Asia: Contrast and change
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| Vietnam's Hoan My Dalat Hospital, designed by HTT Architecture |
Clinical excellence for moderate cost? Or poverty and low health outcomes? Southeast Asia’s healthcare may be sharply divided, but Emily Brooks finds much to celebrate.
Southeast Asia is not easily pigeonholed when it comes to its healthcare. A proportion of its 570 million inhabitants enjoy gold-standard facilities and some of the best health outcomes to be found anywhere; on the flip side of the coin, poverty and its associated disease burden present serious challenges to development in many other areas. In between these extremes sit a number of countries with some of the fastest-growing economies in the world, their governments seeking to deliver quality healthcare for all and improve infrastructure to do so.
With the strengthening of primary care in recent decades, generally speaking the health of southeast Asia has improved considerably, and market analyst Frost & Sullivan identified 2008 as a crucial tipping point for the region, with “a migration from ‘sick care’ mentality to ‘health care’ philosophy”1. However, with the economic downturn, how quickly this promise will now be fulfilled is presently unknown: global recession could have a devastating knock-on effect for nutrition, sexual health and immunisation programmes as well as affecting the growth of infrastructure.
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| Opportunities for retreat and restoration ar provided by purpose built spaces Singapore's new Khoo Teck Puat Hospital, with views of nature, natural light and courtyard garden settings |
Singapore is feted as the world’s ‘miracle’ healthcare system, delivering outstanding results for minimum government spend (4% of GDP; life expectancy at birth is 812). Its success is attributed to its tiered system of funding, consisting of a compulsory savings account deducted from salary, a voluntary insurance scheme (which, crucially, is opt-out, rather than opt-in, from birth) and a ‘safety net’ government endowment fund to cover treatment for those unable to afford it.
A dynamic private sector runs parallel to this, so providers compete side-by-side, encouraging standards to be raised. The basic tenet of affordable healthcare for all is a legacy of British colonisation, and Malaysia’s parallel political history and rapidly rising economy has resulted in a similarly efficient service, with an 80%/20% split between public and private care.
Thailand, too, has overwhelming state involvement in healthcare. Still-developing countries such as Indonesia, Cambodia, Laos and the Philippines, while more stable than ever before, still struggle against a background of poverty, with correspondingly lower health outcomes. National health insurance schemes have seen various levels of success: the Philippines’ PhilHealth scheme, which deducts 2.5% of monthly salary of employers in the public and private health sector, “has little relevance for [the] majority of the population, who remain outside its coverage for various reasons, most notably because of the existence of a large informal sector”3.
Meanwhile, Thailand’s three healthcare funds cover almost its entire population. Across the region there is general a move towards decentralisation (to improve access, equity and effi ciency) and privatisation (to ease state financial burdens for healthcare). Cambodia, for example, unveiled its fi rst ‘international standard’ private hospital, Royal Rattanak Hospital in Phnom Penh, last March, funded by US$8.5m from Bangkok Dusit Medical Services, which owns and runs 19 hospitals in Thailand and abroad. The six-storey hospital is intended to cater to domestic patients, who have previously migrated to neighbouring countries for high-quality treatment, and foreigners.
As a policy, public-private partnership (PPP) is still in its infancy. Singapore leads the way for PPP in the region, but although it has completed projects for education and a large-scale sports stadium, so far there have been no health initiatives. “This is not to say there will be none in the future,” says Amy Lee, chief executive of the leading PPP legal advisors in Singapore, Lovells Lee & Lee. “After all, the mechanism, process and expertise is already here, as evidenced by the deals closed to date and the international players – including international healthcare PPP players like Laing, Plenary Group and HSBC Infrastructure – as well as various contractors experienced in PPPs, who are located here or work in the region.”
Hong Kong and Thailand have also explored this model, but what happens now that lending has been severely curbed is unclear. Many multinational firms, not least architectural practices, have taken up residence in southeast Asia to take advantage of the burgeoning economy there.
Broadway Malyan, for example, opened its Singapore office at the beginning of 2008 and has just won a contract to build the country’s National Heart Centre. “Singapore is very well located geographically to be able to serve the southeast Asian region and be that gateway between India and the Far East,” says its director Jason Pomeroy. “There is also an increasing trend for Middle Eastern investment to come here, because Malaysia and Indonesia are Islamic countries, as well as a burgeoning hospitality economy with the rise of integrated resorts.”
“It is an energetic market,” says Bruce Johnson, principal-in-charge at HKS in Dallas, which in January announced its plans for a new a 500-bed national cancer centre in Taipei, Taiwan. The 1.3m square foot centre will be emphatically patient-focused, with a design that supports this – the curved shape of the main inpatient areas maximises staff effi ciency by reducing travel distances for patients and staff; a ‘medical mall’ area separates the inpatient and outpatient areas, so patients can wait in a less clinical environment, with the aim of reducing anxiety. Waiting areas are large and plentiful, since in southeast Asia patients are often accompanied by several family members.
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| Roof garden and central atrium bring light and greenery into Taiwan's new cancer centre, designed by HKS |
The atrium in Taiwan' new 500 bed cancer centre allows light to penetrate down four levels |
A large circular drum in the atrium will enable light to penetrate down into four basement levels, where many of the radiation therapy rooms will be. “We’ve brought in a lot of natural light for this project, especially in the major waiting areas – you can see daylight in most places within the building,” says HKS’s senior designer Alex Ling. Extensive rooftop gardens offer solace both to patients and the large numbers of live-in staff, as well as having an insulating function: like many southeast Asian countries, natural resources are scarce and therefore sustainability is high on the agenda.
