproofing the many small buildings in the complex, Located in the same floodplain is Kurashiki Central Hospital, a private each with its own particular vulnerabilities, would be complex and teaching hospital with an emergency room and acute care services serv- costly. (Note, however, that each building had already been retrofit- ing 1,000 inpatients and 2,700 outpatients per day, most of them elderly ted for seismic safety, providing 1.25x the level of seismic protection (Hashimoto, 2023). Although this facility was not damaged by the July required by the national design regulations). 2018 flooding, administrators recognized that it was similarly vulnera- ● The most straightforward and cost-effective approach was to protect ble to future heavy rainfall and flood events, especially because much the entire premises with 1.6m high flood barriers around the perimeter of its critical equipment was located on the ground floor and basement of the complex. In the event of a potential flood, in accordance with a Installation of removable flood barriers at the entrance to the hospital. © Kurashiki of the hospital (Ready For, 2023). A flood risk assessment conducted Central Hospital. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 62 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation CASE STUDY Cicendo National Eye Hospital, Indonesia I The Cicendo National Eye Hospital was upgraded to enhance its al.). The program, aligned with Indonesian laws supporting equal access barriers to access. Although these elements were not in the scope of accessibility as part of a pilot program launched by the Ministry to health services for those with disabilities, addressed the lack of the project, the project team engaged with the surrounding community of Health in 2010 to improve disability inclusion for eye health. physical accessibility of eye health care facilities, a primary barrier to and local government to raise awareness about the need to improve the Physical upgrades to the facility were paired with operational disability inclusive healthcare. physical accessibility of infrastructure surrounding the hospital (Marella improvements and staff training on disability inclusion. et al., 2018). Planning, implementation, and evaluation for the project were guided by Featured qualities: Inclusive (universal accessibility and considerations an advisory team consisting of representatives from local organizations for disabled populations) including the Bandung Independent Living Center and the Indonesian Blind Union (Marella et al., 2018). Through stakeholder engagement, the The Inclusive System for Effective Eyecare (I-SEE) pilot program was project team identified examples of failures to understand the purpose implemented between 2010 and 2014 by the Indonesian Ministry of of some accessibility features. For example, wheelchair ramps had been Health and the Bandung District Health Office with support from the blocked and rendered unusable by motorbikes or planters (Marella et Australian government (WHO, 2020) to improve accessibility and safety al., 2018). As a result, the I-SEE program included training on disability at select primary health care centers (puskesmas) managed by district inclusion for hospital staff and improvements to counseling services and municipal government as well as the Cicendo National Eye Hospital, (WHO, 2020). a public tertiary teaching hospital and National Eye Center (Marella et Physical upgrades to the hospital resulting from stakeholder engage- ment included (Marella et al, 2018; WHO, 2020): ● Installation of ramp access and handrails;​ ● Lower reception desks to accommodate wheelchair users;​ ● Accessible toilets; ● Providing tactile markers to guide users from the entry to the regis- Patient undergoing color blindness test. © rudi_suardi / iStock. tration desk​; ● Large format signage throughout the hospital (both text and symbols/ diagrams);​ ● Braille lift buttons and braille signage;​ ● ; and A patient call system which is both visual and auditory​ ● Dedicated parking spaces near the hospital entrance.  Stakeholders also identified that connecting infrastructure such as sidewalks used to travel to a physically accessible facility can present Patients waiting at a hospital in Indonesia. © Mahyuddin / Alamy Stock Photo. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 63 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation CASE STUDY Culebra Community Health Center, Puerto Rico R The Culebra Community Health Center, which benefitted from govern- closed (FEMA, 2018). The storms also disrupted the central power grid evacuated (FEMA, 2018). Operations were able to continue in other ment investment in retrofitting to enhance its resilience to hurricanes, for almost a year. The physical damage and loss of power to hospitals parts of the facility, with power supplied, initially and periodically, by performed better than most health facilities in Puerto Rico during and health centers exacerbated existing health care service delivery backup generators. As Culebra was designated by FEMA as a “Disaster- Hurricanes Irma and Maria in 2017. challenges in Puerto Rico. Resistant Community,” risk mitigation efforts on the island prior to the storms also included retrofits to other community facilities including Featured qualities: Resilient (strong winds, heavy rainfall) Prior to the storms, Puerto Rico residents faced numerous health care the library, municipal building and senior center, further enhancing resil- challenges. Over 15 percent of the population was living with a disabil- ience in the wake of the hurricanes (FEMA, 2018). ity (nearly twice the rate in the US); 19,000 people (approximately 0.5 percent of the population) were living in areas designated as “health Because the loss of power was disruptive and a major factor contribut- care provider shortage areas” (HPSAs); and nearly half of the population ing to the overall lack of resilience of the health care system in Puerto relied on government-sponsored health care for low-income individuals Rico, recovery efforts since the storms have focused on improving the (more than twice the proportion in the US) (KFF, 2017). Community energy resilience of critical infrastructure, including on the island of health centers were the primary source of health care for 350,000 resi- Culebra. Solar photo-voltaic microgrids with battery storage are being dents, approximately 10 percent of the population (Michaud and Kates, installed in residences and community facilities, including the Culebra 2017). In the aftermath of the storms, many health facilities initially Center for Diagnosis and Treatment (Michaud and Kates, 2017). The US used backup generators to keep going at reduced capacity; however, Department of Energy is also supporting efforts for Culebra to become fuel shortages—and generator failures from overuse—led to frequent the first 100 percent solar-powered island in the western hemisphere disruptions and closures. Nearly two months after the storms, almost (AAFAF, 2023). half of the population remained in HPSAs (Michaud and Kates, 2017). Compared to other facilities, the Culebra Community Health Center , which provides primary care and outpatient services to the small island of Culebra off the coast of Puerto Rico, fared well. It suffered only minor damage and was able to continue providing critical services to residents on the island of Culebra using backup generators (FEMA, 2018). The The Culebra Community Health Center © FEMA, 2018. facility already had benefitted from risk mitigation investments, includ- ing structural and nonstructural improvements to resist strong winds Hurricanes Maria and Irma devastated Puerto Rico in 2017, including its made in 1999 with a grant from the US Federal Emergency Management health care infrastructure, which suffered significant physical damage Agency (FEMA, 2018). These included the installation of hurricane clips Minor water intrusion during Hurricane Engineers installing solar panels on roof. from strong winds and heavy rainfall. One month after the storms, more and straps, tie-downs for mechanical equipment, and hurricane-resis- Maria. © FEMA, 2018. © ArtistGNDphotography / iStock. than 10 percent of Puerto Rico’s community health centers, which tend tant windows and shutters (FEMA, 2018). The building suffered only to serve low-income, uninsured populations in rural areas, remained minor water intrusion on the roof of one wing, from which patients were 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 64 Chapter 5.0 Conclusion and Summary Table 65 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation This document brings together, for the first time, comprehensive guidance that communicates key concepts and strategies, along with practical measures to deliver resilient, green and inclusive health facilities. Aimed at a wide audience, the guidance can be used by policy makers, development partners, building practitioners and community stakeholders involved in health facility planning, design and operations. It provides important strategic principles along with global good practice examples and case studies, and a solution catalog for specific resilient, green and universal accessibility measures (refer to Appendices A.1, A.2 and A.3). Appendix B provides examples of other relevant tools for the planning, design and oper- ation of resilient, green, and inclusive health facilities. Appendix C gives a compilation of key questions from each section of the guidance. Appendix D provides a glossary of key terms. Table 5.1 provides a summary of the main steps to consider recommended in each of the planning, design and operations phases of a health facility to intentionally promote, integrate and realize resilient, green and inclusive benefits. Links to the relevant content in each section are also provided for ease of use. Many of the critical considerations that inform the delivery of resilient, green and inclusive health facili- ties must be made in the planning stage, including those related to planning ahead for future expansions and upgrades Today, it is increasingly important to bring future climate scenarios and socio-economic needs to the table during the planning stage, the better to support the delivery of the targeted benefits in the design and operations stages. This process requires engaging an interdisciplinary team of experts with a mix of skills and experience selected to supplement those of policy makers at ministries of health and health practitioners. In addition to these experts’ advice, community engagement is essential to developing health facilities that benefit all users as well as local host communities. Partnerships and global knowledge can also be leveraged to help countries advance rapidly to deliver more resilient, green and inclusive health facilities. The World Bank and GFDRR are committed to working with governments and other development part- ners to make health facilities around the world more resilient, green and inclusive. Solar panel powered hospital in Hungary .© Adam Eszes / iStock. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 66 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation TABLE 5.1 SUMMARY OF GUIDANCE BY IMPLEMENTATION PHASE Resilient Planning Design Operation Study the natural hazards and climatic conditions of the region Design civil engineering measures and landscaping to miti- Use the commissioning process to ensure that the buildings’ and the selected site(s) under consideration and reduce exposure gate identified site risks such as flooding or landslides; protective and emergency systems function as designed to hazards through site selection; Design spaces on the site and within buildings for func- following construction; Identify relevant shock and stress scenarios that must be con- tional needs in normal circumstances as well as emergencies Conduct periodic risk assessments to understand any sidered in planning, design and operations; (including evacuation), both now and in the future; changes in exposure or vulnerability of the facility to shocks Agree acceptable levels of service disruption or reduced ser- Design the structure, building utility systems, cladding and and stresses; vice provision for defined shock and stress scenarios (resilience equipment to withstand the loading and movements from Develop a business continuity plan (BCP) in coordination objectives); design-level hazards with limited or no damage or disruption, with the wider regional network and ensure that facility Study the exposure and vulnerabilities of the infrastructure sys- according to defined resilience objectives; operations are coordinated with the BCP; tems on which the facility will rely to understand redundancy Design redundancy into building utility systems including Use routine monitoring and preventative maintenance and backup systems needs; backup systems that can be deployed in the event of cen- (with sufficient budget allocation) to ensure the buildings Anticipate future needs for expansion, functionality and flexi- tralized service disruption; and their utility systems meet resilience objectives over the bility in master planning; Design interior spaces, circulation and utility systems for long term; Establish the role that the facility will play in regional disas- infectious disease control; Conduct training and routine drills related to emergency ters and how this role will influence functional and spatial Ensure that building design, materials and systems are coor- preparedness and evacuation protocols. requirements; dinated with operational capacity and resource availability. Refer to Resilient content in Section 4.0 Operation Ensure that financial studies consider savings from avoided damages, disruption, and preventable deaths due to resilience Refer to Resilient content in Section 3.0 Design measures. Refer to Resilient content in Section 2.0 Planning 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 