Publications IPH Magazine Magazine IPH Nº19 From Hospital Architecture to Architecture for Health

Although it is a very long process that could even be traced back to the thirteenth century (Rovere, M)4, from certain experiences in some countries in the 60s and 70s and from the goal of ?health for all by the year 2000? of the WHO in 1975, it is especially since the Alma Ata Conference5 (1978) that the Primary Care Strategy of Health: ?essential health care based on practical, scientifically sound and socially acceptable methods and technologies, made available to all individuals and families in the community, through their full participation and at a cost that the community and the country can bear, at each and every stage of development, in a spirit of self-responsibility and self-determination?.6

As several authors 7 have pointed out, this strategy comprehensively conceives the health problems of individuals and society, through the integration of care, disease prevention, health promotion and rehabilitation. This perspective also proposes an organization of health services by different levels of care, which must have the participation of the community to solve problems through accessible, high quality and continuous and comprehensive services.PHC was born as a policy of expanding coverage to solve what at that time was called the crisis of accessibility of health systems. This crisis in developed countries was expressed through skyrocketing health care costs and rising population demand for services, in the face of unequal and incomplete coverage. 

At the same time, in the Latin American region the population began to be mostly urban, in full demographic transition. Inequities in access to health services became increasingly visible, as they were organized with a centralist approach and failed to cover the entire population. Based on this approach, health systems have been pouring policies and resources to the levels of least complexity and closer to where people live. By virtue of the fact that they work on the maintenance of health trying to anticipate the onset of the disease and / or treating the disease at its initial levels, they are therefore more efficient and improve the quality of life of the population. 

The policies developed within the PHC framework are largely responsible for relevant changes in some health indicators; of 8 significant increase in health personnel who work professionally outside hospitals; of a certain tendency in the medical-industrial complex to develop ?portable? technologies; of the multiplication of health centers and other decentralized facilities incorporating themselves as social equipment near the most vulnerable populations; among others. 

In 2018, the Astana Declaration reaffirms9 ?primary health care as the most inclusive, efficient and effective approach to improving people?s physical and mental health as well as their social well-being, and that primary health care is the cornerstone of a sustainable health system for universal health coverage.? It also emphasizes the importance of promotion, prevention, cure and rehabilitation services, and accessibility as a priority. 

In addition, the Pan American Health Organization, through a high-level omission, prepared the document Universal Health in the XXI Century: 40 years of Alma-Ata, where among the 10 recommendations it proposes to promote networks with a first level of resolutive care (recommendation 2), implement initiatives to eliminate barriers to access to health services (recommendation 5), and promote the rational use and innovation of technological resources to serve the health needs of the population (recommendation 9).

It is common to say that in health supply generates demand. As well as the demand for health services, and with them for resources, tends to a continuous and incessant increase. This persistent increase in costs is due to the increase in supply (through new treatments and new technologies), the increase in chronic diseases (which is causing more people to live with a disease that is not fatal but requires permanent care for a long time), the increase in life expectancy (which also increases the incidence of chronic diseases), the increase in consumption habits in a society where access to health is also understood as a good to be consumed, the empowerment of sectors of the population that demand more benefits, and the demand induced due to the asymmetry of information between the patient and the provider who often demands for it. 

Based on this, decision-makers and administrators of health systems began to evaluate as economically more convenient the maintenance of health to the treatment of the disease, just as the treatment of a recent pathology requires fewer resources than that of an advanced one. The steadily rising costs of health services have become a permanent concern of both public and private service providers. A synthesis of these concerns is reflected by the WHO10 in 2010, where they refer to the fact that between 20 and 40% of health resources are wasted and that hospital care absorbs more than half and, sometimes, up to two thirds, of total public health expenditure; being both hospital admission and length of hospitalization the two most important (often excessive) types of expenses. As a way to overcome these economic barriers, it points toinvestment in primary care, ensuring easy and cheap physical access to services and prevention and promotion interventions for all that can be cost-effective and can reduce the need for subsequent treatment. 

In 2018, the Astana Declaration, mentioned above, also refers again to the need to take action on rising health care costs. However, it should be noted that in recent years some authors11 have begun to pose a paradoxical situation: that prevention reduces costs in the short term (since in general it is cheaper to treat a disease at the beginning than when it worsens) but, in the long term, the prolongation of life, product precisely of the aforementioned policies, It makes the demand on health and social security systems, and with it costs, tend to increase.

Pharmacology has allowed the reduction of the duration and even the disappearance of a large number of pathologies, and the outpatient treatment of diseases that previously required hospitalizations (often prolonged). At the same time, it has allowed, or contributed to, pathologies that were fatal have ceased to be so but that are not completely cured and, as a result, a high number of individuals, increasing, live with a permanent disease that limits their abilities and require constant attention. In some cases without hospitalization, but also, in others, with long hospitalizations that do not require greater diagnostic and treatment services. 

