Architectural design strategies for infection prevention and control in resource-limited rural healthcare facilities in developing countries: bridging the gap with context-sensitive design

Introduction

The Sustainable Development Goals (SDGs) have set a broad agenda to advance health and achieve equity by 2030. However, promoting healthy lives and well-being for all remains a challenge in resource-limited settings [1]. Many areas in developing countries still suffer from significant socio-economic imbalances and inequalities in access to healthcare resources and quality medical care. Infection prevention and control (IPC) is particularly challenging in rural areas where health resources are often extremely limited [2,4]. Simultaneously, infectious diseases heavily burden population health outcomes and present a formidable challenge for public health. According to the World Health Organization, a high burden of communicable diseases such as malaria, tuberculosis, and HIV/AIDS puts considerable pressure on healthcare systems in developing countries [5]. Access to care in qualified centres is difficult for a large portion of the population in these areas, and as a result, the SDGs for reducing infection-related mortality rates remain unmet (fig 1) [6]. Given these challenges, the availability of healthcare facilities capable of effectively responding to needs in safe and highly sustainable spaces is a key priority for individual and public health, especially in extremely resource-limited rural areas.

Infection prevention and control in developing countries

IPC represents a fundamental, evidence-based approach aimed at safeguarding patients and healthcare workers from avoidable infections. It influences every aspect of healthcare, including hand hygiene, prevention of surgical site infections, injection safety, antimicrobial resistance, and hospital operations during both emergencies and routine care [4,7-9]. IPC is unique in the realm of patient safety and quality care as it is universally relevant to every healthcare interaction, involving every patient and health worker (fig 2). Achieving effective IPC is a priority in any care programme and requires continuous efforts at all levels of the healthcare system, from policymakers and facility managers to healthcare workers and patients. Supportive IPC programmes are particularly vital in low- and middle-income countries, where healthcare delivery and hygiene standards are often compromised by secondary infections [7-9]. The World Health Organization states that the risk of healthcare-associated infections (HAIs) in developing countries is two to twenty times higher than in industrialised nations. This is due to a combination of factors: limited resources, infrastructural constraints, knowledge gaps, and socio-economic and political factors [10].

Developing countries often face shortages of essential resources such as clean water, sanitation facilities, personal protective equipment, disinfectants, and trained healthcare workers. Overcrowding in hospitals, inadequate ventilation systems, and poor waste management practices can contribute to the spread of infections. The lack of awareness and training on proper IPC practices among healthcare workers can hinder effective implementation. Moreover, poverty, malnutrition, and limited access to healthcare can increase patient susceptibility to infections.

Improving IPC in developing countries requires a multifaceted approach. Strong political will and investment in healthcare infrastructure, resources, and training programmes are essential. Providing healthcare workers with the necessary resources, training, and support to implement IPC guidelines is crucial. Engaging communities in IPC efforts and promoting health education can lead to sustainable behavior change [11]. Sharing knowledge, best practices, and resources between developed and developing countries can accelerate progress. However, in under-resourced and remote rural settings, where access to high-quality healthcare infrastructure is limited, the challenge of adhering to IPC guidelines is even greater [12]. These areas often face not only high burdens of communicable diseases but also significant geographical and climatic obstacles, combined with unique social, cultural, and spiritual beliefs that collectively contribute to the difficulty of infection control [13]. The presence of small healthcare centres in these regions is crucial for safeguarding public health, yet the challenging environmental conditions prevalent in these areas often lead to minimal adherence to IPC standards. Despite the daunting challenge, there are proven strategies to improve IPC even in resource-limited settings. Key IPC strategies can be summarized in seven main points: hand hygiene, environmental cleaning and disinfection, safe injection practices, waste management, isolation precautions, antimicrobial stewardship, and education and training. Addressing these challenges and implementing effective IPC strategies can create safer healthcare environments and improve health outcomes for all, regardless of where they live [12]. A less explored yet critically important aspect of IPC application is the contribution that targeted hospital space design can make. Architectural resources and strategies can substantially enhance IPC standards even under extreme conditions and at minimal cost. Epidemiologically, the healthcare environment is considered one of the extrinsic factors that affect the infectious agent and the opportunity for exposure. Although the relationship between the healthcare environment and infectious disease prevention and control is gaining recognition, developing the knowledge of efficiently adopting design strategies for infectious disease control remains a significant challenge in developing countries [11,14].

Architectural design contributions to infection prevention and control in extremely resource-limited settings: passive design strategies

Architectural design can significantly contribute to infection prevention and control in healthcare facilities, even in resource-constrained settings. Even small design choices can have a big impact on IPC. By focusing on affordability, sustainability, and local context, architects can make a real difference in creating safer healthcare environments in developing countries. By embracing safe and sustainable design strategies, healthcare facilities in developing countries can move towards a more environmentally responsible, cost-effective, and resilient model of care, ultimately benefiting both present and future generations [15,16]. Finally, by engaging with local communities to understand their needs and practices related to hygiene and healthcare, policy makers and architects can organize and design healthcare facilities culturally appropriate and accepted by the community [17].

Some key strategies are reported in table 1.

Passive design strategies involve a suite of sustainable architectural techniques that harness natural resources to optimize a building’s performance, comfort, and energy efficiency. Unlike active design systems that depend on mechanical interventions, passive strategies exploit the inherent characteristics of a site to regulate heating, cooling, lighting, and ventilation (fig. 3).

Essential elements such as solar orientation, wind patterns, thermal mass, local material availability, and geological features play a pivotal role in determining the passive strategies for a healthcare facility project [17]. Therefore, it is imperative for architects working on the design of low-resource rural clinics and hospitals in developing countries to explore passive design strategies that minimize environmental and climate impact, and reduce both construction and maintenance costs.