67 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Green Planning Design Operation Study the climatic conditions of the region and selected site to Design buildings to leverage opportunities for natural venti- Use the commissioning process to ensure requirements for understand those that can be leveraged in the placement and lation where possible; energy and water efficiency are met; orientation of the facility (for example natural light, prevailing Design buildings to leverage opportunities for daylighting Develop and regularly update a sustainability plan for the breezes) and those that must be mitigated (for example shading (and solar shading) where possible; facility and ensure operations and management are aligned for solar exposure); with the plan; Ensure building walls and roofs are well-insulated; Consider connection between site and public, low-carbon Use energy management systems (EMS) and other mon- Use building materials with low embodied energy and high transport; itoring performance evaluations to regularly monitor thermal mass; Understand opportunities to leverage local materials for resource consumption of the facility. Integrate opportunities for renewable energy where possible construction; Integrate energy efficiency measures into the design of Refer to Green content in Section 4.0 Operation Identify natural resources that need to be preserved (for example building utility systems, equipment, and fixtures; trees, wetlands); Design systems for water reuse where possible (for example Determine green objectives for the facility, including alignment rainwater capture, greywater reuse); to green building code requirements and/or green building stan- Integrate water efficiency measures into the design of dards or certifications; building utility systems, equipment, and fixtures; Identify needs for off-grid solutions (for example solar power, Integrate measures to sustainably manage solid waste; boreholes, and so forth) (Note: connection to resilience); Design green infrastructure into the facility (for example Identify opportunities for green spaces and integrating green green roofs, plantings). infrastructure into the facility; Conduct a Life Cycle Cost Analysis (LCCA) to justify value of Refer to Green content in Section 3.0 Design green building measures. Refer to Green content in Section 2.0 Planning 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 68 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Inclusive Planning Design Operation Set objectives for safe, dignified, culturally appropriate access Design site and buildings for universal accessibility according Conduct a post-occupancy evaluation to confirm com- for all facility users; to international best practices; pleted facility complies with goals for inclusivity, including Identify target user groups (including patients and providers) Use human-centered design and patient-centered design universal accessibility; and other key stakeholders; approaches to design facility functions, spaces and equip- Conduct periodic accessibility audits to identify any Develop an engagement plan to leverage local knowledge; ment to meet user needs; changes to design intent for universal accessibility; Study the pre-existing vulnerabilities of the communities that Consider sensitivities of users in the specification of indoor Provide staff training on equitable care; will be served by the facility; environmental quality parameters (for example, tempera- Ensure emergency preparedness planning and evacuation ture, odor, acoustics); planning consider universal accessibility needs; Study the relationship between the site of the facility and the surrounding community to identify access needs, special social Ensure design of emergency evacuation measures covers Where appropriate, identify ways for local communities to or cultural considerations for the facility, and potential unin- universal accessibility needs; support the upkeep and maintenance of facilities. tended consequences to mitigate; Where appropriate, integrate local materials and craftsman- Identify opportunities to leverage local sourcing of materials and ship into the design of site infrastructure and buildings. Refer to Inclusive content in Section 4.0 Operation construction skills. Refer to Inclusive content in Section 3.0 Design Refer to Inclusive content in Section 2.0 Planning 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 69 Appendices APPENDIX A: Health Facility Measures A.1: Catalog of Resilience Measures by Hazard Type A.2: Catalog of Green Building Measures A.3: Catalog of Universal Accessibility Measures APPENDIX B: Tool and Resources APPENDIX C: Key Questions APPENDIX D: Glossary of Terms 70 Appendix A Health Facility Measures 71 Appendix A.1 Resilience Measures by Hazard Type Appendix A Appendix B Appendix C Appendix D 72 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Health Facility Measures Tools and Resources Key Questions Glossary of Terms Flooding: risk reduction and resilience measures Assess the risk of flooding Site-related measures Assess current and future levels of flood hazard in the locality/ Use Nature-based Solutions on the site to mitigate flood risk: region, and refer to regulations currently in force, to determine an appropriate design flood elevation. Flooding types include riverine ● Increase ground permeability by providing more soft ● Allow places for floodwater to collect such as in detention (fluvial), flash flood (pluvial) or coastal. For coastal areas, consider landscaping such as garden beds, swales (shallow, broad and basins, ponds or wetland areas as part of the wide site the impacts of sea level rise. In addition, Early Warning Systems vegetated channels designed to store and/or convey runoff) landscaping and flood management strategy. These store could be used to prepare for and coordinate response to flood and other natural permeable materials such as planting or rainwater and/or allow water to soak slowly into the ground events. woodchip. and can reduce the amount of runoff on site. Water from swales can be directed into detention basins, ponds or wetland Select a site with low risk of flooding where possible. For existing areas. buildings, relocation could be considered. Hospital Landscape. © germi_p / iStock. Flooding at Prachantakam Hospital, Thailand. © suppixz / iStock. An apartment block with green landscaping and a balancing pond for sustainable drainage (a SuDS pond). © Axon / Alamy Stock Photo. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES Appendix A Appendix B Appendix C Appendix D 73 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Health Facility Measures Tools and Resources Key Questions Glossary of Terms Flooding: risk reduction and resilience measures (cont.) Site-related measures (cont.) Use hard engineering flood resilience measures on the site to ● Channel drains collect water and carry it to the main drainage ● Physical flood barriers (permanent or temporary). These mitigate flood risk. These can include: systems. could be as simple and low-cost as sandbags. Other solutions include dismountable door barriers that can act to stop ● Permeable hard surface materials (for parking areas, floodwater from entering at external doors, permanent walkways). These have a porous surface which allows water to perimeter flood walls, or automatic flood barriers which rise run through it to an underlying stone basin. up to block floodwater when there is a need to deploy them. ● Hard drainage solutions such as channel drains or underground attenuation tanks. Permeable pavement as road with rain water drainage structure. © VectorMine/iStock Photo. Flood barriers at the Kurashiki Central Hospital, Mabi-town, Japan. ● Underground attenuation tanks store excess water and © Kurashiki Hospital. gradually release it to the site’s main drainage system. Permeable pavement as road with rain water drainage structure. © VectorMine / iStock Photo. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES Appendix A Appendix B Appendix C Appendix D 74 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Health Facility Measures Tools and Resources Key Questions Glossary of Terms Flooding: risk reduction and resilience measures (cont.) Building design measures ● Raise the level of building above the design flood elevation – e.g., by raising Provid s f on s t hi h r l v ls the level of the building floors that are occupied and/or have critical services. in th buildin durin floodin Ensure universal accessibility requirements are still meet. Refer to Appendix A.3. This may not be practical in some cases, especially for longer return period flood events or where the level of expected flood hazard is uncertain. Therefore, other measures (listed) anticipate the possibility that floodwater may enter the building. Us flood r sist nt ● Avoid locating critical building services below the design flood elevation m t ri ls (structur l nd such as utilities, electrical services and outlets, water pumps, critical ICT, non-structur l) Flood r sist nt doors nd windows emergency generators, medical equipment and supplies and records. R is th l v l of ● Ensure that floodwater cannot enter the building through services th buildin connections (e.g., provide non-return valves in sewage pipes, seal gaps around or of critic ll occupi d sp c s pipework, cable connections). bov th d si n ● Design vents, valves or other openings in the walls of enclosed spaces below flood l v l (whil m int inin the design flood elevation to equalize lateral water pressures or design the D si n flood l v l univ rs l cc ss) structure for anticipated flood loads (e.g., hydrostatic and hydrodynamic loads, debris impact). D si n structur to r sist D si n v nts, v lv s nd oth r op nin s to qu li w t r ● Allow for evacuation to safe zones at higher levels, (e.g., higher floors, h dr ulic lo ds from floodin pr ssur in c s of floodin balconies, roofs) ● To limit damage, use structural and non-structural materials more resistant Avoid loc tin critic l Non-r turn v lv in s w r pip to damage from floodwater. Consider water penetration, drying ability and if quipm nt b low th d si n nd oth r s rvic s integrity and dimensions will be retained. flood l v l ● Install flood resistant doors and windows. Building design measures to improve flood resilience. © Authors. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES Appendix A Appendix B Appendix C Appendix D 75 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Health Facility Measures Tools and Resources Key Questions Glossary of Terms Strong wind: risk reduction and resilience measures Assess the risk of strong wind events Site-related measures to improve resilience to strong winds include: Assess design wind levels, and refer to regulations in force, to ● Design any signage, canopies or other site related appendages ● Consider using structures or exterior planting to act determine design criteria. Also consider design wind levels from to resist strong winds. as windbreaks. extreme weather events such as storms and tropical cyclones (i.e., hurricanes and typhoons) as well as site-specific conditions that may influence the risk of wind effects. Avoid sites with high exposure to winds such as flat, unobstructed areas or highly exposed coastal areas, where possible. Photos: (left) Hospital or emergency sign next to the road. © Moonstone Images / iStock. (right) Solar panels installed over parking lot canopy shade. © Bilanol/iStock. City landscape. © Freepik. ● Assess the vulnerability of surrounding buildings to strong winds. Flying debris could cause damage and pose a ● Explore whether grouping buildings can provide shelter/reduce hazard to those trying to access the health facility. design wind loads. Tropical storm. © galitskaya / iStock. Khayelitsha Hospital, Western Cape, South Africa. Aftermath of Hurricane Helene in Asheville, NC. © FS / iStock. © Grant Duncan-Smith / iStock. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES Appendix A Appendix B Appendix C Appendix D 76 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Health Facility Measures Tools and Resources Key Questions Glossary of Terms Strong wind: risk reduction and resilience measures (cont.) Building design measures Site-related measures Building design measures to improve resilience to strong wind ● Protect window openings with shutters and/or hardened ● Consider if enclosed walkways between buildings are needed events include: glazing. to ensure operations can continue during a storm. ● Detail exterior doors and door mechanisms to resist ● In rare cases where it is impractical to design the structure to ● Ensure a robust and redundant load path for transferring wind load in the main structure and foundation. anticipated wind loads. remain undamaged in expected wind load events, including ● Detail and anchor cladding and other building appendages safe rooms can be considered. ● Consider roof shapes that better resist strong winds and avoid large roof overhangs. to resist winds and remain undamaged, including rooftop ● For more complex and/or taller buildings, a performance- equipment. based design can be adopted, and wind tunnel testing may ● Detail façade to prevent water ingress from driving rain. be required. Elevated walkway connecting buildings in Mount Sinai Medical Center, New Continuous load path for wind uplift in a wood frame building. © FEMA, 2023. Wind The damaged face of St. John's hospital in Joplin, Missouri following an York City. © Terraxplorer / iStock. Retrofit Guide for Residential Buildings in Hurricane-Prone Regions (FEMA P-804). F5 tornado. © eyecrave productions / iStock. