SPECIAL REPORT: Big dreams for the Aga Khan Hospital in Dar es Salaam

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Sunday, 07 October 2012 00:15

Tom Payette (centre) and Mark Careaga (right) with a member of the board of directors of The Aga Khan Health Services (AKHST) in a recent visit to Tanzania. PHOTO | ZACHARIA OSANGA By The Citizen Reporter Dar es Salaam. The Aga Khan Health Services Tanzania (AKHST) has embarked on an ambitious multibillion-shilling expansion programme that will see it offer high-quality medical care and increase its capacity as a teaching institute within the Aga Khan Development Network (AKDN).The Aga Khan Hospital, located at the corner of Ocean Road and Ufukoni Road, is a constituency of the AKHST and is set to be the largest beneficiary of the $55million (Sh86.5billion) growth drive that will see the addition of new buildings and facilities for treatment and training. Established in 1964 the hospital is renowned for the quality of its services. The hospital is also a postgraduate teaching centre with 20 to 25 residencies in various branches of medicine and in 2003 it was awarded ISO certification for offering world-class clinical, diagnostic, administrative and support services. AKHST is part of a group of agencies collectively known as the Aga Khan Development Network (AKDN). Its mandate stretches the gamut, from healthcare and education to architecture, microfinance, rural development and disaster management. Part of the network’s healthcare ambitions involve expanding the Aga Khan Hospital to keep pace with growing demand for high-quality medical care, particularly tertiary services that are not readily available in Tanzania. The hospital has also been earmarked as a future training hospital within AKDN’s system of medical, nursing and allied health education. This Phase Two expansion strategy involves the construction of a new, 10,000 square meters building that will connect to the current structure at Ocean Road. Phase Two will consolidate and expand many of the significant inpatient functions in a new facility, taking the current 74-bed hospital to 150 total beds. Under the plan the hospital will eventually host a comprehensive cardiology programme which will include facilities for catheterization and cardiac surgery. The institute will also host a cancer programme that will include chemotherapy treatment and advanced cancer surgeries. The Sh86.5billion wing will also be the home of new surgical suites; a new diagnostic imaging suite that will include an MRI machine, a CT scanner, and a nuclear medicine suite (which is essential for mapping out cardiac function) as well as facilities for general radiography, fluoroscopy, and ultrasound. A few more projects are also in the works including plans for a new intensive care facility that will include cardiothoracic, surgical, medical, and neonatal intensive care rooms; and a new labour and delivery suite complete with private paediatric and maternity beds. Much of the focus of Phase II is to support a new cardiac program at the Aga Khan Hospital and to strengthen the hospital’s existing paediatric and maternity programmes. The AKHS also recently announced its intention to expand it coverage in Tanzania from the present five primary health care centres to 30 over the next five years. We feature below an interview with project consultants Payette Associates who are represented by Mark Careaga, AIA Associate Principal. Mark Careaga and Tom Payette, Payette’s Principal, recently visited Tanzania for discussions with the Board of Directors of The Aga Khan Health Services Tanzania and with senior representatives of the Aga Khan Development Network. Q: Payette was established in 1960 when the orientation towards innovative health care design was relatively nascent. How did you manage to inculcate a culture of design philosophy fused with innovative processes in the health care design centred on the experience of the patient? A: Our innovative, human-centred approach to healthcare design has its roots in Fred Markus and Paul Nocka. Fred and Paul were very interested in how hospitals function and they used time-and-motion studies and extensive first-hand observations to develop a detailed understanding of how hospitals work and how they could be made to work better. (Founding partner) Tom Payette’s mantra has always been, “architecture is for people, not for the gratification of the architect.” This outlook naturally led to a design philosophy that places an emphasis on the human experience even within the highly technical and demanding environments of hospitals. Q: Payette is one of the world’s leading architectural firms in health care design matching the challenges and complexities of design in your projects with innovative and sustainable built environments. How do you achieve this? A: A lot of our success has to do with our culture as a firm. We maintain a singular office in Boston, Massachusetts in the United States and this allows us to practice as a think tank, cultivating young talent and allowing the accumulated wisdom of our collective intelligence to permeate projects throughout the office. Our firm’s culture sets excellence as the standard by which we measure our work. We are constantly looking for new and better ways of solving the various problems we encounter through the design