Examples of passive design strategies to enhance natural ventilation and lighting

rom an architectural perspective, natural ventilation leverages differences in air pressure, temperature, and wind to ventilate buildings without the need for mechanical systems [18-23]. This method includes various techniques such as stack ventilation, wind towers, and courtyard effects. Stack ventilation utilizes temperature differences to expel warm air from tall rooms or structures. Wind towers cool incoming air through evaporation before distributing it indoors (fig. 4) [24]. Courtyards facilitate the rise of warm air, which is then replaced by cooler air entering at lower levels (fig. 5) [25]. Optimal natural airflow can be achieved through proper building orientation, strategic openings, cross ventilation, and tall structures. While natural ventilation provides cost-free ventilation, it offers less control over air quality compared to mechanical systems.

Prioritize designs that maximize natural ventilation and sunlight is a key resource for the projects of rural healthcare facilities. As previously reported, good airflow helps to remove airborne pathogens, and sunlight has natural disinfectant properties. Natural ventilation and lighting are valuable and integrated tools for infection control, especially in limited-resource settings where mechanical systems might be expensive or unreliable. By thoughtfully integrating natural ventilation and lighting, architects can create healthcare environments that are healthier, more sustainable, and better suited for resource-constrained settings. This can be achieved through strategically placed windows, courtyards, and building orientation [6-7]. Key architectural considerations are that:

1. design should be tailored to the local climate to ensure comfort and effectiveness;
2. cultural preferences and practices related to ventilation and light should be strictly considered for the acceptability of the healthcare users;
3. natural ventilation should be balanced with infection control measures, such as appropriate spatial separation, to prevent cross-contamination.

Integrating natural ventilation and lighting in healthcare facilities in developing countries contributes to a more sustainable and resilient healthcare infrastructure in several ways. Firstly, this architectonic strategy reduces environmental impact by decreasing reliance on energy-intensive HVAC systems and artificial lighting, natural alternatives significantly lower a facility’s carbon footprint and operational costs. Natural ventilation and lighting systems are less susceptible to power outages or mechanical failures, making them more resilient in the face of natural disasters or infrastructure challenges often faced in developing countries. The reduced reliance on mechanical systems translates to significant cost savings on energy bills and maintenance, freeing up resources for other critical healthcare needs. This is particularly impactful in regions with unreliable electricity grids or limited resources. Moreover, by improving indoor air quality and providing natural light, these strategies can contribute to a healthier healing environment, potentially reducing the spread of infections and improving patient recovery times [8]. Natural ventilation and lighting can create a more comfortable and pleasant environment for patients, staff, and visitors, potentially reducing stress and improving overall well-being. Finally, utilizing readily available resources like sunlight and wind can empower local communities to participate in the construction and maintenance of their healthcare facilities, fostering a sense of ownership and sustainability.

Perspectives: strategies to achieve net zero healthcare facilities in developing countries

The drive towards sustainability in the built environment has increasingly centered on achieving net-zero energy consumption, especially in the context of workplace design [25]. The net-zero workplace design framework goes beyond the basic goal of environmental impact reduction. It offers a holistic approach that addresses both environmental sustainability and the well-being of occupants. This design philosophy incorporates natural ventilation, maximizes daylight exposure, and fosters the creation of inspiring work environments, all of which play a vital role in enhancing the quality of life for patients and workers [26-28]. It is important to understand that achieving a net-zero workplace involves a comprehensive approach that includes several critical components. At the core of this endeavor is the principle of energy efficiency, which focuses on reducing energy consumption through the implementation of advanced systems and practices designed to minimize waste and optimize the use of resources. This involves adopting measures such as high-efficiency lighting, advanced HVAC systems, and energy-saving building designs. In addition to enhancing energy efficiency, another fundamental aspect of creating a net-zero workplace is the incorporation of renewable energy sources. This involves integrating clean energy solutions like solar panels, wind turbines, or geothermal systems to meet the workplace’s energy demands. By relying on these renewable sources, businesses can significantly reduce their dependence on fossil fuels and move towards a more sustainable energy future [27]. However, achieving net-zero energy consumption also requires addressing any remaining carbon emissions through carbon offsetting. This final step involves compensating for residual emissions by engaging in activities such as tree planting or investing in carbon offset projects. These efforts help to balance out the carbon footprint of the workplace, thereby contributing to the broader goal of environmental sustainability. Together, these components – energy efficiency, renewable energy, and carbon offsetting – form the foundation of a net-zero workplace strategy. Each element plays a crucial role in not only reducing the environmental impact of workplace operations but also in fostering a more sustainable and responsible approach to energy use and carbon management [26-28]. To achieve a fair and effective transition to net-zero healthcare, strategies must be progressive rather than uniform, addressing population dynamics and essential needs, and ensuring that the most significant polluters reach net-zero emissions sooner to create opportunities for others. Accelerating the net-zero healthcare agenda can not only reduce the climate impact of healthcare practices but also drive the societal transformation essential for meeting the Paris Agreement’s climate objectives. In this decisive decade for climate action, the health sector must play an active and leading role.

Conclusions

One of the key challenges for scientists is health-care innovation in developing nations. Creating a low-cost innovation to address a global health problem is not easy. Scaling it up, securing financing, ensuring distribution, achieving cultural acceptance, and actual utilization are even more challenging. Success depends on understanding the conditions and resources of the local community. Working side by side, integrating diverse disciplines and expertise, even when they seem vastly different and distant, is the only path to achieving widespread and global health.