In addition, new perspectives are now opening up with biological therapies, nanotechnology, personalized pharmacotherapy (see point 3.3.4.), regenerative medicine with tissues and organs artificially made in laboratories (Mauri M. , 2015).12 According to the WHO, medicines (drugs) represent between 20 and 30% of global health expenditure.13

A large number of new and/or more modern diagnostic and treatment devices have been developed that have admitted methods of greater precision and information, less invasive, shorter duration of procedures and, often, outpatient use. New biomedical technologies have provided sophisticated tools such as computed tomography, magnetic resonance imaging and positron emission tomography that allow morphological and functional diagnostics for organs and molecules to be made without surgery. But also treatments such as minimally invasive surgery, surgery with robots, interventional radiology, new types of radiotherapies, and new laboratory methods (Mauri M. , 2015).14

2.3. Information and Communication Technologies (ICTs)

These allow remote communication and real-time information, facilitating diagnoses and treatments. Biomedical sciences are being radically transformed by advances in monitoring, recording, storing, and integrating the information that characterizes human biology and health at scales ranging from single molecules to large populations of subjects.15 The processing and use of this volume of information is affecting the modalities of care and, simultaneously, the characteristics of the physical resource in health. 

The Pan American Health Organization16 differentiates between Telemedicine (provision of remote health services in the components of promotion, prevention, diagnosis, treatment and rehabilitation, by health professionals using information and communication technologies) and Telehealth (set of activities related to health, services and methods, which are carried out remotely with the help of ICTs and include, inter alia, telemedicine and tele-education in health). 

Since the covid 19 pandemic, the implementation of telemedicine and telehealth has greatly accelerated. A series of services that were supposed to be possible to be realized but that were not implemented or that were implemented on a small scale, have been carried out in a much more massive way in a few months. Although the return to the new postpandemic normality again retracts the provision of part of these services to the face-to-face form, the leap that telehealth has taken in a short period of time will most likely have no turning back. 

Is it possible and necessary to think that remote consultations, diagnoses and treatments will now require a specific physical place?

The description of the human genome is perhaps the greatest advance (Mauri M. , 2015)17 of medical knowledge that could open a new era: predictive medicine that would allow to know in advance the predisposition to a disease and the possibilities of getting sick of each individual, allowing the focus of interventions on each person but opening, simultaneously, a large number of technical and ethical questions. In turn, the field of nanotechnology also opens up new therapeutic perspectives.

Artificial intelligence (AI) is defined as the ability of technologically coded algorithms to learn from data so that they can perform tasks automatically without each step having to be programmed specifically by the human being (WHO, 2021).18 The World Health Organization recognizes that AI represents a great opportunity for the practice of public health and medicine, but, simultaneously, in order to reap the benefits of AI, challenges for health systems, professionals and beneficiaries must be identified.

AI can improve the delivery of health services, both in prevention, diagnosis and treatment, and is already changing the delivery of health services in developed countries. The possible fields for AI in health are the different technologies available, genetic information, digitized medical records, radiological images and clinical care. Also in clinical research and drug development, in planning and management of health systems and in epidemiological surveillance. 

In the aforementioned document19, the WHO defines 6 key ethical principles for the use of AI in public health and medicine: 

• Protection of people?s autonomy 
• Promotion of human welfare and security and the public interest
• Ensure transparency, comprehensibility and intelligibility
• Promotion of responsibility and accountability 
• Ensure inclusion and equity 
• Promote responsible and sustainable AI

3. Changes in the epidemiological profiles of the population

Towards the beginning of the twentieth century in developed countries and towards the end of the same century in underdeveloped countries, with Argentina in an intermediate stage, all populations have made an epidemiological transition in the direction of the reduction or disappearance of infectious and contagious diseases and the increase in degenerative diseases. New pathologies have also been incorporated as a result of social and environmental conditions. 

The increase in life expectancy during the twentieth century, and changes in living and feeding conditions are closely related to the epidemiological transition, being both engine and consequence. Likewise, the control of mortality from many diseases has increased the number of people living with some type of chronic disability that requires long treatments, but generally without hospitalization. 

In January 2020, when the Covid 19 pandemic had not yet broken out, the United Nations (UN) identified in a document20 the 13 challenges of global health for the decade that was beginning.

These are generic definitions, framework themes, such as ?good intentions? and it is difficult to find in them elements that can directly influence architecture for health. 

On September 2011, the United Nations General Assembly met to discuss the prevention and control of noncommunicable diseases worldwide. It was the second time in the history of the UN that the General Assembly convenes a summit to address a health issue (the first was AIDS), which accounts for the magnitude and repercussions that the advance of these pathologies is having worldwide. The approved document21 defines the four main noncommunicable diseases as cardiovascular diseases, cancer, chronic lung diseases and diabetes, which according to the World Health Organization claim the lives of three out of five people worldwide and cause great socio-economic damage in all countries. in particular developing countries. It defines the four diseases as preventable and places the focus on health promotion and prevention, as well as changes towards healthier lifestyles and improved living conditions of populations as the main strategies to prevent them. It also identifies as having a significant incidence of mental and neurological disorders, and renal, oral, and ocular diseases. It also emphasizes the need to strengthen the capacities of health systems (mentioning laboratory and imaging services in particular), and to facilitate access to and coverage of them.

