Several months ago, Cannon Design completed the design of a prototype healthcare facility in Afghanistan that would serve as a template for the delivery of medical services in the war torn country. The challenges were many—creating a hospital in a country where basic healthcare was a virtual luxury, did not prove easy. 

Designing affordable, efficient structures with limited availability of modern construction materials, almost no skilled tradesmen, and a political climate rife with corruption and tribal rivalries, meant re-evaluating how hospitals are built. Obviously, there were lessons to be learned, but what was learned would prove surprising.

As the design and construction of healthcare facilities for the Afghan people progressed, something strange occurred. The expectation that our advanced knowledge—developed within the American healthcare system—would provide a strong platform from which to design and build in Afghanistan, was certainly true. What hadn’t been counted on was that in the re-imagining of healthcare for Afghanistan, strategies would evolve that would influence the vision of healthcare design here at home. 

What follows are four lessons learned in Afghanistan.

The hospital prototype in Afghanistan relied on a core competency of sustainability. In a country where the presence of electricity, water, sewers, and heating must be presumed unavailable, every resource had to be treated sustainably. 

Think for a moment about the vast consumption of energy and resources in a modern American hospital—energy and resources always there at the flip of a switch or the turn of a faucet. Now imagine designing a hospital where none of those conveniences exist, or exist on a much more limited basis. 

Water resources, in particular, are scarce in Afghanistan. With frequent droughts and a generally arid climate, hospitals are challenged to find ways to conserve this precious resource. 

A key water conservation strategy involved separating potable water from so-called “grey water.” In this scenario, potable water is pumped and treated from groundwater and stored for use only where required. For uses not requiring clean drinking water, storm and waste water are recycled and treated. The use of this grey water conserves clean water and permits the hospital to become self-sustaining in water use.

Are there lessons to be learned from these sustainably-designed Afghan hospitals that can be applied to the Western world? As energy and water resources become increasing costly, it will become imperative that healthcare design is approached from a sustainable point of view.

The need to rebuild following the devastating aftermath of natural disasters in America—such as New Orleans, Joplin, and the inevitable yet-to-come “big one” in California—create an overnight need for healthcare facilities. The scalable prototype used in Afghanistan can provide the blueprint for these facilities. 

Four healthcare modules were developed for application in Afghanistan: a primary care prototype, a 50-bed women’s hospital, a 20-bed day hospital, and clinic chassis. Each of these modules could be individually constructed as standalone facilities or connected as “plug and play” components. 

By selecting only those modules necessary in a given locale, construction and operational costs are held to a minimum. Because the modules are flexible and expandable, the hospital can be reconfigured as needs change. 

This type of flexibility—absolutely necessary in Afghanistan—has clear applications in other developing countries and should be adaptable for use in the Western world, as well.

Perhaps one of the most pressing issues is that of clinical efficacy—how do specific clinical procedures produce the most efficacious results, or what is often termed “outcome-based metrics.” The United States underperforms many international countries when comparing the ratio of GNI per capita investment.

Could a much more minimalist approach be in the offing? Cannon Design’s experience in Afghanistan points to that possibility. One surprising and shocking finding is that Afghan outcomes are higher in ratio to per capita investment than in the United States.

Another factor that translated into better health outcomes was the human factor. The inclusion of community and family into the healthcare setting was not only desirable from a healthcare delivery point of view, it was also necessary from a cultural point of view. 

The prevalent western paradigm of the hospital as a clinical facility divorced from community could not work in Afghanistan. Could it be that health outcomes were favorably influenced by community stability, education, and family sociological support? 

It was clear that the Afghan hospital model had to embrace greater access from extended families and the community at large, and the planning of these facilities incorporated that access. 

One of the unanticipated benefits was that the lower nurse-to-patient ratios in Afghanistan had neutral impact on health outcomes and, in fact, health outcomes improved with support of allied health professional training and engagement in the care models.

There is no question that Medicare reform is facing the American healthcare delivery system. The difficult questions of how much more can be pared will occupy the body politic and the medical professions for the foreseeable future. Emerging economies like Afghanistan have developed lean professional-to-patient ratios out of necessity, yet have maintained improving health outcomes.

Reform in the United States will require structural changes in healthcare delivery and facilities. Simply cutting costs with no examination of collateral impact is not a formula for success. 

As with many other aspects of our economy, a new paradigm must be developed that will produce high-quality results at reduced costs. Lean healthcare facility planning and design solutions that reduce labor and energy expenditures can yield the greatest substantive impact on year-over-year lifecycle costs of facility operations. Labor costs alone typically represent over 60% of every dollar spent on delivering healthcare in U.S. hospitals.

Sustainability, rebuilding, clinical efficacy, reform—these are the lessons from a distant country radically different from our own. America has a system that is beautiful yet broken in many ways; and, increasingly broke. 

Afghanistan is building hospitals in tent communities and prototype facilities that are catalysts for social and cultural transformation. Their model not only offers us a lesson in building, but also new models for healthcare delivery. America has much to learn from Afghan healthcare.  

Deborah A Sheehan, ACHE, EDAC, LEED AP, is Principal with Cannon Design. She can be reached at 312.960.8078 or at For additional information, visit