Professional Documents
Culture Documents
Introduction :
Hospitals account for 60-80 percent of the government expenditure for health facilities in developing countries (Barnum et al, 1992). The concern about the high costs of healthcare in light of scarce national resources has resulted in the close examination of the hospital sector of the health system. Construction of the Hospitals on the basis of well conceived plans is important, not only because of the large capital outlays involved but also because of the longterm cost implications associated with construction decisions. New health facilities absorb billions of dollars/rupees worth of resources each year in various countries. Avoidance of these (unsaved) costs can result in savings of as much as ten percent of annual health budget. The savings of this magnitude are more crucial in effective facility planning in developing countries with far more critical resource constraints. A careful design of the needed facilities to maximise efficiency and productivity can limit operating cost substantially.
Objectives
To find out the construction cost of the health facility per bed and to examine various aspects of planning and design considerations, constructional practices, and hospital economics that have been observed to create this hospital.
One of the major elements driving up the cost of health facilities construction is construction codes that lag behind the state of the art in the building trades.
Methodology
Average costing Technique has been adopted to compute the unit cost. The total costs of the facility was determined and devided in rational proportion among total number of beds-thereby deducing the cost of construction per bed. The unit cost has been worked out separately for construction work, equipment and housing facility.
y y y y
Hospital construction division Hospital Engineering department Import section Accounts section 02. Questionnaire (for key persons involved in the construction) 03. Interview with Hospital Administrators
04. Project report of the organisation 05. Annual report of the organisation
Observations
The construction of this 500 bedded tertiary Care teaching hospital started in 1975 and the hospital was commissioned in December 1982. The Polyclinic complex supported by 160 bedded complement provides primary ambulatory care. A bed complement of 28 speciality beds, distributed amongst various clinical disciplines provide the intermediate care to patients admitted through the Referral clinic. The Emergency department with 16 observation beds, fully equipped with resuscitation equipments, beside piped Oxygen and suction etc. provides acute care to the admitted patients. A 32 bedded emergency ward serves as a buffer between the Emergency and speciality beds. The intensive care unit with 14 beds provide post operative intensive care and coronary care to the critically ill has been provided with sophisticated equipment. A 16 bedded post operative ward is well equipped having resuscitation facilities with piped Oxygen and suction etc. The other facilities include Library, Seminar hall, Faculty rooms, Mortuary and Auditorium. The disciplines like cardiotheracic and vascular surgery, Cardiology, Neurosurgery, Neurology, Gasteroenterology, Urology, Pediatric Surgery, Plastic surgery, Neonantology, Endocrinology, Hematology, Medical and Surgical Oncology, Radiotherapy, Nuclear Medicine, Radiodiagnosis, Physical Medicine, Anaesthesiology, Medical Physical and Bioengineering, Pathology, Microbiology, Blood Transfusion and Immunohematology Biochemistry, clinical pharmacology and Hospital Administration have been developed as independent disciplines. A floor area of 3.50 lac square feet has been provided for the Main Hospital Block excluding housing and auditorium.
Subject/Title Architects fees Land compensation Site Development/Landscape Civil works Sanitary Installations Electric Installations Mechanical Works (including Air conditioning/ central heating, installation of Lifts etc.) Sewage Treatment Plant Water Treatment Plant Fire Alarm system
Amount in Rupees 5,663,033 7,598,629 6,141586 107,666,846 5,318,180 11,052,561 34,796,254 2,037,060 647,444 576,867
Miscellaneous Total
Most of the land was donated by the Government and some voluntary agencies.
962,634 177,362,914
a) Architects fees
220,030
Married Doctors Quarters 7,252,451 Officers Quarters Faculty Houses c) Sanitary Installations d) Electric Installations e) Miscellaneous works Total
Table 3 Breakup of equipment cost
S.No Speciality 01. 02. 03. 04. 05. 06. 07. 08. 09.
Cardiotheracic & VascularSurgery 2,830,000 Neurosurgery General surgery Pediatric surgery Plastic surgery Gastronterology Nephrology Neonatology Neurology 2,460,000 701,000 2,183,000 110,000 1,696,000 1,965,000 1,781,000 440,000
10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29.
Urology General Medicine Cardiology Physiotherapy Blood Bank Pharmacology Pathology Immunology Biochemistry Hematology Microbiology Radio diagnosis Nuclear Medicine Radio therapy Med. Physics & Bio- engineering Anesthesiology Intensive care unit Operation theaters Inpatient areas (wards) CSSD, Laundry & Dietetics (60,000+70,000,000+15,00,000) Total
982,000 127,000 5,396,000 362,000 723,000 702,000 678,000 689,000 122,000 1,777,000 1,004,000 1,257,000 3,922,000 1,827,000 25,000 1,430,000 5,120,000 400,000 1,500,000 145,000,000 186,477,000
Discussion
Constructional Practices Civil Works
The buildings are R.C.C. framed structures ranging from single-storeyed Referal Clinic to seven storeyed ward block, Keeping in view the severe climatic conditions of the region emphasis has been laid on the construction of the buildings so as to provide for the most economical heating arrangements. This has been in the form of hollow clay brick walls on the external skin of the buildings. The roof and floors also have hollow cement concrete blocks used in conjuction with R.C.C. ribs and slabs, to avoid heat loss.