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES Appendix A Appendix B Appendix C Appendix D 77 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Health Facility Measures Tools and Resources Key Questions Glossary of Terms Seismic: risk reduction and resilience measures Assess the site seismic hazard Site-related measures for site-wide infrastructure Assess the seismic hazard level and related design levels at ● Ensure site-wide infrastructure is seismically designed: ● Assess whether adjacent buildings could cause damage to the site. In some cases, a site-specific seismic analysis may be linear infrastructure, walkways, site-wide utilities, smaller the facility (either by collapsing and/or through pounding required. support structures (such as canopies, etc.), and equipment damage) and provide adequate separation between the Assess and mitigate any relevant secondary hazards that located onsite. For example, linear infrastructure such as facility and adjacent buildings. may impact site selection such as fault rupture, landslide, soil utility lines and connections may need to be designed to liquefaction, and tsunami. Also see ‘Soil instability: risk reduction accommodate seismic movements. measures’. Pipe crossing seismic joint between two buildings. © FEMA (from M. Phipps). Pounding damage in Santiago due Fault rupture caused after an earthquake in Indonesia. © Heri Mardinal / iStock. to the 2010 Chile earthquake. © S. Brzev. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES Appendix A Appendix B Appendix C Appendix D 78 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Health Facility Measures Tools and Resources Key Questions Glossary of Terms Seismic: risk reduction and resilience measures (cont.) Building design: performance objectives Use of advanced seismic systems ● Set seismic performance objectives (a combination of the design seismic hazard level and the acceptable level of structural ● Where feasible, consider advanced systems such as base and non-structural damage and service disruption) for each building/the wider facility that align with the wider resilience isolation and/or specialized seismic systems with added objectives for the facility. damping to achieve more stringent performance objectives for ● For example, most codes require buildings to meet a Life Safety performance objective where occupants are protected from health facilities that need to remain operational or have limited life-threatening damage due to structural collapse or failure of non-structural components in a design-level earthquake. A disruption following a major earthquake. more stringent performance objective would be when structural and non-structural components are designed for limited ● These approaches require more advanced analysis methods, damage during a design-level earthquake so the facility would remain operational and allow the facility to continue specialized products and construction techniques. providing critical health care services. Also see ‘Use of advanced seismic systems.’ Earthquake Performance Level FULLY OPERATIONAL LIFE NEAR OPERATIONAL SAFETY COLLAPSE Earthquake Design Level Frequent     (43 year) Occasional  Ess  Bas   (72 year) en ic O tia bje l/H cti Sa aza ve Rare fe rdo  ty Cr  us Ob   (475 year) itic al O jec Illustration of seismic performance levels. © FEMA, 2004. Primer for Design bje tiv cti e Professionals: Communicating with Owners and Managers of New Buildings on Very Rare ve Earthquake Risk (FEMA 389). https://mitigation.eeri.org/files/fema389.pdf.    (970 year) Seismic performance objectives. Adapted from FEMA 356: Prestandard and Comparison of seismic behavior between fixed base and base isolated structures. © commentary for the seismic rehabilitation of buildings. chombosan / iStock. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES Appendix A Appendix B Appendix C Appendix D 79 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Health Facility Measures Tools and Resources Key Questions Glossary of Terms Seismic: risk reduction and resilience measures (cont.) Design: local construction environment Design: key good practice seismic design principles Choose construction materials and structural systems that can ● Aim for symmetry, regularity and compactness in building ● Ensure a clear and connected load path – as well as be reliably designed and constructed to a high standard of quality, form and structure to reduce torsion and plan irregularities. redundancy in load path – throughout the structure with considering the local construction environment, resources and ● Aim for uniform strength and stiffness at different levels (e.g., ductile detailing of connections that allows for seismic capacity. This is particularly important for seismic design, as avoid weak or soft stories.) movement and energy dissipation without brittle failure. seismic design and detailing can result in more complex types of Ensure that non-structural components (building utility ● Aim for uniform distribution of seismic mass at different ● construction, depending on the structural system selected. systems, exterior glazing and cladding, ceiling panels) are levels and avoid heavy loads/increased mass at the roof level of the building. designed to withstand seismic forces and movements ● Ensure ductile detailing of the main lateral-resisting system without damage. to avoid sudden, brittle failures. ● Anchor non-structural components and equipment to prevent falling hazards. Maternity and Paediatric Hospital in Tambacounda, Senegal, by Manuel Herz. © Iwan Baan 2021. Courtesy of the Josef and Anni Albers Foundation and Le Korsa. (a) Cantilever wall (b) Coupled wall Examples of concrete shear wall systems with regular layout of walls for the height of the building. © FEMA, 2018. Assessing Seismic Performance of Buildings with Configuration Irregularities (FEMA P-2012). 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES Appendix A Appendix B Appendix C Appendix D 80 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Health Facility Measures Tools and Resources Key Questions Glossary of Terms Soil stability: risk reduction measures Assess the risk of soil instability Site-related measures to improve resilience Building design measures to improve to soil instability resilience to soil instability When considering potential sites and for a selected site, assess geotechnical hazards at the site and related risks by performing ● Appropriately designed retaining walls can stabilize nearby ● To mitigate the impacts of soil liquefaction, mat/raft site soil/geotechnical investigation. Soil instability hazards slopes and reduce landslide risk in some cases. foundations can be used in combination with piles down to the could include landslides, rockfalls, mudflows, collapsible soils, ● For expansive soils, careful management of drainage and soil level below the liquefiable layers (ensure piles are designed to expansive soils, soil liquefaction and others. Often, it is best to moisture changes can reduce the risks. have integrity in the event of liquefaction). avoid sites with significant geotechnical hazards (such as landslide For landslides with shallow failure mechanisms, foundations ● Problematic soils including liquefiable soils can be remediated ● risk) for critical facilities such as hospitals. with piles for buildings sited on slopes can reduce the risk, but in various ways by soil improvement methods. this approach will not address the risk of landslide for slopes ● Steeper slopes prone to rockfall can be stabilized in various with deeper failure mechanisms. ways to reduce the risk of falling rocks. Road damaged by landslide in the Philippines, © Tunatura / iStock. Munini District Hospital by Mass Design Group. © Rosemarie Goldrick. Pile driving construction site. © Chaiyaporn1144 / iStock. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES Appendix A Appendix B Appendix C Appendix D 81 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Health Facility Measures Tools and Resources Key Questions Glossary of Terms Extreme heat: risk reduction and resilience measures Assess the risk of extreme heat events Site-related measures Building design measures When considering potential sites and for a selected site, assess Site-related measures to improve resilience to extreme heat Building design measures to improve resilience to extreme geotechnical hazards at the site and related risks by performing include (also refer to Appendix A.2 for details on green building heat include the following green building measures (also refer to site soil/geotechnical investigation. Soil instability hazards measures): Appendix A.2): could include landslides, rockfalls, mudflows, collapsible soils, ● Exterior plantings and water features (where possible) to ● Cool roofs and/or walls using reflective materials or coatings. expansive soils, soil liquefaction and others. Often, it is best to support increased evapotranspiration. Solar shading. avoid sites with significant geotechnical hazards (such as landslide ● risk) for critical facilities such as hospitals. ● Trees and other site structures for shade. ● Building insulation. ● Cool pavements and road surfaces using lighter colored ● Window-to-Wall Ratio (WWR) considerations. materials with a high reflectivity index. ● Natural ventilation as a passive cooling method. ● Design site infrastructure (utility lines, road surfaces, etc.) ● Building orientation. for expected temperature changes. ● Green walls and roofs. ● Energy efficient lighting to reduce heat gains inside buildings. Urban outdoor digital thermometer. © Jose Gonzalez Buenaposada / iStock Photo. Vegetation on building providing cooling and shade. Park with in front of an office building. © Dicky Sutjiptohadi / iStock. © baona / iStock. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES Appendix A Appendix B Appendix C Appendix D 82 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Health Facility Measures Tools and Resources Key Questions Glossary of Terms Water scarcity: risk reduction and resilience measures Assess water supply and risk of water Site-related measures Building design measures scarcity Site-related measures to improve resilience in case of water Building design measures to improve resilience in case of water Perform a water risk assessment to assess sources of water scarcity include the following green building measures (also refer scarcity include the following green building measures (also refer supply and the risk of water scarcity – both the current situation to Appendix A.2): to Appendix A.2): and future trends. This can include consideration of water supply ● Rainwater harvesting in tanks or collection ponds. Also see ● Rainwater harvesting, greywater, condensate recovery agreements and water allocation plans in the event of a long- Flood Resilience measures. and other methods of water reuse for toilets and other non- term water supply interruption to inform Business Continuity ● Use of greywater for irrigation. potable functions Planning. ● Native and/or drought tolerant landscaping. ● Water-efficient fittings and fixtures ● If irrigation is used, use of drip irrigation rather than sprinklers. ● Water-efficient equipment Health centre in Mpwapwa, Tanzania, equipped with a rainwater catchment system. Doctor washing hands. © Stígur Már Karlsson /Heimsmyndir / iStock. Construction site with new water pipes in the ground. © kckate16 / iStock Photo. © IRC, licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 83 Appendix A.2 Catalog of Green Building Measures Appendix A Appendix B Appendix C Appendix D 84 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Health Facility Measures Tools and Resources Key Questions Glossary of Terms Site and Context Ensure sustainable site development through assessment of the environmental impact of site development, habitat restoration, managing stormwater, minimizing heat-island effects and light pollution, and maximizing open space. Efficient community access to the site is particularly important for health facilities, including access by public transportation and other low-carbon forms of transport. Also see “Accessible facility location” in Appendix A.3, Universal Accessibility measures. In addition, health facilities benefit from designs that allow access to outdoor space for patients and staff, including access to places of respite. Also see “Occupant Health and Comfort”. Control air, water and noise pollution during site activities, including during construction. If the construction is an addition or upgrade to an existing health care facility that is partially or fully occupied, disruption for patients and staff should be minimized. B.P Koirala Memorial Cancer Hospital, Nepal. © Wirestock / iStock. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES Appendix A Appendix B Appendix C Appendix D 85 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Health Facility Measures Tools and Resources Key Questions Glossary of Terms Energy Efficiency – Passive Measures Building orientation Daylighting Natural Ventilation Orient the building to avoid excessive heating through solar Adequate daylighting to allow for perception of changes in Natural ventilation may be appropriate in some facilities (non- radiation in hotter climates or to let in solar radiation during natural light (circadian rhythm) throughout the day and to reduce acute care facilities) to reduce dependence on air-conditioning. In cooler months. This will minimize energy needed for heating or air dependence on artificial lighting. Adequate exposure to natural all health care settings, adequate ventilation and fresh air flow is a conditioning. light has been shown to improve the wellbeing of patients and key requirement to reduce the spread of airborne disease. staff in health care settings; however, some patients, including premature infants and critically ill patients require control of light stimulation. Building orientation to minimize solar heat gain in the summer months and reduce energy needed for heating in the winter. Source: Adapted from https://www.greenspec.co.uk/building-design/direct-solar-gain/. Large windows providing natural light in hospital room. © Ninoon / iStock. Patient wards designed for cross ventilation at Ng Teng Fong General Hospital. © HOK and Rory Daniels Photography. