Mapping New Healthcare Infrastructure After Genocide
In July 1994, the Great Lakes region in Central Africa was in tatters as mass genocide marred the land. “No people, no nation” was a common call; the Tutsis who represent 14% of the region’s population were deemed worthy of death by the government.
Of survivors, widows and orphans were traumatized. Repatriates and refugees became disoriented. As for the nation’s civic infrastructure, there were no markets, no food, no hospitals, and no schools.
From the days of horrific tragedies to the present, pieces of the broken country had to be rebuilt by this shattered, vulnerable society.
As a result, epidemics in the form of HIV/AIDS, meningitis, tuberculosis, measles, malaria, and malnutrition, among others, led to decades of unimaginably high child mortality rates and low life expectancies throughout the region. Inadequate healthcare coverage and poor health system performance resulted in the deaths of nearly 9 million children under the age of five each year.
The most devastating, yet at the same time promising, fact is that the primary causes of these diseases and deaths are now preventable. The World Health Organization (WHO) stated that even though the health resource base has been steadily climbing for decades, mainly in developed areas of the world, “The health sector remains massively under-resourced in far too many countries.”
For instance, for every 1,000 people living in Central Africa, there is one doctor. Despite ample resources in the developing world, the WHO calls the international response to struggling nations “inadequate and naïve,” not to mention “too little, too late” or “too much in the wrong place.”
Last year, both the Healthcare Initiative in The Design School and the College of Nursing and Health Innovation at Arizona State University had the incredible opportunity to offer students a traveling design studio experience focused on addressing some of the critical health and wellness issues facing people in the Great Lakes region of Central Africa, specifically child mortality.
Led by professors James Shraiky and Gerri Lamb, this traveling studio utilized the skills and expertise of an eager, multidisciplinary team of 12 students from architecture, landscape architecture, healthcare innovation, social sciences, and design research.
During fieldwork in Rwanda, as well as back on campus in Tempe, Arizona, students worked tirelessly to propose the design of a new multifunctional clinical facility, plan a healthcare campus, develop a comprehensive site plan template, create a suitable and sustainable landscape program, and conceptualize an effective and efficient healthcare delivery model.
As the program for this research experience is highly uncommon in today’s academia, so, too, was it unique and exciting for all participants. The unusual class structure united students from varied academic disciplines to collaborate in an effort to solve a healthcare problem from a design research perspective while under the direction of two professors with distinct backgrounds: one a nurse scientist and the other a design researcher.
Team members arrived to the first day of class worlds apart in perspective and focus. The following represents the diverse ways of thinking, processing, and understanding that they brought to this project.
Healthcare innovation and nursing
Arriving in a design studio for the first time, the healthcare and nursing students did not know what to expect. In accordance with traditional healthcare environments, they anticipated structured schedules; pre-set, incremental semester plan rollouts; and innovative uses of technology, not only for all presentations and renderings, but also in the documentation of the healthcare system design.
Online collaboration and discovery is the natural mode of study for this group of students. They assumed that classwork and teamwork would be performed during daylight hours. A patient-centered, holistic focus is foundational to this group.
On the first day, the term “pin-up” conjured up thoughts of colored photos of women. The suggestion that the class spend time doing pin-ups had them frozen in their chairs in confusion, wondering what sort of world they entered.
Most of them were full-time graduate students and had full-time jobs. Being that they are so highly structured, timing of class projects was considered mandatory in order to accomplish the goals of this class.
Architecture and landscape architecture
A holistic approach is fundamental to these groups, as well, but from a different perspective. Their architecture and landscape architecture academic roots were well-established in design studio settings, which appeared to be an advantage from the beginning in that an orientation to a new learning methodology was not required.
This group valued a flexible, creativity-based approach over a structured environment with reports and hard timelines. All were full-time students with part-time jobs whose best work was often produced between midnight and 4 a.m.
Architects and designers learn and communicate visually. As such, pin-ups are common to the practice, and the students often utilized them in formal presentations as well as casual conversations. Three-dimensional miniature models of structures are as natural to these students as laboratory specimen tubes and syringes are to the healthcare innovation group.
Their conversations centered on functionality of design, accessibility to materials, holistic concepts of air flow and seasonal lighting patterns, and the relationship of Rwandan rural family lifestyle characteristics to the necessary components of a functional healthcare facility.
