Kolandoto Healthy Hospital
During 2015 - 2017 a collaboration between Kolandoto Hospital in Tanzania and the Swedish NGOs Involvaid, Engineers Without Borders and Architects Without Borders resulted in hospital infrastructure improvements worth 963 000 SEK. All implementations were chosen by the hospital management team with the intention of decreasing morbidity and mortality of patients at the Kolandoto Hospital in the Shinyanga Region. 8 master theses were written by 14 master students from Chalmers University of Technology. The students spent two months each at Kolandoto Hospital. The project included professional visits by nurses, architects, civil engineers and electrical engineers who provided professional support in the planning and procurement of infrastructure improvements. As a first step a hospital masterplan was created by Kolandoto Hospital with the assistance of a Swedish architect to make sure that subsequent implementations followed the overall development plans of the Kolandoto Hospital. After this first step major project implementations were: increased water availability and improved water quality, stabilized and solar assisted electricity supply, and construction of an emergency department and the creation of a mass casualty plan. The primary objective of the project was the reduction of morbidity and mortality in the Shinyanga region. Secondary objectives were learning outcomes for the organizations and people involved in the project.
Access to health care is both a human right and a humanitarian issue. Investing in health care has direct positive consequences for beneficiaries, but the investments need to be made in a way that ensures long-term operation. The Kolandoto Hospital has been cooperating with NGOs and foreign aid organisations for many decades, and the track record of successful and sustained projects shows the broad competence of the management team of Kolandoto Hospital. The management team has juggled finances from aid organisations, patient fees, church organisations and state funds in a manner that has enabled the hospital to develop and increase the access to health care for a significant portion of the Shinyanga residents as well as the rest of Tanzania. One of the organisations with which Kolandoto Hospital has been collaborating for a more extended period is Involvaid (former I Aid Africa). The Kolandoto Healthy Hospital Project was created as a collaboration between Kolandoto Hospital, Involvaid, Engineers Without Borders and Architects Without Borders in 2014. Involvaid, Engineers Without Borders and Architects Without Borders are smaller Swedish aid NGOs without large donor support and volunteers do all work.
The motivation for working voluntarily in these aid organisations vary but we have often agreed on the following key components of our motivation:
• Healthcare is a humanitarian issue and will have a direct impact on people’s lives.
• We want to learn from and see if we can overcome challenges of long-term foreign aid projects. We had some principles which we tried to follow throughout the project:
• Decisions on investments were to be made by the hospital management team.
• Ownership of the physical implementations should be ensured by the decision-making process and by co-financing by Kolandoto Hospital.
• By not leading the physical implementation projects but instead support the Kolandoto Hospital in the procurement of local construction agents we wanted to make sure that maintenance and system upgrades were easily made after the end of the project.
• We wanted to be present for a long time to develop a cultural and contextual understanding as a base for project implementations, as well as developing good relations over the years.
DESIGNS AND IMPLEMENTATIONS
Phase I - 2015
Eye clinic design
Water pump installation
Maternity theatre design and construction
Phase II - 2016
Solar cells and UPS installation
X-ray entrance construction
Waste zone construction
Emergency department design
Phase III - 2017
Emergency department construction and training
Private and maternity ward design
Phase I: Masterplan design
Decades of aid dependent growth has led to inefficient logistical flows of patients, staff, material and air throughout the hospital site which create risks of medical errors, harmful service delays and cause infections.
A masterplan was developed based on numerous design iterations with hospital management and staff to guide the development of the built environment. The masterplan supports the access to appropriate healthcare in a healing environment free from factors causing illness or injuries. It defines the next 10 larger building projects and the sites for them. It also clarifies good medical zoning and flows to make the hospital site safer and easier to navigate.
The masterplan was created to give the hospital management team increased possibilities to control the development of the hospital. The first two identified building projects were completed during phase III and are in use. One more building project has been designed but not built.
Phase I: Water pump installation
One of the main problems that the hospital management brought up in the beginning of the project was a shortage of water. There was one existing borehole with an old pump with poor capacity that provided water to the whole hospital, the nearby nursing college, and the Kolandoto village. The pump broke down often which resulted in times when there was even less available water for the hospital. The shortage of water made it difficult for the hospital to uphold appropriate and safe hygiene standards. It also resulted in shortage of quality drinking water for the inhabitants of Kolandoto as a whole, posing a considerable health risk.
After the pump testing and mapping of the current water system a submersible water pump was bought and installed in the existing borehole. The process was undertaken in close collaboration with the water team of Kolandoto and the hospital management team. A local engineering company was hired to install the pump. The new water pump has doubled the availability of water and reduced the health risks due to shortages of safe drinking water.
Phase I: Maternity theatre design and construction
The existing operating theatre for c-sections at the maternity department was not in use in 2015 due to that the hospital could not guarantee the needed hygienic conditions for performing safe c-sections. The building lacked a place for changing clothes, scrubbing before surgery, and cleaning of used equipment and linen. Instead, pregnant mothers who were in need of emergency c-sections had to be transported out of the maternity building, along an outdoor path to go into the general operating theatre, and wait if another surgery was on-going.
A maternity building extension to counteract these problems was designed and constructed by a Swedish project team member together with hospital staff and local craftsmen. Since completion the extension has been in use on and off. For example, during the beginning of 2016 the maternity theatre was not in use due to missing spare parts for previously donated Swedish medical equipment.
Phase I: Eye clinic design
The eye department used to consist of two buildings – the operating theatre building and one building for both the ward for inpatients and the clinic for outpatients. The outpatient clinic was small and crowded which resulted in poor patient privacy as well as a risk of transmission of infections. Kolandoto Hospital had at the time already in mind to construct a new building for the eye clinic. A design proposal from a local firm had been made, but the design was too large for the available sites.