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES Appendix A Appendix B Appendix C Appendix D 86 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Health Facility Measures Tools and Resources Key Questions Glossary of Terms Energy Efficiency – Passive Measures (cont.) Solar shading Insulation Roof and wall reflectivity Solar control windows with fixed and operable shade devices Well insulated walls and roofs to stop the building from Reflective roofs and/or walls either using a solar reflective (including automated systems) control solar heat gain. Exterior overheating during the summer and losing heat during the winter material or a reflective coating absorb less of the sun’s energy shading is one of the most effective ways to avoid direct heat (low U-value walls). Use of structural materials with higher and can reduce overheating of buildings. This is a relatively from sunlight entering a building. In addition, glazing with low UV thermal mass such as concrete and brick. Air-tight windows and low-cost and highly effective measure to help regulate building coatings that can block out excess heat from sunlight or prevent doors and use of low-emissivity glass to improve insulation. temperatures in hot climates. heat from escaping from the building. Installation of wall insulation. © ronstik / iStock. Flat roof covered with bitumen membrane and silver lacquer for reflectivity. Perforated screens provide solar shading in Tambacounda Hospital by Manuel Herz. © Roman Mykhalchuk / iStock. © Iwan Baan 2021. Courtesy of the Josef and Anni Albers Foundation and Le Korsa. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES Appendix A Appendix B Appendix C Appendix D 87 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Health Facility Measures Tools and Resources Key Questions Glossary of Terms Energy Efficiency – Passive Measures (cont.) Green walls and roofs Exterior planting Window-to-Wall Ratio (WWR) Green walls and roofs can cool buildings both externally and Planting trees and other vegetation (such as planters or Windows and structural glazing provide light and ventilation, but internally. Vegetation (often drought tolerant varieties like landscaping) near and around buildings can provide shade and in warm climates they also bring in unwanted heat, increasing the sedums) are planted in a growing medium over a waterproofing generally cool spaces. In water-scarce environments, care must be load on air-conditioning systems and thus increasing energy use. membrane on the roof structure. Buildings must be structurally taken to select plants that are drought tolerant and require limited Having the optimum window-to-wall ratio (WWR) helps balance designed for the additional weight. irrigation. the two opposing requirements. Green roof on building. © Wirestock / iStock. Plantings and shaded walkway at a hospital in Tanzania. © Moshe Einhorn / iStock. Windows on a hospital facade. © TBE / iStock. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES Appendix A Appendix B Appendix C Appendix D 88 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Health Facility Measures Tools and Resources Key Questions Glossary of Terms Energy Efficiency – Active Measures Energy-efficient Lighting Energy-efficient HVAC equipment Energy-efficient hot water systems Energy-efficient lighting: Lighting consumes about 15 percent Energy-efficient heating and cooling and ventilation systems: Energy-efficient hot water systems: Hot water is needed for to 30 percent of the total energy. Hence energy-efficient lighting For large hospitals, conventional air conditioning or heating (HVAC) health care facilities, especially in hospitals. It is required for must be selected. Typically, LED lights have a high output to can account for roughly 40 to 60 percent of overall energy usage. personal hygiene, food preparation, for medical equipment and/ input ratio compared to incandescent lighting (75 to 110 lumens Therefore, specifying energy-efficient HVAC equipment is a key or space heating. Many energy-efficient technologies like air of light per watt of electricity). Energy efficient lighting can also measure to lower energy consumption. Air and ground source heat source heat pumps and solar water heaters are preferred over reduce heat gains in buildings. Daylight and occupancy sensors pumps can sometimes be used as more efficient and low- emission conventional fossil-fuel fired boilers. Water-efficiency measures can automatically switch lights on and off to reduce energy heating and cooling systems. can also reduce the demand for hot water. consumption. Waiting area in a hospital. © Chadchai Krisadapong / iStock. Hospital ventilation pipes of the air infection control system. © Aguus / iStock. Solar hot water heaters on rooftops. © welcomeinside / iStock. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES Appendix A Appendix B Appendix C Appendix D 89 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Health Facility Measures Tools and Resources Key Questions Glossary of Terms Energy Efficiency – Active Measures (cont.) Zoning Often, health care facilities will have areas within buildings that have different requirements in terms of heating and cooling depending upon use and time of use. Designing zoned areas with separate controls can save energy and increase occupant comfort. Heat recovery Consider using systems that recover heat from health care facility functions to increase energy efficiency such as catering facilities and laundries, sterilization, and disinfection processes. Ancillary equipment Hospitals tend to use a varied set of equipment like motors, pumps, fans, compressed air systems, etc. It is recommended that more energy- efficient equipment options be selected for the functions of ancillary equipment. Hospital laundry services © wanderluster / iStock. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES Appendix A Appendix B Appendix C Appendix D 90 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Health Facility Measures Tools and Resources Key Questions Glossary of Terms Renewable Energy Renewable Energy Use of on-site renewable energy sources such as solar panels or geothermal. This could range from a small solar panel to power essential functions for a remote health post to large-scale arrays of solar and/or geothermal installations to support a large complex such as a hospital facility, including areas that require air conditioning such as pharmacies or operating theaters. Solar panels line the roof at Bitale Health Center in Bitale village, Western Tanzania. © Contributor: Jake Lyell / Alamy Stock Photo 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES Appendix A Appendix B Appendix C Appendix D 91 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Health Facility Measures Tools and Resources Key Questions Glossary of Terms Water Efficiency Measures Water-efficient supply fixtures and fittings Water-efficient equipment Water Reuse Water-efficient fittings and fixtures for toilets, showers and Air-cooled refrigeration systems can be used rather than Rainwater can be harvested from roofs and stored in tanks and/ sinks such as low-flow taps, push taps, infrared tap sensors, low- water-cooled systems. Selecting medical equipment that uses or in collection ponds for irrigation and flushing toilets. Greywater flow shower heads and low-flow toilets can reduce water flow by recirculated water can also significantly reduce demand. Also, the can also be collected from laundry services and showers for around 15-20 percent. use of digital imaging equipment rather than film-based imaging non-potable purposes. Condensate can be recovered from (to eliminate water and chemicals for developing) is encouraged. air- conditioning systems as well as water from other hospital processes such as dialysis systems. Handwashing station in hospital. © Tempura / iStock. Digital X-ray machine. © K_Thalhofer/ iStock Rainwater storage tanks for a building. © Sharon Wills / iStock. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES Appendix A Appendix B Appendix C Appendix D 92 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Health Facility Measures Tools and Resources Key Questions Glossary of Terms Building Materials and Resources As for other building types, use sustainably sourced materials (low embodied energy materials), maximize the use of recycled materials, and reduce the release of persistent, bio- accumulative and toxic chemicals (PBTs) associated with the life cycle of the building materials. For refits or existing building upgrades, retain or reuse existing floors, walls and roofs. For design of facilities, ensure the building can be adapted in future and used flexibly. For example, many facilities struggled to adapt during the pandemic when additional capacity was required for COVID-19 patients and isolation of patients to reduce the spread of infection in hospital. Increase amount of recycling or salvaging of materials during construction. Facility design can also consider how building materials can be recycled at the end of the building design life. Adja Ouere community health center in Benin. © Olivier Asselin / Alamy Stock Photo. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES Appendix A Appendix B Appendix C Appendix D 93 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Health Facility Measures Tools and Resources Key Questions Glossary of Terms Occupant Health and Comfort Maintaining good indoor air quality is particularly important for occupant health and comfort in health care facilities. This includes adequate ventilation and filtration, removal (or encapsulation) of hazardous materials, control of indoor pollutants and providing low-emitting materials. Ventilation can be achieved by using natural ventilation, active mechanical systems (as part of HVAC) or a mixed system. Monitoring systems and operational procedures for air quality should also be in place. To address the risk from COVID-19 and other airborne pathogens, ASHRAE has issued a pathogen mitigation standard which is at the forefront of indoor air quality and infection control (ASHRAE, n.d.). Standards such as this could be implemented in future health care facilities. Other areas that contribute to occupant health and comfort include attention to acoustical and lighting design, thermal comfort, provision of daylighting and views. Evidence is growing that experiencing a connection to nature – through views or access to gardens and plants – can reduce stress for patients and staff and improve health outcomes (Franklin, 2012). Nurse with patient in a hospital garden". © Authentic Images / iStock. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES Appendix A Appendix B Appendix C Appendix D 94 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Health Facility Measures Tools and Resources Key Questions Glossary of Terms Solid Waste Management Proper management of medical waste is critical to prevent the spread of disease and protect the environment. This became even more apparent during the COVID-19 pandemic where, in some cases, solid waste (such as PPE) was generated faster than it could be safely disposed of. Internationally recognized best practices for medical waste management include: to reduce the generation of waste (such as hazardous medical waste), to segregate waste, to reuse as much as possible (i.e., to reuse after high-temperature treatment), to promote recycling, and appropriate disposal methods (Lee & Lee, 2022). Solid waste management for health care facilities requires effective coordination and operational management. A system-wide approach across multiple facilities in a geographic area is often required for waste transfer and disposal of waste generated from medical sources. Hazardous medical laboratory waste. © pidjoe / iStock. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 95 Appendix A.3 Catalog of Universal Accessibility Measures Appendix A Appendix B Appendix C Appendix D 96 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Health Facility Measures Tools and Resources Key Questions Glossary of Terms Site Location and External Environment Accessible facility location Accessible and safe external environment As part of a broader health care network, health facilities should Access to the external environment. The site should be accessible Key external environment features include pedestrian access, be located where they are easily accessible for the community for all users - access routes, facilities and features provided within vehicular drop-off areas, parking, level, sloped, ramped or stepped they serve. For example, locating facilities within a reasonable the external environment on approach to a building entrance, access routes, handrails, external lighting, signage, places to geographic range that can be accessed on foot or by affordable including parking facilities and circulation routes between rest and security measures. Health care facilities require a higher public transportation. buildings. number of disabled parking spaces, for example, than other types of facilities. Bus stop in the African town of Libreville in Gabon. Mulago Hospital in Kampala is Uganda's largest health facility. © Jake Lyell / Alamy Drop off, disabled and family parking spaces at building entrance. © cribea / iStock. Stock Photo. © richard johnson / iStock. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES Appendix A Appendix B Appendix C Appendix D 97 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Health Facility Measures Tools and Resources Key Questions Glossary of Terms Entrances, Doors and Lobbies Accessible entrances, doors and lobbies Communication and wayfinding Waiting areas As the first point of contact for most users, entrances doors, Communication and wayfinding aids can include visual as well Quiet, adequately lit waiting areas should be provided as well lobbies and reception areas must be accessible to all users. This as audio announcements, braille signage and contrasting color as a places to rest. These should be designed to accommodate may include level access, doors of adequate width, automated signage. Also see ”Fixtures and Fittings”. wheelchair users, persons with mobility aids, guide / service dogs doors, clear layout of the space to identify reception or the clear of circulation spaces; other considerations may include mixed Pre-visitor information (e.g., online) can be useful for users to main circulation route, and a lower reception desk to allow seating types to suit a wide range of users. understand how to reach the building, where to go and how to get communication with wheelchair users. to reception or other relevant destinations. Wheelchair accessible hospital corridor. © gorodenkoff / iStock. Child playing with toys in clinic waiting room © DMP / iStock. Set of symbols with braille text on special sign near the entrance to the building. © Timur Malazoniia / iStock. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES Appendix A Appendix B Appendix C Appendix D 98 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Health Facility Measures Tools and Resources Key Questions Glossary of Terms Horizontal and Vertical Circulation Horizontal circulation Vertical circulation Inpatient circulation on each floor Stairs, ramps and elevators provide essential access to floors within a building should be clear and in multistory buildings. Vertical features should be closely easy to navigate for all users. Special integrated with elements of the horizontal circulation to provide a consideration may be required, for logical and convenient means of moving through an entire building. example, for allowing for navigation For smaller health clinics, it can sometimes be more cost-effective of hospital beds, stretchers, mobility to keep buildings to one story to avoid any need for elevators. scooters and bariatric patients in hospitals. Within a floor, adequate space should be provided to allow all users to maneuver and pass one another. Obstacles and projections into the circulation space should be kept to a minimum where practicable and, where required, should be protected from accidental collisions or trips. Floor coverings and thresholds should be designed not to cause difficulty for wheelchair users or people with limited mobility or sight. Abrupt changes in light levels should be avoided. Nurse pushing stretcher gurney bed in hospital corridor. © Spotmatik / iStock. Medical team in elevator transferring a patient to treatment room. © Tongpool Piasupun / iStock. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES Appendix A Appendix B Appendix C Appendix D 99 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Health Facility Measures Tools and Resources Key Questions Glossary of Terms Building Facilities Including Medical Equipment Building facilities for patients and staff Specialist medical equipment In addition to basic facilities such as sanitary facilities, health care Medical equipment needs to be specified with the needs and building facilities can range from provision of primary care with abilities of all users in mind. For example, height-adjusted waiting areas and examination rooms to complex hospitals with examination tables, patient-lifting equipment, special scales for specialized treatment facilities and medical equipment, inpatient wheelchair users, adjustable medical equipment for x-rays, and accommodation, cafeterias, changing rooms and waiting areas. beds adapted for patients with limited mobility. Facilities should be able to accommodate care givers (for example, in changing rooms or toilets). The facilities provided should be safe, accessible and useable by the widest range of people, where practicable, and should encourage active participation by all users. Great discomfort and loss of dignity can be caused for users if the sanitary facilities (toilets and hand-washing facilities) do not meet the requirements in terms of access and use. For example, if a door is too heavy for a user to open, a toilet could become inaccessible for a frail, elderly user. Elderly patient using accessible toilet facilities. © EyeEm Mobile GmbH / iStock. Getting patient out of bed with lift. © Trish233 / iStock. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES Appendix A Appendix B Appendix C Appendix D 100 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Health Facility Measures Tools and Resources Key Questions Glossary of Terms Building Finishes, Fixtures and Fittings Essential fixtures and fittings in health care facilities must be usable by people of all ages and abilities. Some examples include signage, furniture, lighting and services controls and surface finishes. The detailed design of the building’s interior – the surface finishes, lighting, acoustics, ventilation, etc. – are all important components, often not noticed within a building, which will make the space comfortable for everybody to use. For example, people with head injuries or neurological conditions may be very sensitive to light and noise. Careful consideration for the layout, relationship of rooms and spaces, the use of color and symbols, audible and tactile information as well as the use of signage are aspects of the building that can make the difference between a comfortable space and constant discomfort within the environment. These elements inform the overall experience of the building for users. Beyond physical fixtures and fittings, digital wayfinding can help patients navigate to their destination. They can work by the user scanning a QR-code upon arrival at the health care facility and then selecting a destination. Then, a route can be generated in a web browser (similar to the interface in an App such as Google Maps). These tools can also provide patients with other information, such as departmental hours of operation, what they will need for their appointment and special routes for disabled patients. Italian hospital ward floor plan. © Cineberg / iStock. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES Appendix A Appendix B Appendix C Appendix D 101 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Health Facility Measures Tools and Resources Key Questions Glossary of Terms Evacuation and Safe Egress Health care facilities must be designed and operated to ensure safe egress and evacuation for patients, visitors and staff of all ages and abilities. This must recognize that people with mobility, sensory, cognitive and mental health impairments along with people with hidden disabilities, may need assistance in order to escape in the event of fire or an emergency. These special needs and related aspects of facility design must be considered as part of a wider plan that defines the scale of evacuation, stages of evacuation, zoning of facilities, internal and external communications, and prioritization of patients and staff by vulnerability level. For example, a hospital may have different zones for fire containment and evacuation. Horizontal evacuation zones may be needed where vertical evacuation of certain types of patients is not feasible. These considerations extend to the wider site. For example, designing space where emergency vehicles can be staged for patient transport after an evacuation. Hospital emergency drill. © Kurashiki Central Hospital. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 102 Appendix B Tools and Resources 103 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation ● Australasian Health Infrastructure Alliance (AHIA), 2024. Key bitstream/handle/10665.2/51448/9789275120293_eng. en/285171633074966748/pdf/Green-Resilient-and-Inclusive- Sustainability Guidance Climate Resilience and Adaptation pdf?sequence=1&isAllowed=y Development.pdf Guide. https://healthfacilityguidelines.com.au/content/ ● Pan American Health Organization (PAHO), 2018. INGRID-H: ● World Health Organization (WHO), 1996. District Hospitals: key-sustainability-guidance Disability Inclusion in Hospital Disaster Risk Management. Guidelines for Development, 2nd Edition. https://iris.who.int/ ● FEMA, 2007. FEMA 577: Design Guide for Improving Hospital Washington, D.C.: PAHO; 2018. https://iris.paho.org/ handle/10665/206791 Safety in Earthquakes, Floods, and High Winds bitstream/handle/10665.2/51059/9789275120521_eng. ● World Health Organization (WHO), 2009. Healthy Hospitals, ● IFC EDGE certification system. https://edgebuildings.com pdf?sequence=9&isAllowed=y Healthy Planet, Healthy People: Addressing climate change in ● ISO, 2021. ISO 21542 Building construction — Accessibility and ● Pan American Health Organization (PAHO), 2023. STAR-H: health care settings https://www.who.int/docs/default-source/ usability of the built environment, 2nd Edition Strategic Toolkit for Assessing Risks in Health Facilities. climate-change/healthy-hospitals-healthy-planet-healthy- Washington, D.C. https://iris.paho.org/handle/10665.2/57956 people.pdf?sfvrsn=8b337cee_1 ● Institution of Structural Engineers (IStructE), 2022. The Structural carbon tool - version 2. https://www.istructe.org/ ● Pan American Health Organization (PAHO) and World Health ● World Health Organization (WHO), 2018. Guidance for business resources/guidance/the-structural-carbon-tool/ Organization (WHO), 2024. Resilient Hospitals: An Inter- continuity planning. Geneva. https://iris.who.int/bitstream/ Regional Guidance on Strengthening Resilience to Health handle/10665/324850/WHO-WHE-CPI-2018.60-eng.pdf ● LEED rating system. https://www.usgbc.org/leed, Also: https:// Emergencies and Disasters in Health Facilities. Washington, World Health Organization (WHO), 2020. Guidance for climate- www.usgbc.org/resources/healthcare-v2009-checklist-xls ● D.C. https://iris.paho.org/handle/10665.2/61339 resilient and environmentally sustainable health care facilities ● MCEER, 2009. Enhancements to Hospital Resiliency: Improving ● UNDP, 2019. Universal Design in Healthcare: Manual https:// https://www.who.int/publications/i/item/9789240012226 Emergency Planning for and Response to Hurricanes https:// www.undp.org/sites/g/files/zskgke326/files/migration/ua/ World Health Organization (WHO), 2021. Disability-inclusive www.buffalo.edu/mceer/catalog.host.html/content/shared/ ● Manual_UD-in-Healthcare_eng.pdf Health Services Toolkit https://apps.who.int/iris/bitstream/han www/mceer/publications/MCEER-09-0007.detail.html ● U.S. Department of Health and Human Services, 2014. dle/10665/336857/9789290618928-eng.pdf ● Nations Joint Inspection Unit, 2021. Business continuity Primary Protection: Enhancing Health Care Resilience or a World Health Organization (WHO), 2021. Climate Change and management in United Nations System Organization. Geneva: ● Changing Climate https://toolkit.climate.gov/sites/default/ Health Vulnerability and Adaptation Assessment https://www. United Nations. https://www.unjiu.org/sites/www.unjiu.org/ files/SCRHCFI%20Best%20Practices%20Report%20final2%20 who.int/publications/i/item/9789240036383 files/jiu_rep_2021_6_english_2.pdf 2014%20Web.pdf ● Pan American Health Organization (PAHO), 2017. Smart ● World Health Organization (WHO), 2021. Checklists to ● World Bank, 2021. Frontline: Preparing healthcare Assess Vulnerabilities in Healthcare Facilities in the Context Hospitals Toolkit. https://iris.paho.org/bitstream/ systems for shocks from disasters to pandemics https:// of Climate Change https://www.who.int/publications/i/ handle/10665.2/34977/9789275119396_eng. www.worldbank.org/en/news/feature/2021/04/13/ item/9789240022904 pdf?sequence=1&isAllowed=y frontline-preparing-healthcare-systems-for-shocks ● Pan American Health Organization (PAHO), 2018. Hospital ● World Health Organization (WHO), 2021. Health service ● World Bank, 2021. Green, Resilient and Inclusive Development continuity planning for public health emergencies: A handbook Safety Index: Guide for Evaluators. https://iris.paho.org/ (GRID) https://documents1.worldbank.org/curated/ for health facilities https://www.who.int/publications/i/ item/9789240033337 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 104 Appendix C Key Questions 105 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation TOPIC KEY QUESTIONS TOPIC KEY QUESTIONS Considering Resilient Selecting and Resilient context, ● What are the shocks and stresses that can affect the current and future assessing a ● For the selected site(s), what are the potential site hazards? Planning service area, service delivery and/or demand needs as well as disrupt or damage the site and wider ● Can these be mitigated, or are alternative sites available that are less Resilient, Green health facility? network exposed to such hazards? and Inclusive ● For resilience objectives, what level of disruption to service delivery is Health Facilities ● Does the selected site have adequate connection to public utilities, transport acceptable in different types of shock or stress scenarios? networks or roads for normal operations and in the aftermath of disasters? ● How do the facility and its services fit into the wider health network and how Green does this affect resilience objectives? ● What local climatic conditions should be considered in master planning ● How are the facility functions reliant on wider infrastructure systems? How and building design? Which ones should be leveraged (for example, rainfall can this inform requirements for backup systems? capture for watering landscaping, natural breezes, plentiful natural light) Green and which should be mitigated (for example potential heat-island effects)? ● What are the climatic conditions in the region? Which types of green building ● What natural and environmental resources in the immediate area should measures are appropriate for the climatic conditions? be protected or preserved? What potential environmental impacts from the ● Depending on the local construction environment and available resources, new facility must be mitigated? which types of construction, materials and green building measures and ● Is the site served by public utilities? If not, will utility networks be expanded systems will be feasible and appropriate to implement? to provide service, or will off-grid solutions be necessary (for example Inclusive renewable sources such as geothermal energy, solar power arrays, and so forth)? ● What types of universal accessibility needs are anticipated for the facility based on services provided and user types? ● Can the site be accessed through lower-emission forms of transport (for example, walking, biking or public transport)? ● What types of cultural practices need to be considered in the planning and design of the facility? Inclusive ● How can any potential negative impacts of the facility be mitigated? ● How can communities be engaged in selecting and assessing the site? ● How can the facility have a positive impact on the local economy? ● How far is the facility from residential areas and other related health and public facilities? ● How can broader community investment in maintaining the facility be encouraged? ● How will users access the facility in normal circumstances? Are there affordable, safe and efficient transport options that are appropriate for all types of users of the health facility? ● Is the site exposed to loud noises, vibrations from nearby activities, or other nearby hazardous facilities that could negatively affect patients? ● Is the site or surrounding area currently used by the community? Does it have cultural significance? If so, how will the new health facility be sensitive to existing uses? 