Social innovation and design research
These students added yet another component to the complexity of this interdisciplinary team. The importance of multiple data collection methods, accurate and extensive documentation of data, unlimited investigation, and tireless striving toward the perfection of the final documented recommendations of this study drove their efforts.
The students also had jobs outside of their academic commitments, but were somewhat familiar with the design studio environment and therefore served as a bridge for communication and translation between the other two extremely diverse groups.
Their investigative nature and structure connected them to the healthcare innovation group. Their familiarity and ease with design perspectives related directly to the big-picture, holistic view of people and how they interact with design and physical structures, which the architecture students hold so dear.
The students also added the facets of family member roles and how historical cultural impacts on the current Rwandan society should factor into the final design and recommendations.
Introductions and ice breakers opened the kickoff discussion for the class. Instructors asked students about their academic background relating to the project, their motivation to participate, and what they hoped to accomplish. They led the group of varied and unique individuals through a brainstorming session to begin to identify pre-travel research, using the instructors’ preliminary research as a launching point.
The team determined probable stakeholders using mind-mapping to facilitate the identification of relationships and themes. This, in turn, led to the development of a tentative schedule of research activities to occur during the 11-day Rwanda trip.
The research identified government agencies, families, healthcare professionals—both urban a
nd rural, mental health workers, and indigenous healers—as key stakeholders in the Rwandan healthcare system. At the end of the trip, the team organized a charrette with the stakeholders to present their findings and validate the collected data.
The professors conducted literature reviews on the health and wellness needs of children in Central Africa for more than a year prior to the beginning of this course. For the first three weeks of class, during the travel prep period, students conducted their own literature reviews on the same topic but each through the lens of their perspective disciplines.
After synthesizing the instructors’ research with the students’ research, the collective team developed a methodology based on the following hypothesis: High child mortality rates can be greatly reduced in the Great Lakes region of Africa through the development of a self-sustaining and culturally adaptable mobile medical clinic that delivers healthcare and healthcare training for the community.
To test this hypothesis in the field, the team generated a series of design questions to assess the current healthcare system. Questions sought to define the availability of and access to healthcare, the barriers to receiving it, and who is most affected by the lack of resources. Additional questions looked to identify where the delivery of healthcare occurs, and the level of public awareness of healthcare treatment and the causes of serious health problems.
In Rwanda, students and instructors divided into interdisciplinary teams to collect data. Data collection occurred through stakeholder observation, shadowing, storytelling, and interviews. It was recorded through field notes, photos, videos, and audio recordings. Research teams visited various locations, including nursing schools, non-governmental organizations (NGOs), medical schools, the Ministry of Health, rural community health workers’ homes, villages, urban and rural hospitals, the Rwanda Development Board, and a refugee camp.
Upon return to the United States, data processing took center stage and was painstakingly carried out. The research and social innovation students took the lead of this process by transcribing all notes to assure accuracy and verify sources.
The revised problem statement
After synthesizing and reviewing all data collected, the research team concluded that the original hypothesis did not fully address the high-priority health and wellness needs for children in central Africa. Though lack of access to adequate healthcare facilities and technologies affects public health in Rwanda, the research pointed to even greater gaps in wellness, prevention, and health education for the community.
Based on these findings, the team developed a new hypothesis, which focuses on education and awareness for both healthcare providers and patients on healthcare accessibility.
The preliminary literature reviews, field work in Rwanda, and data analysis uncovered underlying and unified themes that are critical to the success of future design interventions. The team concluded that the design solutions must facilitate community engagement, be designed for flexibility and adaptability, support existing infrastructure, incorporate technology, and focus on prevention, detection, and referral.
Utilizing the design themes to support the revised hypothesis, the team established three final design solutions. The first solution focuses on the region’s overall healthcare system, the second on a campus scale, and the third on a specific clinical environment. The students divided into three interdisciplinary teams, each tasked to investigate one of the three final design solutions.
The system template
A systems approach to develop a holistic solution was utilized because research identified numerous interconnected issues that were collectively impacting public health. Many health ailments were not being addressed until they had progressed into severe acute stages, requiring immediate attention and maximum resources.