Assistance was provided in both writing a funding application to send to a German NGO, and with making a new design proposal adapted to the site and spatial needs expressed by staff. The proposal was a clear, calm and comfortable building design based on building techniques adapted to the local climate.
Two years later, in 2017, the Kolandoto Hospital received funding for the building and hired a local contractor to build it.
Phase II: Solar cells and UPS installation
One larger problem at Kolandoto Hospital were the frequent power cuts which led to medical hazards at the three operating theatres. Installing an UPS-system (Uninterruptible Power Supply) would prevent power cuts mid-surgery; an UPS is working as an instant back-up system for electricity.
Three separate UPS-systems with feeding solar cells were installed in the eye theatre, general theatre and in the maternity theatre. The solar power does not only work as a power bank for the UPS but also as an asset for lowering the cost of electricity. Each individual UPS was therefore also dimensioned for future expansion.
Power cuts during surgery dropped from approximately two to zero times per week. Furthermore, the hospital electricity bill also reduced by approximately 50%. This cost reduction was well received by the Kolandoto Hospital since the hospital economically operate at the margin, and even have challenges in paying staff salaries. In 2018 the Kolandoto management team specifically asked if it was possible to further increase the solar electricity capacity.
Phase II: Dosatron installation
When the water pump was installed during phase I, a water quality test was conducted. The test showed the presence of e. coli in the water. E. coli is an indicator of faecal contamination which can cause water related disease outbreaks and health hazards for the weaker individuals who are staying at the Kolandoto Hospital and in the Kolandoto Village.
A dosatron which adds an adjustable dosage of chlorine was installed to disinfect the water. Trainings were provided for the Kolandoto technical team to operate and run the dosatron. The same company that installed the water pump and the UPS and solar electricity system was hired for the installation to ensure that the hospital easily could receive technical support if needed.
Phase II: Waste zone construction
The waste zone had deteriorated because of a lack of funding and the need to prioritize more central hospital functions. While the waste zone itself is not an immediate health risk for the patients, a functioning waste system is. It is much easier to implement proper infection control if the hospital waste zone is working well. In addition, the staff concerned with handling waste are exposed to health risks if the waste zone is not safe to operate.
As a minor project implementation, the waste zone was given a new roof and new tools were purchased for safe separation and management of waste fractions.
Phase II: X-ray entrance construction
The masterplan identified the emergency department as the second larger building project to be made. To provide proper emergency department services a functioning x-ray and imaging department is key. The masterplan identified that the flows in between the site for the emergency department and x-ray department had to be simplified to not cause dangerous delays in the care. In addition, the door to the x-ray department was too small for stretchers to come through, which resulted in patients being dangerously carried on mattresses instead.
A reorganization and primarily a new entrance situation to the x-ray department was designed together with staff. A new waiting area, a new wide entrance door, and a new reception window was constructed and installed. The entrance to the x-ray department is now located in close connection to the emergency department and the general operating theatre which makes it easily accessible. The waiting area is outside with solar shading to make it comfortable. The door to the room with the x-ray machine is wide enough for injured patients to be safely transported on a stretcher.
PHASE II: Emergency department design
Kolandoto Hospital did previously not officially provide emergency health care, although there was a need for it and patients did arrive at the hospital in a state of emergency. The emergency flow of patients was undefined, inefficient, and caused dangerous delays in providing critically ill patients with care. To build an emergency department was the second large building project in the masterplan. In addition, having an emergency department is one criteria of fully becoming a ‘Council Designated Hospital’, which is an official type of hospital receiving certain government funds.
A design proposal for a new emergency department building was developed through a design process that focused on participative methods to generate the best ideas adapted to local health care requirements and the local culture.
Since the design proposal was made as part of an architectural master thesis it became a bit too large and difficult to construct. After the thesis was finished the building design was simplified and made smaller and more economically realistic.
PHASE III: Emergency department construction and training
In addition to the spatial and physical needs to provide emergency care, the hospital staff was not trained in emergency care and there was no mass casualty plan in place.
A procurement process was carried out by the hospital management assisted by the Swedish engineering students, to find a suitable local contractor to construct the building. A contractor was selected, who then constructed the building in six months. In addition to the construction of the emergency department, simple Swedish medical equipment, such as stretchers and trolleys, were sent to equip the emergency department. To provide capacity building for the staff a series of meetings, workshops and mass casualty trainings was conducted.
Kolandoto Hospital emergency department is the first in the region. Two years prior to the construction, meetings were held with regional medical officers to anchor the plan of building an emergency department at Kolandoto with mass casualty capacity. A learning outcome was that construction errors can be avoided by having a physical 3D model available for the contractors and workers at the construction site.
PHASE III: Private and maternity ward design
The third large building project identified in the masterplan was the private ward and maternity ward. The current maternity ward does not have enough capacity as it shares the building with the private ward. The congestion of inpatients poses a risk of transmission of diseases and infections. With an increasing number of patients coming to give birth at the hospital for free, it is even more needed to expand the facilities. At the same time there is a growing demand for private care. Constructing a new private ward with higher standards in terms of sanitary facilities and single/double patient rooms is therefore an income opportunity for the hospital since patients seeking private care pay more.
Design proposals for a new private ward and maternity ward was made in close collaboration with both staff and patients. The private ward is designed to resemble a village with smaller houses. In the proposal the maternity ward is extended to occupy the whole existing building. A new extension is included to accommodate mostly single/double patient rooms. The outdoor spaces are designed to provide social and healing spaces.
Kolandoto Hospital has a sister hospital called Mkula Hospital. It faces similar challenges of shortages of water and electricity as Kolandoto Hospital did at the start of this project. A first survey of Mkula Hospital was made in 2017, and is a first base for a new project there during 2018 and 2019.