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 106 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation TOPIC KEY QUESTIONS TOPIC KEY QUESTIONS Identifying Resilient Preparing for Resilient regulatory ● Do current planning requirements and building design and construction the design ● Does the design brief clearly set goals, design criteria and other Planning requirements codes capture expected hazards and risks? If not, what other regional and/or phase requirements related to resilience? Resilient, Green international regulations or standards could be used? ● Has the relevant expertise needed in the design team to address the and Inclusive Green resilience aspects in the brief been identified? Health Facilities ● Do green building requirements exist in the applicable building codes/ Green certification schemes? Are the provisions mandatory, voluntary or a mix of ● Does the design brief clearly set goals, design criteria and other both? requirements related to incorporating green building measures into the ● If there is no standard or if gaps exist in the current standard, what other facility? green building regulations or certification schemes could be used? ● Has the relevant expertise needed in the design team to address green Inclusive building aspects in the brief been identified? ● Is there a universal accessibility standard in place in the relevant jurisdiction? Inclusive ● If there is no standard or if gaps exist in the current standard, what other ● Does the design brief clearly set goals, design criteria and other regional or international universal accessibility standards could be used? requirements related to universal accessibility and inclusive design for the Facility Resilient facility? master ● Does the master planning and programming phase take sufficient account of ● Has the relevant expertise needed in the design team to address inclusive planning and resilience considerations that reduce the risk from key hazards, and enable aspects in the brief been identified? programming the facility to adapt and recover with only limited disruption of critical services? Green ● Have opportunities to incorporate green building measures for the facility been fully explored in the master planning and programming phase? Inclusive ● Have universal accessibility needs and broader inclusive considerations been taken into account in the master planning and programming phase? Financial Resilient, Green and Inclusive considerations ● What information (for example, costs, quantitative and qualitative benefits) is needed to assess the value of investments for options to achieve a resilient, green and inclusive health facility? ● What tools and approaches could be used to communicate the value of investments to achieve a resilient, green and inclusive health facility (both qualitative and quantitative)? 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 107 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation TOPIC KEY QUESTIONS TOPIC KEY QUESTIONS Site and Resilient Building Resilient external ● What other infrastructure systems does the facility depend on to function design, ● Does the design consider what will be required during emergencies or Design of environment (for example, energy, communications, transport, waste and water structure, and disasters (for example, ability to adapt spaces to increase capacity, isolate Resilient, Green infrastructure)? materials patients, accommodate staff, store emergency supplies)? and Inclusive ● To reduce vulnerabilities, what backup systems are required, and have they ● Does the design consider evacuation needs for users of all ages, abilities and Health Facilities been considered in the site plans? health conditions? ● Have more refined risk assessments related to the site been performed? ● Do the structural system and materials selected meet architectural design Have appropriate measures to mitigate risks been incorporated into site needs (for example, for flexibility, modular design, clear span distances) planning? including for future expansion? ● Have site security and emergency planning and related site requirements ● Do the structural systems and nonstructural components meet required been considered? performance objectives per design regulations, or to meet resilience ● Can the site plans accommodate future needs and options for expansion/ objectives to limit disruption which may be above the minimum code change of use? requirements (for example, for the earthquake design level, or wind design level)? Green ● Are the materials selected locally available or imported? Are they durable ● Does the site plan make the most of opportunities to incorporate green and easy to maintain? spaces, and are some accessible for patients, staff and visitors? ● Is the local construction industry familiar with the selected structural ● If rainwater harvesting is used, is the related infrastructure accommodated systems, architectural components and materials? and included in the site plan? ● Depending on the local hazards, which hazard-specific resilience measures ● If on-site renewable energy systems are used, is adequate space allocated in can be considered for incorporation into the design? the site plan for them, any related equipment and grid connections? Green Inclusive ● What are the climatic conditions for the site location? ● Does the site design ensure facilities are accessible for users of all ages and abilities as well as accommodate the needs of specific vulnerable user ● Are there opportunities to maximize the use of passive green building groups? measures such as natural ventilation (even if active measures are also needed)? ● Has consultation with users taken place to test accessible design features for the site and its immediate environs? ● What is the embodied energy of different material options and are there ways to reduce the embodied energy for the design? ● Have users of all ages and abilities been considered in relation to the site design for emergency evacuation? Inclusive ● What was learned from stakeholder engagement in terms of types of users and their needs and cultural practices that are relevant for the design of health facilities? ● How can each key aspect of inclusive building design respond to these needs? 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 108 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation TOPIC KEY QUESTIONS TOPIC KEY QUESTIONS Building Resilient Finishes, Inclusive services ● Has the design of services considered the potential vulnerabilities to relevant fixtures, and ● Are fixtures, fittings and medical equipment provided suitable or adaptable Design of hazards and related mitigation measures? equipment for different types of user needs? Resilient, Green (cont.) ● Has the design considered adding redundancy and backup systems? ● Are finishes user friendly for all types of users? and Inclusive Health Facilities ● How effective is the services design to reduce the spread of airborne ● Are wayfinding methods provided for users of all types? pathogens and are isolation rooms provided (if required)? Construction Resilient Green considerations ● Has the local context and construction environment been considered when ● Have a range of active energy efficiency measures been explored for the in design designing the facility, including the selection of structural and nonstructural facility (this can be in combination with passive measures)? elements and the level of complexity of the build? ● Have a range of water efficiency measures been explored? ● Have construction contingency plans been formulated in the design stage ● Have measures for sustainable waste management been explored and how and are they reflected in the construction procurement documents? is waste management connected into the wider network? Green Inclusive ● Does the design consider how to reduce waste during construction or ● Does the services design for control of indoor environmental quality and incorporate recycled or salvaged materials? comfort meet user needs? ● Have efforts been made to incorporate local materials, and materials with ● Can users control some aspects of the indoor environment? green credentials (for example, sustainably grown timber)? Finishes, Resilient Inclusive fixtures, and ● Have relevant loading and allowable movements—including from design- ● Does the design incorporate local materials? equipment level hazard cases—been considered for the performance of finishes, fixtures ● Does the construction type allow for local labor to be involved in building the and equipment? facility? ● Is equipment located to reduce the risk of damage for different design-level hazard types? ● Is an appropriate level of redundancy built into the provision of medical equipment for critical functions? Green ● When specifying finishes, fixtures and fittings, have energy- and water- efficient options and strategies been explored, where applicable? ● For finishes and furniture, have sustainably sourced and low- emitting materials been selected? 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 109 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation TOPIC KEY QUESTIONS TOPIC KEY QUESTIONS Commissioning Resilient Operational Inclusive ● How can the commissioning process be designed to identify potential policies and ● Are there plans and requirements to carry out periodic accessibility audits? Operation of failures in the system, such as arising from interdependencies that need to plans (cont.) Is training in place to ensure staff treat patients and each other equitably, Resilient, Green ● be considered during operations? including those with disabilities and/or other accessibility challenges? and Inclusive ● Does the commissioning process measure the redundancy of systems? Does the evacuation plan accommodate the needs of different staff and Health Facilities ● ● Does the commissioning process include testing of backup systems (for patients of all ages and abilities? example, water, power, ICT)? Monitoring Resilient Green and ● Is there a plan and allocated budget for building maintenance and capital ● Does the commissioning process include testing that the green building maintenance improvements for the facility? performance targets set in the design phase are met (for example, through ● Are there requirements to routinely monitor function and test backup pre-functional checklists, functional tests and reporting)? systems and/or systems that provide additional capacity during surges (for ● How can the commissioning results inform current facility requirements as example, in O&M manuals)? well as a strategy for operations and maintenance? ● Are staff adequately trained to operate and deploy backup systems and Inclusive other system components that may be needed in an emergency? ● Does the commissioning process include testing systems and equipment Green related to universal accessibility? ● Are maintenance and capital improvements and related budget allocation ● What staff training for universal accessibility features is needed ahead of for equipment, systems and green building features included? operating the facility? ● Are staff allocated and trained to carry out necessary monitoring and Operational Resilient maintenance of green building components and systems? policies and ● Is a Business Continuity Plan in place, with fixed requirements for regular Inclusive plans updates (for example, a yearly plan update)? ● Are there opportunities to engage local communities to help maintain ● Is there an Emergency/Disaster Response and Preparedness Plan in place? and monitor the health facility or help determine planning for capital improvements? ● Are the roles and responsibilities for business continuity and emergency planning clearly set? ● Are the facility’s materials, systems and equipment cost effective to be maintained locally? ● Are protocols and resources in place for the training of the staff and other key stakeholders who will implement those plans if and when necessary? Green ● Is a sustainability plan in place for operations? ● Are there clearly defined roles and responsibilities for delivery of the plan? 