The data suggested that public health in Rwanda is currently affected by the lack of access to adequate healthcare facilities and technologies, as well as prevention-based education. Additionally, healthcare providers are in need of continuing educational opportunities to further improve their knowledge and skills. To further complicate the problem, access to clean water is a daily challenge for many Rwandan citizens, causing numerous health problems for individuals and families.
The proposed system template involves stakeholders from the community, health workers, healthcare professionals, and the Rwandan government, and consists of multiple, interconnected, operational models. An education and knowledge transfer model delivers prevention-based education for community members as a bottom-up and top-down organizational learning tool. A mobility/connectivity model provides bicycles, Internet, smart phones, and telemedicine options to community health workers and staff.
A transitional patient care model aims to increase efficient patient movement across the healthcare system while also providing for return patient care support. A partnerships model improves the communication among the NGO and foreign aid efforts and resources, as well as local government and universities, and thus increases their overall effectiveness.
A facilities model addresses access to clean water that is necessary for public health and can be incorporated into the funding model. The team devised a water social entrepreneurship model to provide such funding.
Tuition from a residency program may also support operation costs.
The campus template
The final solutions address a needed shift in the healthcare delivery system to bridge the gaps at the early stages of treatment and prevention. This concept occurs at the community health center level, between the clinical facility (also referred to as a health post in Rwanda) and district hospital.
In Rwanda, healthcare tends to be perceived as acute care only, a way to manage illness when it progresses to the point of being intolerable or even life-threatening. This fact was validated in a small district hospital in Munini, Rwanda, where the team interviewed several patients who waited to the point of severe health problems before seeking treatment.
The campus design structure allows the community to take ownership of its local wellness system. It redirects the health system to a more holistic, wellness model through education at all levels and a gradual redirection toward prevention and healthier lifestyles. Major dysfunctional aspects are revised using local resources, skilled labor, and working elements of the current system’s structure as a framework.
The intention is to enhance the strengths of the current system rather than present a complete system overhaul. This new typology of a wellness campus provides minimal yet preventative services to include primary care, counseling, family planning, maternity care, pharmacy, laboratory, screening, referral, telehealth education, and traveling specialists.
The flexibility of this campus design allows for continued growth in size to meet the needs of the community. The development is planned in three phases to accommodate gradual implementation while addressing the high-priority areas first. Phase one involves the immediate local infrastructure deficiencies and educational processes.
Phase two establishes the design implementation and construction strategies developed in conjunction with the community. Phase three expands the functions of the community health center within a campus concept, assessing the completed system prior to turning over facility operations to the community.
The clinical template
Field research indicated that a typic
al community health worker delivers care from his or her home, and is compensated and trained by the Ministry of Health and NGO partners. During interviews, the community health workers indicated that a new work facility would be needed due to the inadequate conditions of their homes. Health posts are intended to support the limited capacity of the community health worker, whose primary responsibilities are detection, referral, and serving the basic needs of care delivery.
As the clinical team focused on supporting the role of the community health worker through improved facilities, technology, and education, the goal was to maintain the current physical scale of the village home through the creation of a new health post typology. The health post design solution would offer the community health worker a new environment that maintains the current scale of the home and is respectful of the culture, social structure, and local vernacular.
In order to achieve a scale for the facility representative of the village, a density study was first used to establish an approximate number of community members currently and potentially served by a community health worker.
The resulting design of the studio is not only a valuable outcome, but also represents the students’ growth through complex, collaborative efforts. The interdisciplinary model, introduced at an elementary level during the first class, evolved and adapted to support the planning and implementation of a powerful charrette in Rwanda, and carried through to the development and presentation of the final design.
Research team: instructors/students
Gerri Lamb, James Shraiky, Allison Magley, Al Peyketewa, April Ward, Denise Santiago, Linda Voyles, Lisa Santy, Matt Krise, Mary Villarreal, Rhoda Collie, Sheila Wakelam, and Taylor Gloeckler
James Shraiky, M.Arch, MA, is the director of the healthcare design initiative at The Design School, part of Arizona State University’s Herberger Institute for Design and the Arts. He can be reached at email@example.com. Linda Voyles, MHI, RN, BSN, CNOR, is a holistic perioperative nurse, author, speaker, and certified Dream Coach with more than 30 years of nursing experience. She can be reached at firstname.lastname@example.org.