The Indian healthcare industry is expected to grow to $79 billion in 2012 from $40 billion in 2010. This number will increase to $230 billion by 2020. This exciting growth responds to various demographic and economic trends, including an increasing population, rise in disposable income, increasing consumerism and demand for high-quality healthcare, greater incidence of lifestyle-related diseases, increasing employer-based insurance coverage, and increased government spending on public healthcare. Advancements in medical sciences and technology as well as an influx of foreign-trained doctors in the workforce also have led to an increasing focus on providing state-of-the-art equipment and services to patients.

In the last 10 years, there has been a parallel demand for high-quality hospital infrastructure to support the growing demands for healthcare. In India, healthcare is provided in primarily three types of settings: government-funded and run hospitals and healthcare clinics that provide free healthcare services, private for-profit hospitals and health centers, and mission-based nonprofit hospitals. The first two types of settings comprise the majority of the healthcare infrastructure in the country.

Trends in private healthcare projects

Private for-profit hospitals are seeing a marked growth with several facility design projects underway in different parts of the country. According to WHO health statistics from 2010, around 75% of the total annual healthcare spending in India came from the private sector. Hospital systems such as Fortis and Apollo have been immensely successful in the last 10 years in providing high-quality healthcare services to a growing educated and affluent urban population. While revenue generation is a key goal for these hospitals, emulation of Western standards and ensuring the best outcomes for patients is important in order for them to attract and retain customers.

To stay competitive in the market, hospitals are opting for external accreditation through international organizations such as Joint Commission International or India’s National Accreditation Board for Hospitals and Healthcare Providers. Accreditation also is seen as an important process for improving patient safety and quality of care provided to patients. With medical tourism being an important driver, many private hospitals aspire to provide high-quality built environments similar to those found in U.S. and European hospitals.

Commenting on some of the key drivers for private hospital design in India, Gaurav Chopra, vice president and director, South Asia region, HKS Architects, says, “While there is a growing focus on patient-centered care, many new private hospitals are investing heavily in new technology and equipment, and often the built environment mandate is to house this technology. Also, given the demand for hospital beds and its direct relation to the bottom line, the focus of hospital design projects is primarily on increasing bed capacity.”

According to Chopra, many private hospitals provide a combination of multi-bed wards (15-20% total bed count), single occupancy rooms (around 70%), and luxury single rooms for high-paying customers (around 5%). Infection control is an important concern for healthcare facilities in India and selection of cleanable and durable materials is a key design driver. Local culture and traditions, as well as climate, are important factors that impact the layout of spaces and building form and design.

For example, family members are usually present at all times during a patient’s hospital stay, which requires larger patient rooms. Providing larger waiting rooms for families in the emergency department, surgery, and ICU also is necessary. In addition, spirituality and religion are an important part of life in India, and hospital artwork may refer to symbols and images of the dominant culture in the region.

Private hospitals usually are financed, built, and managed by the hospital developer. Hospital chains, such as Apollo, have developed a prototype hospital that is being replicated in cities across the country in order to deliver projects effectively in a relatively short time frame. Several American, Australian, and European healthcare architecture firms and healthcare consulting firms have opened offices in India and are key players in the market. However, hospital administrators usually seek to balance their project teams with Indian architecture firms that have a stronger understanding of the Indian design and construction standards, climate, and cultural factors that must be taken into consideration to deliver a successful healthcare facility project.

With an increasing focus on wellness and short stays for noncritical episodes, ambulatory care centers are coming into prominence. These are designed to be one-stop shops that provide a range of diagnostic and patient care services (dental, imaging, ophthalmology) outside of the hospital setting. Primary care is largely provided in small private doctor’s offices in India, usually located in storefronts or in private residences. These providers are not accountable, and the quality of care varies widely between practices.

There are some innovative efforts underway to provide low-cost, standardized, high-quality primary care in many Indian cities. For example, the Razi Clinics are being developed in existing storefront spaces in the twin cities of Hyderabad and Secunderabad to address an increasing need for high-quality, affordable, primary healthcare for low-income and middle-income families in India. Clinics designed and developed with support from San Francisco-based Architecture for Humanity use a standard design template and are distributed throughout the city, enabling patients to visit any location since patient information is maintained on a central repository. This and other emerging innovative healthcare models suggest a way to bridge the healthcare disparities so evident in India.

Trends in public healthcare projects

Healthcare and healthcare infrastructure in India varies widely in quality and accessibility. In 2009, only 1.27 beds were available per thousand people, which is less than half the global average of 2.6. Further, while 70% of the Indian population lives in rural areas, in 2009, there were more than double the number of public hospital beds available in urban areas. Private hospitals catering to paying customers tend to be located in urban areas as well. As one might expect, the doctor-to-population ratio is six times lower in rural areas.