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 110 Appendix D Glossary of Terms 111 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Active measures/methods/systems nonstructural elements that make up the building, such as walls, Cost-effectiveness analysis (CEA) Green building measures which rely on power-driven mechanical floors, ceilings, and roofs. This approach examines the costs and health outcomes of one or systems to operate. Also see HVAC systems. more interventions. It compares one intervention to another (or the Building utility systems status quo) by estimating how much it costs to gain a unit of a Adaptive capacity The utility lines and systems, as well as drain lines, serving a building, health outcome, such as a life-year gained or a death prevented. The adaptive capacity of a system describes its ability to change including, but not limited to, gas, water, sewer and electric lines, Because CEA is comparative, an intervention can only be considered itself to deal with future disruptions. It means changing current from the point where they enter or leave, to the location outside the cost-effective compared to something else (CDC, 2024). practices or policies, and learning from disruption—revising plans, building site or perimeter where they connect into the wider utility modifying procedures, and introducing new tools, technologies, and network. Daylighting training exercises before the next crisis hits. The adaptive capacity Daylighting is the practice of placing windows, skylights, and other of a system is mainly determined by the social component (human Business continuity planning (BCP) openings, or reflective surfaces so that during the day natural light actions), rather than technical characteristics (Mentges et al, 2023). Business continuity is “the capability of an organization to continue provides effective internal illumination. In addition to mental and delivery of essential and time-critical services at acceptable physical health benefits of adequate daylight for occupants, it can Benefit-cost analysis (BCA) predefined levels during and/or following a disruptive incident” also involve the controlled admission of natural light—direct sunlight Benefit-cost analysis compares the benefits and costs of an (United Nations Joint Inspection Unit, 2021). Business continuity and diffuse skylight—into a building to reduce electric lighting and intervention, where both are expressed in monetary terms. Key planning means proactive policies and strategies to safeguard save energy. parameters to determine as part of this are the period over which organizational continuity. to evaluate benefits and costs, the discount rate (to account for Design basis the Net Present Value or time value of money), and how to quantify Capital improvement (cost) The information necessary to accomplish the facility’s project potential benefits and costs (for example, earthquake losses avoided Any renovations, additions, repair or capital improvements other requirements, including service delivery requirements, system from investing in a more seismically resilient building). than operations and maintenance costs. descriptions, indoor environmental quality criteria, design assumptions, and references to applicable codes, standards, Building envelope Commissioning regulations, and guidelines (adapted from USGBC, n.d.). A structure’s primary and secondary weatherproofing system, The process of verifying and documenting that a building and all including waterproofing membranes and air- and water-resistant of its systems and components are planned, designed, installed, Early warning alert/system barrier materials, and all building elements outside that system tested, operated, and maintained to meet the owner’s project An integrated system of hazard monitoring, forecasting and (adapted from USGBC, n.d.). requirements (USGBC, n.d.). prediction, disaster risk assessment, communication and preparedness processes that enables individuals, communities, Building mass Community-based Disaster Risk Management (CBDRM) governments, businesses and others to take timely action to reduce Building mass refers to the physical structure of a building, including Disaster risk management (DRM) in which local communities disaster risks in advance of hazardous events (UNDRR, 2017). its size, shape, and volume. It encompasses all the structural and actively participate to reduce their vulnerabilities and enhance their capacities to prevent and reduce losses from hazards and risks. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 112 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Epidemiology Green infrastructure Heat-island effect The study of how often diseases occur in different groups of people A soil- and vegetation-based approach to wet weather management The thermal absorption by hardscaping, such as dark, nonreflective and why. Epidemiological information is used to plan and evaluate that is cost-effective, sustainable, and environmentally friendly. pavement and buildings, and its subsequent radiation to surrounding strategies to prevent illness and as a guide to the management of Green infrastructure management approaches and technologies areas. Other contributing factors may include vehicle exhaust, patients in whom disease has already developed. infiltrate, evapotranspire, capture and reuse stormwater to maintain air-conditioners, and street equipment. Tall buildings and narrow or restore natural hydrologies (adapted from US Environmental streets reduce airflow and exacerbate the effect (USGBC, n.d.). Embodied energy Protection Agency). Embodied energy refers to the energy used for raw material Heating, Ventilation, Air Conditioning (HVAC) systems extraction, manufacturing, processing, and transportation. Hardscaping HVAC systems, including air handlers, ducts and other equipment, Landscaping made of nonpermeable materials such as asphalt, supply fresh air and control air temperature and humidity in a Energy Management Systems (EMS) tarmac, stone, concrete or brick. building by supplying, filtering, heating, cooling and distributing the A system of computer-aided tools used by operators of electric utility conditioned air into targeted interior spaces. They need a power grids or smaller scale microgrids to monitor, control, and optimize Hazard source to operate. the performance of the generation or transmission system. A natural or anthropogenic phenomenon that may cause loss of life, injury or other health impacts, property damage, social Importance factor Environmental Impact Assessment (EIA) and economic disruption, or environmental degradation. Natural The Importance Factor is a multiplier that increases or decreases the The process of assessing the anticipated environmental effects hazards relate to natural processes (such as floods, storms, base design loads. It is typically based on the building occupancy/ of a proposed project on a specific site—from consideration of droughts, earthquakes, and so on) and may be single, sequential, or use category and/or the building risk category. environmental effects at design stage, through consultation and combined in their origin and effects. They may differ in intensity or preparation of an Environmental Impact Assessment Report magnitude, scale, and frequency and are often classified by cause, Indoor environmental quality (EIAR), evaluation of the EIAR by a competent authority, and the such as hydrometeorological or geological. Anthropogenic hazards Indoor environmental quality encompasses the conditions inside a subsequent decision as to whether the project should be permitted are those caused by human activity. building—air quality, lighting, thermal conditions, ergonomics—and to proceed (EPA, n.d.). their effects on the building’s users. Health impact assessment (HIA) Exposure HIAs aim to inform decision-makers and stakeholders about Interdependencies The situation of people, infrastructure, buildings, production the benefits and risks to health of interventions, policies, and How operations or systems are dependent on other people, capacities, and other tangible human assets located in hazard- projects. The process typically involves gathering stakeholders, institutions, processes, information, technology, facilities, prone areas. understanding the scope of the health intervention, assessment third-party service providers and critical business services. of impacts, reporting to decision-makers and monitoring (WHO, Interdependencies can be spatial, temporal, or cross-sectoral. Furniture, Fittings and Equipment (FF&E) 2023). The movable furniture, equipment, and other physical items that if Key performance indicators (KPIs) removed will not damage the main structure of a building. These measure how well a system performs or functions. 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 113 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Life-cycle cost analysis (LCCA) perspectives) and quantitative elements (using models to represent Prescriptive-based design This approach estimates the overall costs of project alternatives over stakeholder preferences and the performance of different options). A prescriptive-based design approach where a set of procedures the whole building life cycle to evaluate which investment options and methods must be followed to achieve compliance. or design and construction approaches provide the best value. Life Multihazard approach cycle costs include initial costs (purchase, land acquisition, design, This aims to assess the likelihood and severity of various types Programming (programmatic) requirements for spaces and construction costs), operational, maintenance and repair costs, of hazard on a system or asset, analyze their interactions, and Programming in the context of facility design occurs in the Planning end of life costs (resale, salvage, demolition and disposal costs) and incorporate them into resilience planning. If considered individually, Phase. Based on the value that the facility should deliver and related financing costs (for example, loan interest). mitigation measures proposed in response to one hazard or risk may functional requirements, it identifies the scope of work for the design. increase vulnerability to another. The interdependencies between A key aspect of programming is to determine how much floor space is Master planning different types of hazard are considered in a multihazard approach. needed for different functions, and the spatial relationships between Master planning is the process of developing overarching planning different spaces and functions, all of which will hugely influence the documents and spatial layouts used to structure land use and Passive measures/methods/systems size and configuration of buildings. Programming also incorporates development. This typically involves designating boundaries, Green building measures that do not rely on power-driven systems additional factors such as site analysis, aesthetic considerations, buildings and built forms, pedestrian and vehicular access/routes, to operate (for example, fixed or hand-operated solar shading, quality of building, circulation, exterior envelope, outdoor space needs, and open spaces and landscaping. Master planning should consider building orientation, consideration of window-to-wall ratios, natural regulatory requirements, costings, scheduling limitations, universal how the site development and facility needs might grow or change ventilation, cool roofs or wall, and so forth). accessibility needs and more. over time. Payback period Redundancy Mechanical ventilation The time, usually measured in years, needed for a project or The availability of one or more alternate pathways for the system See Heating, Ventilation, Air Conditioning (HVAC) systems. investment to recoup its initial capital investment. to operate—or even several independent parts of the system able to carry out the same function—thus allowing one part to replace Microgrid Performance-based design (PBD) another in the event of a partial breakdown and thus ensure A microgrid is a self-contained energy system that serves a small An engineering approach to designing elements of a building based functionality of the system (Mentges et al., 2023). community or facility. It can operate either independently or in on meeting specific performance goals, such as for energy efficiency parallel to the main power grid, and consists of a renewable energy or seismic performance objectives, without prescribing a method by Rehabilitation source in combination with energy storage capacity. which to achieve these goals. Improvements to an existing building which aim to restore the building to its original condition, including the original design level Multicriteria decision analysis Post-occupancy evaluation of performance for structural and nonstructural elements. This can help decision-makers rationally choose between multiple The process of obtaining feedback on a building’s performance in options where there are several conflicting objectives. It combines use after it has been built and occupied. Reliability qualitative elements (working with stakeholders to explore their The ability to meet an acceptable performance level over extended periods of time, even under unfavorable operating conditions 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 114 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation (involving disruptive events of any sort). Bear in mind that this that scenarios are neither predictions nor forecasts but are used Social Impact Assessment (SIA) does not simply equate to safety. In contrast to safety, reliability is to provide a view of the implications of developments and actions This is the process of research, planning and management of social always related to specifications regarding the required performance (IPCC, 2021). change or consequences (positive and negative, intended and (Mentges et al., 2023). unintended) arising from policies, plans, developments and projects. Serviceability Resilience objective In the civil/structural engineering context, serviceability refers Social Return on Investment (SROI) The goals and desirable outcomes