Areas of the world that were once considered remote have become thriving centers of global economic development. The dramatic financial growth of these nations, and an increased awareness of the consumer market, has created a driving demand by developing nations to provide the infrastructure once considered the foundation of free capital societies.

The newly discovered conveniences of economic growth have been accompanied by some less desirable health conditions. A less active work force, the increased use of the automobile, and an appetite for fast food have increased the instances of obesity, diabetes, cardio-disease, asthma, and renal failure across the world. Coupled with these new health problems for rapidly growing populations, there is an increased awareness and desire for a Western Hemisphere model of healthcare.

Because of these and other factors, many U.S. architectural firms specializing in healthcare design find themselves working on healthcare projects all over the world.

The sense of urgency is real. Many countries seeking expertise from the Western Hemisphere have fewer beds than the Western average of five to six beds per 1,000 population. Some nations seeking to build healthcare infrastructure have fewer than the worldwide average of 3.5 beds per 1,000. International healthcare clients are looking for healthcare design that supports best practices, but with the caveat of cultural and budgetary limitations.

In the United States, the 2010 Guidelines for the Design and Construction of Health Care Facilities, published by the Facilities Guidelines Institute, mandates that all new inpatient units must consist only of private rooms. In countries where the numbers of existing beds are well below average standards, maximizing the number of beds is a much higher priority than providing private rooms. The healthcare designer needs to establish very early during the design process what international standards and codes will be followed and where the project will deviate from those standards.

When designing healthcare projects in other countries, the typical assumptions that a designer might make for domestic projects will not always be appropriate, requiring a fresh approach to design solutions. The international healthcare designer must be open-minded and listen with care and imagination to the hospital administrators, physicians, and caregivers. Care delivery, operational management, and cultural considerations can dramatically impact the healthcare designer’s programming approach.

Additionally, budgetary considerations and aggressive project schedules can make the transition from domestic to international healthcare design a tricky business. Such constraints require the design team to approach their work process with new efficiency.

Internationally, many practicing physicians have been trained in the United States, United Kingdom, and Canada, or by international outposts of Western medical schools. As a result, the impression at first encounter is of familiar surroundings—one could easily be in “Anytown, USA.” However, upon further inspection, subtle differences begin to appear.

For instance, many populations have historically lacked basic primary or preventative care. Clinical care options have increased in many countries, although many still have deficient primary care to serve their growing population. Even in countries with an adequate primary care system, patients have a hard time breaking old habits and seek care only after a sickness or condition has progressed.

For that reason, patients tend to enter the healthcare system at the hospital’s emergency department. Clinical appointments are typically not scheduled in advance; most people just “walk in.” Therefore, the clinics associated with a hospital or emergency department are much larger than what is typical in the United States, and the clinical areas should be zoned adjacent to the emergency department.

Alternatively, a separate triage area is useful to sort patients before entrance into the ED so that the less acute can be directed to an outpatient area. Because many patients wait until they are very sick before seeking care, the percentage of medical inpatient beds dedicated to sick patients is much higher than what is customary domestically—an important factor in healthcare design programming.

Another significant difference in clinic design is that many hospitals base their clinic practices on the U.K. or Canadian consult room model, where the exam room (or consult room) also serves as the physician’s office. In this situation, American assumptions about the clinic’s size, configuration, adjacencies, and throughput goals will not apply.

With the consult room model, an exam room would typically be 180 square feet in lieu of the 130 square feet typically seen in a U.S. academic medical center clinic, or the minimum clear floor space of an 80-square-foot exam room one might see in an American private physician’s office. Patient flow differs from the U.S. profit-based system.

In the consult room model, the physician occupies the room during clinic hours, with the space serving as both physician office and exam space. Instead of the physician moving from exam room to exam room, the physician stays in one location and the patients move in and out. This model may impact the quantity of subwaiting areas, patient/physician zoning inside the exam room, and increased storage requirements for both exam supplies and the physician work zone.

In an effort to provide as many beds for care as possible, other international care models that differ from U.S. common practices are open ward units and shared rooms. Open ward intensive care units with as many as six ICU beds may be grouped in one open ward with cubicle curtains between patients providing privacy. Emergency departments may also follow the open ward model. In inpatient units, semiprivate patient rooms are much more common. Some hospital systems may utilize multiple bed inpatient wards with three to six beds per large room.

Operational management also may be different in international settings. In regions where unemployment rates for young nationals average 40%, even labor costs for skilled, educated workers is very inexpensive. Consequently, priorities that domestic hospitals would value regarding FTE’s and adjacencies may not apply for an international healthcare project. For example, using a courier in lieu of a pneumatic tube system may ultimately be a less expensive way to get items around the hospital. Note that the savings for the hospital may not just be in capital costs, but also in continued operational costs.

Designers also must be sensitive to cultural conventions of the region where they work. Religious beliefs, practices, and cultural definitions of privacy should be respected and incorporated into the design. The healthcare designer should give special consideration to the dignity of women, as dishonor of women can have cultural costs that are hard for the Westerner to imagine. Family involvement and the number of family members who come to the hospital with the patient also should be studied and reflected in the design.

As U.S. hospitals make big efforts to “green” their operations and save energy costs, there is much to learn from overseas hospitals with budget and infrastructure constraints. In the arid Middle East, water conservation is standard practice. In Qatar, efficient fixtures and water harvesting for site irrigation are standard building code requirements. In Riyadh, Saudi Arabia, an existing hospital copes with the lack of plentiful water by implementing an onsite water treatment plant. In Africa, many areas have never become dependent on energy-sapping HVAC systems.

Recent hospital projects in Ghana, Kenya, and Rwanda are planned and designed to take advantage
of natural ventilation. Only the most critical portions of the diagnostic and treatment areas are air-conditioned: departments that are equipment-heavy, like imaging, or where temperature control is desirable, like in surgical theaters. For these projects, the architects are orienting the inpatient wings to take best advantage of prevailing winds, with corridors on the exterior of the building to gain the most benefit of the circulating breezes.

Ultimately, care providers and patients in other nations are seeking the same objectives as patients in North America—human dignity, quality care, and pleasant spaces that encourage healing. For the healthcare designer, providing expertise to an international audience is an opportunity to make a positive impact for the care of thousands, but not without challenges. The budgets and schedules demand innovative solutions and creative approaches to the process of project delivery.

The culture and care models require design teams to respectfully listen and learn. The international work environment calls for an adaptable and adventurous personality. Collectively, these requirements enrich the healthcare designer’s perspective of what is possible for designing high-quality healthcare environments— experience that benefits their work both internationally and in their own communities. HCD

Brenda Smith, RID, IIDA, LEED AP, is a Senior Interior Project Manager and Senior Associate at Perkins+Will in Atlanta. She can be reached at Dawn Mixon Bennett, RA, LEED AP, is a Senior Project Manager and Associate at Perkins+Will in Atlanta. She can be reached at