Government-run hospitals and clinics often are the only affordable healthcare resources available for the majority of the Indian population. Government spending on healthcare has been low in India as compared to other nations. Dr. R. Chandrashekhar, chief architect for the Ministry of Health and Family Welfare (MOHFW), Government of India, says, “In recent years, there has been a shift, and the government is actively exploring strategies to make high-quality affordable care available to a larger section of the population and to bridge the healthcare gap. The key driver for public healthcare projects is to increase capacity—provide more beds to meet the high demand for healthcare services now and in the future.”

To that end, the Government of India has developed a plan to set up hospitals and health centers in several urban and regional centers around the country. The National Rural Health Mission is focused on strengthening health services at district and rural levels. Further, the government is developing medical
colleges and centers of excellence such as the All India Institute of Medical Sciences (AIIMS) in different parts of the country. The government also is investing in upgrading existing medical colleges to bring them up to the level of AIIMS. Shamit Manchanda, chief architect, Manchanda Associates, New Delhi, is engaged in several large government hospital projects around the country. According to him, there is a serious push to develop healthcare facilities in tier-two and tier-three Indian cities (smaller urban centers) that were lacking in healthcare infrastructure.

Telemedicine is envisioned as one of the key drivers in future healthcare projects, as it provides an effective way to reach the largely rural population that does not have access to specialty care. The technology as well as infrastructure to support telemedicine is yet to be developed in an integrated way in the Indian health system, but the early experiments are promising. There is an increasing shift toward lifestyle-related diseases, such as heart ailments, diabetes, and obesity. Specialty hospitals focused on these diseases as well as diagnostic centers are being planned around the country. The Sports Injury Center in New Delhi was developed to be a world-class healthcare facility specifically focused on sports-related injuries.

Infection control is a key concern in public hospitals—and the focus is on selecting finishes that are easily cleanable and are low- maintenance or no-maintenance. Chandrashekhar emphasized this point by saying, “Inadequate consideration to hospital maintenance after construction and occupancy is the primary reason for failure in Indian hospitals and poses a serious patient safety hazard.”

He contends that the lack of coordination between engineering services that develop and implement healthcare projects and housekeeping services that maintain healthcare facilities is the source of the problem. To ensure that the building and equipment continues to function effectively after commissioning, the Ministry of Health, Government of India has directed all healthcare infrastructure of the MOHFW to create five-year maintenance contracts with its allied engineering services to ensure that equipment and physical facilities are well maintained post occupancy.

There is a strong push toward sustainability in all public projects in India, including healthcare projects. Similar to the LEED accreditation system in the United States, the GRIHA (Green Rating for Integrated Habitat Assessment) rating system has been developed in India by the Tata Energy Research Institute. Manchanda says, “The GRIHA assessment is mandatory for public healthcare projects, and they are being designed with the goal of obtaining a minimum of a three-star rating.” Some of the design features being considered for these projects include rain water harvesting, use of high-efficiency light sources, utilization of natural light, and energy recycling.

Healthcare design process in India

According to both Manchanda and Chopra, private and public healthcare projects rarely utilize a participatory process. Usually, the decision-makers are the architects and healthcare consultants along with the hospital client, often the hospital executive or clinician. The architects play a key role in sensitizing the clinicians and hospital administrators regarding issues such as infection control, design of the ventilation system, selection of materials, etc. However, projects often suffer due to lack of communication of design goals with other individuals involved in the process, such as contractors, maintenance teams, and nurses.

All individuals interviewed for this article were aware of the term “evidence-based design.” Chopra feels there is a growing awareness about the term in the Indian healthcare design industry but a lack of clarity about what it is and how it could be applied to the Indian healthcare context. He defines EBD “… as a way of understanding how design impacted performance and outcomes.” According to Manchanda, “EBD is learning from past experiences and using that knowledge to improve future projects.” According to both these individuals, case studies, stories, and research conducted in India would make it more relevant for this audience.

Future opportunities

The healthcare sector in India is poised for sustained growth over the next 20 years. There is increasing collaboration and information exchange between healthcare design teams in India and those from other countries fostered largely by the entry of multinational design firms in the Indian healthcare market. There is also a push to develop stronger healthcare design teams within India by creating national programs for teaching healthcare design principles to architects, engineers, and healthcare professionals.

National graduate level courses in health facilities management, and engineering and health facilities planning and design will shortly be launched in Indian universities. This is an exciting development that further opens the opportunity for information exchange and learning efforts in the United States and India. There is openness to understanding more about new concepts such as sustainability and evidence-based design. However, it is clear that these concepts have to be relevant to the Indian healthcare context for these to be readily accepted and applied. HCD

Acknowledgements

Thank you to the following individuals for their time and assistance with developing this article:

Dr. R. Chandrashekhar, Chief Architect, Ministry of Health and Family Welfare, Government of India; Gaurav Chopra, Vice President & Director, South Asia Region, HKS India; and Shamit Manchanda, Chief Architect, Manchanda Associates.

Anjali Joseph, PhD, EDAC, is Director of Research at The Center for Health Design. She can be reached at ajoseph@healthdesign.org.