In order to save on the maintenance costs. Kota stone flooring has been provided, in all the public areas. The external finish is of exposed grit finish which requires minimum maintenance. Emphasis has been laid on the utilisation of locally available materials from the local industries (Joinery Mill, Brick & Tile Factory). Adequate space has been provided for ducting passages which cater to all the needs of the services such as electric and public heath installations, central heating and medical gases and suction.
Electric Installations
Whereas electricity is being made available by the local government, but at the same time in view of the frequent power failures, provision has been made for 2x300 KVA standby diesel generating sets (to ensure uninterrupted power supply). which are used in the case of emergency. These generators cater to the needs of the operation theaters, lifts and other essential areas. Stabilisors have been provided to take care of frequent voltage and frequencey problems. The system of conduction has been evolved in such a manner that electric throughs have been introduced in the floor systems at regular intervals which entail lot of savings in as far as the electric fixtures are concerned.
Central Heating
In view of the climatic conditions, provision has been made for central heating on the basis of cost benefit studies and suitability.
Air Conditioning
The Operation theater block is fully air-conditioned which conform to the latest trends of air changes, temperature and humidity control and provides Saminar ventilation (air flow) in the operating rooms. ICU, emergency department, other therapeutic and investigating departments also have this facility. The system has been designed at -10C Ambient temperature to give 21 - 23C inside temperature.
accomodation has been provided to house the nurses, house surgeons and post graduate students who have to perform round the clock duties in the hospital. The total expenditure on housing is Rupees 59,046,584 (Table 2).
Equipment
The hospital is providing referral care of the highest order and has been equipped with sophisticated equipment for the diagnostic and treatment of the rarest of the disease. The total expenditure on the equipment is Rupees 186,477,000 (table 3).
Support Services
The services like CSSD, Laundry and Linen, Dietary Service, Boiler House, Electric Substation Medical Gas section, medical and general stores supply service etc. (directed towards the development of replenishment system within the hospital) contribute towards the effectiveness of patient care. A greatemphasis has been laid on the optimum performance of this supply line and the repair and maintenance of equipment in the design of the institute. Ground floor of the ward block houses the support and utility services, which during working hours reaches out to patient care areas to top up their supplies through an efficient communication link between them.
Hospital Economics
While developing the investigative, operating sterilisation, laundry, dietetics and other such Services, a very careful analysis of the workload in relation to patients needs has been made and the layout planning of these services has been done to satisfy the total needs of the hospital. All the investigative, therapeutic, support and utility service departments have been thoroughly investigated in terms of their scope of work before physical designs have been prepared. The physical plans of this health facility have been so structured over the functional system that the design goes well with quality of service and the economy and promptness at which it can be rendered.
Sign Posting
The hospital building has been designed as a definite system with 300 feet corridor serving as a spine. All the departments emerge out of this spine as ribs. This helps in locating any of the hospital unit from the corridor through scientific sign posting.
Conclusion
Going by the survey conducted in some developed economics (Table 4) it appears that the construction cost per bed 28,166 USD (1985) is much less as compaved to construction cost of US teaching hospital 250,000 USD (1975), keeping in view the escalation (increase in costs) by at least ten percent per year.
Table 4
Illustrative construction costs*
Year Location-Type 1975 U.S., 100 bedded 1975 US, 400 bedded
250,000 1975 US, teaching hosp 105,000 1980 US, 200 bedded 25,000 1975 Singapore
375,000 1975 Abu Dhabi 290,000 1981 Saudi Arabia 19,000 1986 Malawi
(Costs are estimated to have increased by at least ten percent per year since the survey done in 1975) * Courtesy : Timothy D.Baker. Planning Health Facilities.
Alternatives
Planner should be familiar with the new techniques in hospital architecture such as:
y y y y y
The computer design for similar health facilities the "fast track" system for initiating construction before design is complete (to prevent increased construction costs from inflation). the use of interstitial floors to provide easier access for the various services such as water and electricity. The use of traffic models for hospital design, and the use of flexible designs with open options for expansion or change of facilities. Hospital administrators should be called on to make estimates of the saving in personnel and materials through the use of new systems in comparison to old systems before reaching decisions as to whether to continue with the old system, to renovate, or to build a new. Master planners must take a comprehensive view of the rapid changes that are occuring in most developing countries. They must build for the future, not the past, anticipating world side trends, such as urbanisation, and plan for facilities to meet these major trends.
References
1. 2. 3. 4. Barnum H, Kutzin J. Public Hospital in Developing Countries : Resources, Use, Costs, Financing. The World Bank, Baltimore : John Hopkins University Press, 1992. Dodge building cost calculator and evaluation Guide, New York : Macgraw-Hill Information system co. Godfrey, R.S. (ed). Building Construction Costs Data, Kingston, MA : R.S. Means co; Inc. Project Report, Institute of Medical Sciences, 1975.
* Sr. Consultant and Administrator, S.K. Institute of Medical Sciences, Srinagar - 190011. ** Professor, Deptt. of Hospital Administration S.K. Institute of Medical Sciences Srinagar-190011.