Since the transformations mentioned above, the modalities of care have been modifiedand also, as a consequence, the characteristics of the buildings intended for the provision of health services. This includes hospitals, as well as the great development of two large groups of new building types:

The main characteristic of these buildings is the absence of hospitalization as we know it in hospitals (more than 8 or 12 hours), although they may have hospitalizations called short stay (some hours). 

These buildings for outpatient care can be low (health center, primary care center, rehabilitation, dental, outpatient, etc.) or medium complexity (diagnostic imaging, outpatient surgery, endoscopies, radiotherapy, cancer treatments, dialysis, emergency, assisted fertilization, laboratories, blood processing, etc.), as well as consultation, diagnosis or treatment, or having more than one of these particularities simultaneously. They are small or medium scale, are embedded in the habitat of the population and must have resolution capacity.

Ambulatory care buildings have a greater heterogeneity than hospitals in the sense that the latter are much more repetitive and regular in the services that compose them and in how they are organized. 

A hospital requires a minimum number and type of services to be able to function as such, and the existence of certain services requires the presence of others. If we define that a health care building to be called a hospital must have hospitalization, it must also inevitably have diagnostic and treatment services complementary to hospitalization since it would lose meaning without them. That is why we always find, even in hospitals of less complexity, services such as laboratory, imaging, surgery, and most likely deliveries. These services in turn require the existence of others such as intensive care and neonatology. On the other hand, a series of supply and processing services (pharmacy, food, laundry, sterilization, warehouses, etc.) will be necessary for the previous ones to function and the hospital can remain in activity continuously and permanently: 24 hours a day, 365 days a year. To these may be added others, but even the smallest and least complex hospital, will have a minimum of ten or twelve services and a basic organization from them. In contrast, (only) ambulatory care buildings can have from one sunor service to more than ten. Mostof them do not require practically another to operate since the benefits that are made in them are commonly self-sufficient. This makes the variability of this type of buildings much greater, and that they are much less repetitive in their programming and organization than hospitals.

The essential particularity of these buildings is that they become the habitat of people with chronic diseases (permanently) or semi-chronic diseases (for a prolonged period of time) that require long hospitalizations in spaces with specific physical characteristics according to the pathology. 

This has involved the development of new types of buildings for certain diseases, whose main characteristic is to become the temporary or permanent habitat of populations with chronic diseases, such as buildings for complex rehabilitation, Alzheimer?s disease or palliative care. Although the hospitalization of these buildings usually has characteristics that differ from the acute hospital, a certain continuity can be established with the old chronic hospitals such as mental health, leprosariums, etc. 

Buildings with hospitalization for specific chronic diseases require particular spatial resolutions according to the pathology they attend (due to conditions of the pathology), require hospitalizations more similar to a home (specific places to sleep, specific places for activities of day life, places of recreation, etc.) than to that of an acute hospital hospitalization, They have few or no diagnostic services, do not require urgent or emergency services, treatment services are specific and limited, therefore occupying high percentages of the building?s surface in hospitalization.

4.3. The new (or not so much) disciplinary field

IPH Library

This title outlines an overview of architecture in health, analyzing the historical evolution of physical spaces from ancient times up to today. It discusses the basic concepts of architecture and hospitality, as well as the importance of humanization in environments and their services as a differential in the market, in addition to analyzing the health building from the perspective of sustainability and social and environmental responsibility.

Conhecendo a arquitetura hospitalar

Renata Dejtiar Waksman (Coordination); Renata Dejtiar Waksman and Olga Guilhermina Dias Farah (Editing) 

Santana do Parnaíba [SP]: Manole, 2022 (Manuais de Especialização; 23)

Belongs to Manuais de Especialização series, published by Albert Einstein Israeli Institute of Teaching and Research. This title was developed in a multidisciplinary way, seeking to reinforce the importance of Hospital Architecture in present times. It addresses topics such as: master plan, design, design process, approval and development of a hospital project; organization of flows in the hospital; ambience and humanization; neuroscience applied to comfort architecture; hospital hospitality processes, among others.

The Patient Room: Planning, Design, Layout 

Wolfgang Sunder, Julia Moellmann, Oliver Zeise and Lukas Adrian Jurk 

Basel: Burkhäuser, 2020

This book addresses the current challenges in planning, designing, and conceiving the layout of patient rooms in the hospital context. Moreover, it examines the most appropriate measures under the aspects of hygiene to promote patient recovery and contain the spread of infections. The chapters address aspects such as nursing care, possibilities for patient room design and the research project Krankenhaus, Architektur, Mikrobiom and Infektion (KARMIN), in English, ?Hospital, Architecture, Microbiome and Infection?. 

All books are available to the public. To schedule an appointment to study them, please send an email to biblioteca@iph.org.br.