process. I think a lot of our innovativeness is a result of this open, inquisitive firm culture. The sustainable dimension of our work is deep-seated and has roots in our human-centred approach to design. Q: Payette has been notably associated with the use of research in healthcare design, a practice that is changing the way healthcare facilities and indeed other building types are designed. What are your thoughts on this? A: Evidence-based design (EBD) is a relatively recent field that is doing some excellent work in identifying spatial configurations that are directly linked to improved clinical outcomes. Essentially, EBD applies the rigors of the scientific method to techniques of performance evaluation that architects have used for decades, such as post-occupancy surveys. In our work we combine detailed first-hand observations of how existing facilities are configured and operated with our long-term experience with what has been successful. Our research is an on-going evolving project that builds on the collective body of our work. Q: The Aga Khan University (AKU) Karachi Hospital, Medical College and School of Nursing was one of your first projects outside the United States. AKU was lauded as a benchmark for responsible development in the region. How did you achieve this? A: A lot of the credit for the success of this first project should be attributed to His Highness the Aga Khan who is a highly educated patron and an astute critic of architecture. One of the first things Tom and his core team did at the outset of the project was at His Highness’ direction, undertook a six-week tour of historic Islamic architecture in Spain, North Africa, Persia, and South Asia. From these first-hand observations the team came to realize that truly sustainable architecture lies at the intersection of climate and culture. By seeking a building form that reflects history and local patterns of inhabitation, the design team adapted traditional methods of building that are fundamentally sustainable: roof forms and portals that help channel prevailing breezes, veranda walkways that are shaded and which filter the harsh Karachi sunlight with terracotta block screens, and lushly-planted courtyards that mitigate the local microclimate. Q: What is your experience with health care design in East Africa or elsewhere on the continent? A: Africa is relatively new for us, though Tom Payette did some consulting for the Aga Khan Hospital in Nairobi in the 1970s. We have been working with the Aga Khan University Hospital in Nairobi since 2009, starting with master-planning that campus. We are currently designing a medical office building for AKU Nairobi that will start off as a temporary home for their new Faculty of Health Sciences (School of Medicine and School of Nursing). Q: The Aga Khan Hospital Dar es Salaam Phase II, with a preliminary budget of over $50 million, is the single largest private health care project in the country’s history. How did you come to be associated with the project? A: Since 2009 we have been engaged in master-planning and conceptual design work for the Aga Khan University Hospital in Nairobi. In 2010 we were informed that His Highness has approved our appointment for similar work in Dar es Salaam. This marked the beginning of a broader engagement in projects for the Aga Khan Development Network (AKDN), beyond the original hospital project in Karachi. Q: This is Payette’s first major assignment in Tanzania. Can you tell us the scale of the project and what you expect it to cost? What type of building are you doing and when it will be done? A: The Aga Khan Hospital in Dar es Salaam is currently a 74-bed secondary hospital on a relatively small site. An effective teaching hospital needs to be something on the order of 300 beds at a minimum in order to offer the range of tertiary-level medical and surgical specialties that are needed to support post-graduate medical education residency programs. Our current project is an important first step. Another key factor is the age of the hospital’s facilities. The original hospital building is from the 1950s and it cannot keep pace with the changes in medical technology and their associated needs for space and infrastructure. The building needs to be replaced by a modern facility that can carry the Aga Khan Hospital into, say, the next 50 years. Phase Two projects are designed to take over the bulk of the hospital’s functions. We will be able to shift lower-intensity functions, such as consulting clinics and offices, to the old hospital building which will facilitate its eventual demolition in future phases of expansion and redevelopment. So Phase Two expansion will involve the building of a 10,000 square metre premise that connects to the current Phase 1 structure which will improve many of the hospital’s inpatient functions. Q: What would you highlight as your client’s key vision and objectives for this project? A: His Highness the Aga Khan has taken a personal interest in this project and is keen to see it move forward quickly. He has expressed a desire that the quality of the facilities and the services provided keep pace with the best international institutions including the Aga Khan University hospitals in Nairobi and in Karachi. His Highness is also interested in having facilities that attract and retain high-quality