for the resilience of a system, to the conditions under which a building is still considered useful This is a framework to measure and account for the value created service provision or a facility. For example, a health facility could and fit for purpose (for example, it is sufficiently durable, retains by a facility or delivery of services beyond purely financial value. It aim to have the capacity to treat a certain number of casualties stability, has adequate fire resistance, and does not suffer from incorporates social, health, environmental and economic costs and after a design-level earthquake event and have disruption confined unacceptable deflections, cracking or excessive vibration under benefits. to a limited period in the immediate aftermath of the event. normal service loading). Stress Retrofit Service catchment area Disruptive events whose intensity increases over a longer period Improvements to an existing building which aim to improve the The geographical area from which an institution or facility attracts of time, for example, repeated outbreaks of disease or increased building’s performance level (both structural and nonstructural a population that uses its services. frequency and intensity of extreme temperatures due to climatic elements). This can involve the addition or removal of building changes. It should be noted that a slow-onset disruptive event can elements and often involves strengthening of existing elements and Shock still lead to a sudden collapse of performance, for example, when improving overall load transfer in the structure. A disruptive event marked by an immediate build up of intensity, approaching a bifurcation or tipping point (adapted from Mentges such as an earthquake or a tidal flood. In the context of resilience, et al., 2023). Risk many authors focus on such sudden-onset disruptive events. It The potential loss of life, injury, and destruction or damage to assets refers to one of the two extremes regarding the onset speed of Sustainability/sustainable development that could occur in a system, society, or community in a specific disruptive events, the other extreme being included in the class of Sustainable development is characterized as “development that period and can be defined through the combination of three terms: slow-onset disruptive events or stress (Mentges et al, 2023). meets the needs of the present without compromising the ability hazard, exposure, and vulnerability. of future generations to meet their own needs” (WECD, 1978). Site-specific investigations Examples following the idea of sustainable development are the Risk assessment These focus on investigating ground conditions and any existing circular economy, material and energy efficiency, end-of-life The qualitative and/or quantitative scientific estimation of risks. subsurface structures and related environmental issues at the site. recovery, and minimizing carbon emissions (Mentges et al., 2023). They typically involve a combination of desktop study and physical Scenario planning testing of soil/rock strata, data analyses and reporting. Target Value Design (TVD) Planning for a set of plausible descriptions of how the future TVD begins with setting project budgets based on a business case may develop based on a coherent and internally consistent set that demonstrates the worth to the owner or operator of the asset of assumptions about key driving forces and relationships. Note to be constructed. After a project has been funded, the design is 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 115 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation performed to meet set targets, namely, the conditions that must Universal accessibility be met in order for that value to be realized. Achieving the targets Ease of independent approach, entry, evacuation, and/or use of a continues to be tracked in preparation for and during construction, building and its services and facilities by all of the building’s potential with emphasis on process design and execution. users—including people of all ages and abilities—with an assurance of individual health, safety, and welfare during the course of those Thermal mass activities. Describes a material’s capacity to absorb, store and release heat. Vulnerability Thermal Resistance (R-Value) The conditions determined by physical, social, economic, and The inverse of thermal transmittance (U-value), which is the environmental factors or processes that determine the level of measure of how well an insulation resists the flow of heat. Also see damage from hazards suffered by an individual, a community, below. assets, or systems. Thermal Transmittance (U-Value) Wayfinding Thermal transmittance or U-Value is the amount of heat that a A system of elements working together to provide clarity and material transfers from outdoors to indoors to raise the temperature assistance to people in the built environment to help them orient by 1°Kelvin. The lower the U-value, the greater the insulating themselves in a space and navigate to a specific destination. properties of the material. 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November 2017, https:// Health, December 2018, https://pubmed.ncbi.nlm.nih.gov/30583466/ for integrating community priorities in health planning, resource files.kff.org/attachment/Issue-Brief-Public-Health-in-Puerto- allocation and service delivery: Results of a literature review, Rico-after-Hurricane-Maria MASS, 2014. Rwanda Hospital Design Standards, MASS Southern African Regional Network on Equity in Health (EQUINET) Design Group, https://massdesigngroup.org/work/research/ For the Governance and Equity Research Network (GoVERN) KFF, 2017. Puerto Rico: Fast Facts, Kaiser Family Foundation. rwanda-hospital-design-standards Theme. https://www.equinetafrica.org/sites/default/files/uploads/ October 2017, https://www.kff.org/racial-equity-and-health-policy/ documents/DIS13gov.pdf>> fact-sheet/puerto-rico-fast-facts/ 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 119 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation Multi-Hazard Mitigation Council (2019.). Natural Hazard Mitigation PAHO, 2024. Resilient Hospitals: An Inter-Regional Guidance on Coordination Partnership (RCP), https://www.epa.govt.nz/assets/ Saves: 2019 Report. Principal Investigator Porter, K.; Co-Principal Strengthening Resilience to Health Emergencies and Disasters Uploads/Documents/Fast-track-consenting/New-Dunedin- Investigators Dash, N., Huyck, C., Santos, J., Scawthorn, C.; in Health Facilities. Washington, D.C. https://iris.paho.org/ Hospital/Application-documents/Attachment_23_NDH_Response_ Investigators: Eguchi, M., Eguchi, R., Ghosh., S., Isteita, M., Mickey, handle/10665.2/61339 to_CIA.pdf K., Rashed, T., Reeder, A.; Schneider, P.; and Yuan, J., Directors, MMC. Investigator Intern: Cohen-Porter, A. National Institute of Building Partners in Health, 2023. Watch the first-ever IG live tour of the Sam-Awortwi F.Y., 2021. An Emergency Approach to the Design and Sciences. Washington, DC. www.nibs.org. Material Center of Excellence, October 16, 2023,(Instagram video), Construction of the Ghana Infectious Disease Centre in the Time https://www.instagram.com/partnersinhealth/ of the COVID-19 Pandemic, PowerPoint Presentation, International Nah, Seung-Hee; Osifo-Dawodu, Egbe. 2007. Establishing Private Union of Architects, June 2022, https://www.uia-architectes. Health Care Facilities in Developing Countries : A Guide for Medical Partners in Health, n.d. Maternal Center of Excellence, https://pih- org/wp-content/uploads/2022/06/Arc.-Fiifi-Y.-Sam-Awortwi- Entrepreneurs. WBI Development Studies;. © http://hdl.handle. canada.org/programs/maternal-center-excellence Presentation-.pdf net/10986/6600. Partners in Health, n.d.1. Sierra Leone, Maternal Center of Excellence, Franklin, D., 2012. How Hospital Gardens Help Patients Heal, Scientific NHS, 2009. Saving carbon, improving health: NHS carbon reduction https://www.pih.org/maternal-center-excellence American Magazine Vol. 306 No. 3, https://www.scientificamerican. strategy. National Health Service, Sustainable Development Unit, com/article/nature-that-nurtures/. https://www.england.nhs.uk/greenernhs/wp-content/uploads/ Prince Salman Center for Disability Research, 2010. Universal sites/51/2021/02/NHS-Carbon-Reduction-Strategy-2009.pdf. Accessibility Guidelines for the Kingdom of Saudi Arabia, http:// Stathaki E., 2022. Manuel Herz wins Senegal hospital project in v2.kscdr.org.sa/media/16933/uap-be-en.pdf Tambacounda, Wallpaper, October 2022, https://www.wallpaper. NBC News, 2018. Deadly landslides and flooding in Japan after com/architecture/manuel-herz-hospital-senegal torrential rains, July 2018, https://www.nbcnews.com/slideshow/ Prota, 2023. Prota Engineering, unpublished correspondence, deadly-landslides-flooding-japan-after-torrential-rains-n889716 December 2023 Studio 505, 2015. Ng Teng Fong General Hospital, https://www.stu- dio505.com.au/work/project/ng-teng-fong-general-hospital/62. NSW Government, 2018. Tweed Valley Hospital Development: Site Qu, Z., Wang, F., Chen, X., Wang, X. & Zhou, Z., 2023. Rapid report of html Selection. Final Summary Report. https://tweedvalleyhospital. seismic damage to hospitals in the 2023 Turkey earthquake sequences. health.nsw.gov.au/www_tweed/media/tweedvaley/20180424_ Earthquake Research Advances. 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Hospital Design Awards & Achievements, Ng Teng terminology/early-warning-system Fong General Hospital, https://www.ntfgh.com.sg/about-ntfgh/ Morris, R., 2021. New Dunedin Hospital: How the New Dunedin awards-and-achievements/hospital-design Hospital responds to the Cultural Impact Assessment. Resource 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 120 Resilient, Green, and Inclusive Health Facilities Guidance on Planning, Design, and Operation USAID, 2009. Energy Efficiency in Hospitals: Best Practice Guide. WHO, 1996. District Hospitals: Guidelines for Development, 2nd Edition. World Bank, 2023. Building Code Checklist for Green Buildings. https://www.beeindia.gov.in/sites/default/files/HospitalEnergy WHO Regional Office for the Western Pacific. https://iris.who.int/ https://www.gfdrr.org/en/publication/building-code-checklist- EfficiencyBestPracticesGuide.pdf handle/10665/206791 green-buildings US EPA, 2021. “Basic Information”. Green Building. 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U.S. Green Building Council, https://www. for Europe. https://iris.who.int/handle/10665/373930 usgbc.org/glossary Yamanouchi, S., Sasaki, H., et al. 2017. Survey of Preventable WHO, 2023a. Maternal mortality ratio (modeled estimate, per Disaster Deaths at Medical Institutions in Areas Affected by the Van Iperen, I.D., Maas J. and Spronk, P.E., 2023. Greenery and out- 100,000 live births) - Togo. WHO, UNICEF, UNFPA, World Bank Great East Japan Earthquake: Retrospective Survey of Medical door facilities to improve the wellbeing of critically ill patients, their Group, and UNDESA/Population Division. https://data.worldbank. Institutions in Miyagi Prefecture. Prehosp Disaster Medicine, Vol. families and caregivers: Things to consider. Intensive Care Medicine, org/indicator/SH.STA.MMRT?locations=TG 32, Issue 5, pp. 515–522.  Vol. 49, Issue 10. pp. 1229-1231. World Bank, 2021a. Green, Resilient, and Inclusive Wainwright O., 2021. Bauhaus in Africa: the hospital in sweltering Development, https://documents1.worldbank.org/curated/en/ Senegal inspired – and funded – by the Albers, The Guardian, November 285171633074966748/pdf/Green-Resilient-and-Inclusive- 2021, https://www.theguardian.com/artanddesign/2021/nov/11/ Development.pdf. bauhaus-africa-hospital-senegal-inspired-anni-josef-albers World Bank, 2021b. FRONTLINE: Preparing Health Care Systems WECD, 1987. Our common future: report of the world commission for Shocks from Disasters to Pandemics. https://documents1. on environment and development. https://sustainabledevelopment. worldbank.org/curated/en/932971618251523386/pdf/Frontline- un.org/content/documents/5987our-common-future.pdf. Preparing-Healthcare-Systems-for-Shocks-from-Disasters-to- Pandemics.pdf WHO, 2009. Healthy Hospitals, Healthy Planet, Healthy People: Addressing climate change in health care settings https://www. World Bank, 2022. Disability Inclusion and Accountability who.int/docs/default-source/climate-change/healthy-hospitals- Framework. https://documents1.worldbank.org/curated/en/ healthy-planet-healthy-people.pdf?sfvrsn=8b337cee_1 437451528442789278/pdf/126977-WP-PUBLIC-DisabilityInclu- sionAccountabilitydigital.pdf 1.0 INTRODUCTION 2.0 PLANNING 3.0 DESIGN 4.0 OPERATION 5.0 SUMMARY APPENDICES 121 Access to safe and affordable health services is essential for the well-being of people and the health of societies and economies. The impacts of climate change and environmental degradation are placing greater demands on health services by increasing the exposure of people around the world to extreme heat, water insecurity, poor air quality and communicable diseases. As investments are made in new health facilities and existing facility upgrades, it is critical that health facilities are designed to withstand shocks and stresses to support more resilient health systems. At the same time, there is a drive to reduce the carbon footprint of health facilities to meet climate mitigation targets as well as incorporate inclusive design approaches to meet the needs of all health care users, particularly underserved populations. Resilient, Green, and Inclusive Health Facilities: Guidance on Planning, Design, and Operation communicates key concepts, considerations and practical measures to support the delivery of resilient, green and inclusive health facilities. It is intended as a primer for policy makers, development partners, facility design professionals and health sector practitioners involved in the three key phases of the facility investment life cycle: planning, design and operation.