The sheer scale of the Taiwan project is indicative of the size of some of the building opportunities in southeast Asia. There is a burgeoning trend to incorporate retail parks and step-down facilities alongside hospitals, creating vast complexes. Singapore’s Farrer Park MediPlex, opening in 2011, is just such an example. Designed by DP Architects for Singapore HealthPartners, it will incorporate a mall on its ground fl oor, above which a 220-bed private hospital and a 260-room hotel form high-rise west and east wings respectively. The hotel will service family members as well as patients who need some continuity of care without constant supervision.
The ‘medical hotel’ is the fi rst of its kind in the region and 40-60% of its patients are expected to be foreigners. It will also hold the highest ‘green’ building rating in Singapore, the Platinum BCA Green Mark.
The future is green
Sustainability has also been placed at the centre of the design for the new National Heart Centre Singapore, due to be completed by the end of 2012 (see also Placemaker pp12-13). As Jason Pomeroy, director of architects Broadway Malyan in Singapore, explains: “What we’re really trying to advocate are passive, low-energy, back-to-basics ideas – for example, looking at orientation, cross-ventilation and minimising water consumption.”
The hospital responds to its tight urban site with a series of stepped ‘sky gardens’ to provide natural light and ventilation as well as space for recreation, social interaction and working wirelessly. The orientation of the building has been given particularly thoughtful consideration. “The two shorter faces of the fac¸ade are presented to the east
and west, in order to minimise heat build-up from the low-angled sun and to minimise cooling costs,” explains Pomeroy.
“Then, on the two of the fac¸ades that have greater exposure to low-angled sun, there is an applied screen that helps mitigate that heat build-up and reduce the element of glare.” The materials used will be considered for their life cycle and recyclability as well as the distance they will travel to the site.
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| Parkway Health's new Novena Hospital will have Platinum Green Mark status |
Leading Singaporean private healthcare provider ParkwayHealth’s new project in Novena, opening in 2011, will also have Platinum Green Mark status, using a similar ‘intelligent planning’ approach that encompasses building orientation, exterior shading devices, rooftop gardens and a host of other strategies. Furthermore, its design is informed by several areas of research – for example, the use of same-handed patient rooms resulting in less noise and better sleep for patients. The hospital incorporates extensive outdoor spaces as well as interior ‘light courts’ in nursing areas and lots of daylight provided by windows and views – a response to research that has proven that staff exposure to light, views and access to nature reduce stress and improve job satisfaction, retention rates and, ultimately, better care for patients.
Novena Hospital will also have the state-of-the-art technology that Singaporean hospitals have become known for – and this, combined with a ‘five-star’ hospitality-type environment, is a big draw for foreign patients. Medical tourism is growing significantly and, while it was previously more confi ned to southeast Asia (patients coming from Indonesia to Singapore for treatment, for example), many countries operate an aggressive policy to attract people from further afield.
Singapore, with its reputation for excellence and its many JCI-accredited facilities, leads the way, with an estimated 400,000 international patients a year. Sharoja Mohanasundaram, chief executive officer of Healthbase, a US-based agency that connects patients with international hospitals for treatment, explains a further reason for its appeal: “Healthcare in Singapore is very strictly regulated by the Government and hospitals have to publish quality data about their success rates, so it’s easy for patients to see that. In other countries, they do have the data but it’s not so easy to get it.” She also identifies certain markets for certain treatments – Singapore for high-end procedures, especially cardiac care, but Thailand for cosmetic surgery, for example.
New hospitals in particular are increasingly dependent on foreign patients for long-term fi nancial stability, says Mohanasundaram: “In Thailand they’re spending lots of money on infrastructure, so they’re really relying on it for payback.”
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Malaysia's Prince Court Hospital markets itself as a five star establishment
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International outreach
Malaysia’s Prince Court is a new private hospital that is marketing itself internationally and has already seen 30% of its patients come from overseas since opening in 2008. JCI-accredited last December, its facilities refl ect its ambitions as a five-star establishment – a ratio of 300 beds to 800 nurses, 100% single rooms and suites, and luxurious services such as 24-hour a la carte dining and in-room check-in and check-out. Vietnam’s Hoan My Dalat Hospital, designed by HTT Architecture, is set up as a hospital and spa in one: the main hospital is a low-slung semicircular building, with separate buildings for a health and beauty spa. The buildings nod to the French-colonial style of the region, with steeply pitched roofs to cope with the heavy rain; the peace and quiet of the mountainous setting is enhanced by giving access to only pedestrians or electric cars.
Healthcare is also becoming increasingly patient-focused, and design refl ects this. Singapore’s Khoo Teck Puat hospital, profiled in April 2008’s World Health Design and due to open in March 2010, has used a radical holistic approach – for example, the diabetes clinic will include endochrinologists, dietitians, oncologists and podiatrists working in close physical proximity so that patients do not have to travel long distances between departments. A large auditorium with regular lectures and events will encourage the further cross-fertilisation of ideas between departments.
The next stage of the site’s development is to build an adjacent 220-bed community hospital that will provide care for an ageing population by embracing the American concept of ‘slow medicine’. “The acute care hospital will always be very fast-paced; it will very strict about handwashing and hygiene, and have controlled visiting hours,” says Tek Lit Liak. “But next door is more like a spa – quiet and Zen-like, where you encourage patients and family members to be together, so you design facilities for family members to hang around together.” This increased segmentation and personalisation of care means more satisfied patients and better health outcomes.
Emily Brooks is an architectural writer
References
1. Ng Wee Pin. 2008 Healthcare Asia Pacifi c Outlook. Frost & Sullivan; 2008.
2. World Health Organization. World Health Statistics 2008. Geneva: WHO; 2008.
3. Ramesh M, Wu X. Realigning public and private healthcare in southeast Asia. The Pacifi c Review
2008; 21(2):171-187.
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