physicians and staff. Q: Can you share with us aspects of the design philosophy and morphology of Phase II? What are some of the key distinctive architectural features of the project? A: We are at the very early stages of planning and design so it’s a little too early to answer these questions. That said we do have some ideas about how the building will appear. Since we are building from the current Phase 1 building on Ocean Road we anticipate a similar design attitude with horizontal visual cues that come from the use of projecting balconies which provide a place to enjoy the view as well as shade from the heat and the sun. Passive sun-shading is important to reduce the building’s energy footprint and to minimize glare and discomfort for the occupants. We also envision a strong, unifying roof form so that when viewed from a distance, the hospital is seen as an ensemble of fairly small pavilions with a lively roof-scape. Q: Hospital design is a complex humanistic process. How have you ensured in this environment that people, process and place come together to create a paradigm for defining the patient’s experience? A: This is one of the constant challenges of architecture and design especially in healthcare. Since we embrace a fundamentally humanistic approach to design, it comes somewhat naturally though it does require constant focus.  In the case of the Aga Khan Hospital in Dar we had some early, rather obvious, observations about what makes this place special, such as the location overlooking the ocean. What a wonderful amenity for those who are sick and for their families! So we started with that, using views of the ocean as a touchstone for the patient and visitor experience. Everything revolves around that. Q: How do you approach your work here and what are some of the key challenges you foresee? A: Distance is one of the key challenges we always face in our work for the AKDN, given that we are based in Boston, Massachusetts, in the United States. Advances in communications technology over the past decade have helped overcome this challenge in many respects, but there is still no substitute for meeting face-to-face. So I envision that we will be in Dar pretty regularly as design and construction progresses. Another key challenge is the process of translating design intent to the local construction market, in terms of available materials and products, workmanship, construction techniques, and other things. We are looking to assemble a team that includes a strong local component, which will be essential for this process of translation. Q: Based on your knowledge of health care design, what advice would you give to the local architectural fraternity? A: I feel fortunate that during our recent visit to Dar, we had an opportunity to visit B. J. Amuli’s Kariakoo Market building, which I learned about after discovering ANZA Magazine last year. I think American architects have as much to learn from Tanzanian architects as the other way around. I think the best advice we can offer is for architects everywhere to stay focused on what is really important: the experience of those for whom we are designing and building. Holistic and integrated built environments will emerge if we approach design in a holistic way, keeping all aspects of the problem—functional, environmental, technical, experiential—in play and developing them simultaneously. Nothing should be an add-on and the emphasis should be on experience without sacrificing the other aspects. Q: Do you expect to collaborate with local consultants on this assignment or even consider building local capacity in this highly specialized area of healthcare design?  If so, how would you expect to accomplish this? A: Yes, we fully expect to collaborate with the local construction industry whether they be designers, builders or suppliers. Our first goal on behalf of our client is to get the project designed and built within the context what we can. We will require strong interaction with the local industry to be able to accomplish that task. We trust that in doing so, this interaction will lead to capacity building locally. We have started the process of meeting some members of the local design and building industry; assembling the team is a work in progress that will take a number of months to accomplish. Q: Based on your experiences in developed markets what would you suggest government does to embrace integrated health care design as a tool for building a healthy community? A: I am not sure we are in a position to offer advice to the government given that we are newcomers to Tanzania. As a general rule, healthcare in developing countries starts with treatment of diseases, usually infectious diseases, and eventually progresses to preventative medicine that starts outside the hospital. And this evolution usually tracks with a corresponding evolution in economic development and improvements to urban infrastructure, such as sanitary sewer systems and clean water supply, both of which have a direct impact on the health of the populace. So government can play a strong positive role in the health of its citizens by investing not only in hospitals and clinics but also in infrastructure by enacting and enforcing codes and standards that provide safe buildings and by implementing public health initiatives related to safe food and clean water.