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Issue : July-September 2002

Planning for HVAC Systems in Hospitals in India

By Dr Vivek Desai
Director Hosmac India Pvt Ltd., Mumbai

Dr Vivek Desai is the founder director of Hosmac India Pvt Ltd, a hospital planning and management consulting firm based in Mumbai. He is a medical graduate with formal training in hospital and business administration from prestigious universities in India. Being consultants to more than 70 projects in India & abroad, the firm has excellent insight into planning and building of healthcare facilities in India. Dr. Desai is on the faculty of Tata Institute of Social Sciences and Indian Institute of Health Management Research, where he teaches Hospital Planning & Design as a subject.

Everyday of their lives, the wellbeing of vast numbers of people lie in the hands of health systems. From the safe delivery of a baby to the care with dignity of the elderly, health systems have a vital and continuing responsibility to people throughout their lifespan. They are crucial to the healthy development of individuals, families and societies everywhere. After spending centuries, as small scale, largely private or charitable, mostly ineffectual entities, health systems have grown explosively in this century, as knowledge about them has been gained and applied. They have contributed enormously to better health, but their contribution could be greater still, especially towards improving the health of the poor. Failure to achieve that potential is due to systemic failings rather than technical limitations.

The planning of hospitals today is a very complex process for a variety of reasons, which are:

1. Medicine today has become technology-intensive. At the same time there has been a large increase in the number of patients and hence the need to cater to them. Hospital planners will have to strike a balance between these two requirements.
2. The planning of hospitals has become very scientific. Hospital architecture and engineering design have become a specialty and the physical design of a hospital is based on scientific criteria.
3. Patients are beginning to have increasingly higher expectations from health care delivery facilities and planners have to respond to that need. Hospitals can be classified as:
   1. General Hospital - provide more than one kind of treatment i.e. they provide treatment for different kinds of illnesses such as medical, surgical, obstetric, etc.
   2. Specialty Hospital - provides specialized treatment for a particular type of illness such as cardiac, orthopaedic, paediatric or kidney hospitals etc.

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The environmental needs of these facilities will differ widely; while a general hospital may not need sophisticated HVAC systems, the specialty hospital's operation theatres will need HEPA filters with 100% fresh air which has a substantial cost implication.

The field of hospital planning and design in India has been hitherto unknown as a specialty. There are no regulations for hospital buildings and there are no norms that one can follow. Most of the time, one has to rely upon standards prevalent in Western countries that may not suit our environmental conditions. The Indian healthcare domain is also peculiar in another aspect in that it has almost equal distribution of public and private health care facilities, which are quite different with respect to their infrastructure provisions. In most other countries the sector is dominated either by the private sector (90% in USA) or the public sector (80% in UK, Germany and Australia) wherein there exists a standard building engineering code for hospital facilities.

Unfortunately in India, over the decades, many problems including overcrowding, lack of ethical standards, absence of sound management as well as absence of hospitals with a human face have created a situation where going to a hospital has become a nightmare for the common people. On the whole, hospitals in the Government sector have decayed over time. The hospitals in the private sector are primarily run for profit, hence there is always an effort to cut corners, sometimes at the cost of quality of care. Since engineering services do not have any revenue-generating value, they are the most neglected area in any hospital. Considering that engineering services costs are generally in the range of 50% of the total cost of a hospital building, such neglect has led to sub-optimal planning of such services. An HVAC system is considered to be more of a luxury than a necessity and hence it lags behind other needs in terms of budgetary allocation.

A central AC system is no doubt expensive but has many long-term advantages over several small individual plants spread out all over the hospital building. Operating and maintenance costs of AC plants are also high and need to be budgeted while working out the daily rates charged for patient rooms and other facilities. Apart from this, electric supply companies have withdrawn the subsidy on electricity for hospitals and the same is being charged on a commercial rate at par with other industrial institutions. Large centrally air conditioned hospitals in India have been spending up to Rs 1.5 lacs per day, which is quite substantial. The capital costs of good central air conditioning may be as high as Rs 0.75 lacs per ton taking into consideration “clean” room requirements for the operating surgical suites, specialized insulation requirements, ducted return air requirements etc.

Unfortunately, in India, most planners do not understand the importance of energy conservation. While some hospitals are centrally airconditioned and thereby have huge energy bills, at the other extreme are hospitals which have operation theatres working with window-type comfort air conditioning. The quality of the healthcare facility environment needs to be supportive of the users and functions served. Designing blindly for energy conservation should not compromise patient health and safety. Informed planning and selection of mechanical and electrical systems, as well as efficient utilization of space and consideration of climatic conditions can significantly reduce overall energy consumption and thereby running costs. Life-cycle costing can give promoters a long-term view of the costs involved which will help them in decision making, a concept not prevalent in India and which leads to high recurring costs, eventually leading to a shutdown of the central airconditioning system. This could be disastrous as the building would have been designed to operate as centrally air conditioned and hence ventilation will be poor leading to more chances of air-borne crossinfection amongst patients.

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Basic requirements for planning HVAC systems in hospitals are:

• Identify areas which need airconditioning/ heating/mechanical ventilation
• Identify the air quality requirements of specialized clinical areas like operation theatre suites, laboratories, central sterilization areas, bronchoscopy rooms, isolation rooms, MRI rooms, and other imaging department requirements
• Climatic conditions and usage time of various facilities should be considered
• Availability and cost of various fuels that one can use for operating the chiller plants, as this will have significant bearing on life-cycle costs for the option chosen
• Consideration for phased airconditioning, wherever required, as these costs will have to be budgeted for by the promoters
• Area allocation for chillers, cooling towers, AHUs etc.
• Identification of appropriate technology viz reciprocating/ centrifugal/screw/VAM/package units/room air conditioners and their linkage to a building automation system
• Deriving a patient-friendly, yet cost-effective, budget for the system

In view of the fact that most promoters of hospitals in India are not familiar with the engineering technologies involved in hospital HVAC systems, it is of paramount importance that they are educated about the norms and importance of adhering to the same. There have been many instances where patients have been affected by malfunctioning of HVAC systems leading to infections that have had crippling effects like blindness and in some cases even death. It would be a welcome practice to make the promoter visit similar facilities and educate them about the need for providing a healthy and clean environment for their patients.

With the impending entry of health insurance, it will become mandatory for health care facilities to follow certain basic standards to get accredited as a safe facility for patient care. Hopefully this will promote the use of HVAC systems in hospitals as a means of making them ‘buildings that heal’, in a more literal way.

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