Kibuye Hope Hospital

KIBUYE HOPE HOSPITAL Hope Africa University Kibuye, Burundi eMi Project 9134 | April 2013

Volume One: Site Assessment

Engineering Ministries International - East Africa Mailing Address: PO box 3251, Kampala, Uganda Physical Address: Plot 7244 Kiwafu Road Phone: +256-41-426-7849 Email: info@emiea.org Website: www.emiea.org

designing a world of hope

Engineering Ministries International ‐ East Africa

Project No. 9134

TABLE OF CONTENTS

REPORT 1.0

INTRODUCTION ................................................................................................................. 1

1.1 1.2 1.3

MINISTRY OVERVIEW ............................................................................................................ 1 EMI TRIP AND TEAM PERSONNEL ......................................................................................... 1 SCOPE OF WORK ................................................................................................................... 2

2.0

SITE EVALUATION .............................................................................................................. 3

3.0

ARCHITECTURAL SITE ANALYSIS ......................................................................................... 4

3.1 3.2 3.3 3.4 3.5 3.6 3.7 4.0

GEOGRAPHIC LOCATION ....................................................................................................... 4 CAMPUS ZONES .................................................................................................................... 4 SITE MODEL ........................................................................................................................... 5 CIRCULATION ........................................................................................................................ 6 CLIMATE ................................................................................................................................ 8 ACCESSIBILITY ........................................................................................................................ 9 SITE VIEWS .......................................................................................................................... 10 HOSPITAL ARCHITECTURAL PROGRAM ............................................................................ 10

4.1 4.2 4.3 4.4 4.5 5.0

INTERNAL MEDICINE & EMERGENCY CARE ........................................................................ 10 SURGERY DEPARTMENT ...................................................................................................... 11 PEDIATRICS DEPARTMENT .................................................................................................. 12 MATERNITY DEPARTMENT .................................................................................................. 12 COMMUNITY HEALTH DEPARTMENT .................................................................................. 13 STRUCTURAL ASSESSMENT .............................................................................................. 14

5.1 5.2 6.0

STRUCTURAL CONDITION INSPECTION ............................................................................... 14 DESCRIPTION OF NEW ON‐SITE CONSTRUCTION METHODS .............................................. 16 WATER SUPPLY SYSTEM ASSESSMENT ............................................................................. 21

6.1 6.2 6.3 6.4 6.5 6.6 6.7 7.0

OVERVIEW ........................................................................................................................... 21 INFORMATION SOURCES .................................................................................................... 22 WATER USE (WATER DEMAND) .......................................................................................... 23 SOURCES ............................................................................................................................. 24 STORAGE ............................................................................................................................. 28 WATER QUALITY AND TREATMENT .................................................................................... 29 DISTRIBUTION SYSTEM ....................................................................................................... 29 WASTEWATER SYSTEM ASSESSMENT ............................................................................... 29

7.1 7.2 8.0

DESCRIPTION OF EXISTING FACILITIES ................................................................................ 29 PERCOLATION TESTS ........................................................................................................... 30 SOLID WASTE MANAGEMENT ASSESSMENT .................................................................... 30

8.1 8.2 9.0

OVERVIEW ........................................................................................................................... 30 RECOMMENDATIONS .......................................................................................................... 31 ELECTRICAL ASSESSMENT ................................................................................................ 31

9.1 9.2 10.0

CAMPUS ELECTRICAL SURVEY ............................................................................................. 31 EXISTING BUILDINGS ELECTRICAL INSPECTION................................................................... 34 CONCLUSION ................................................................................................................... 39

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LIST OF TABLES Table 1‐1: Assessment Team .................................................................................................................. 2 Table 4‐1: Hospital inpatient bed count ............................................................................................... 11 Table 5‐1: Material properties .............................................................................................................. 20 Table 5‐2: Mix ratios ............................................................................................................................. 20 Table 6‐1: Estimated off‐campus use of springs supply ....................................................................... 23 Table 6‐2: Calculation of Kibuye FMC water use .................................................................................. 25 Table 9‐1: Electrical demand according to utility billing records .......................................................... 32

LIST OF FIGURES Figure 1.1: Assessment Team ................................................................................................................. 1 Figure 2.1: FMC Kibuye site survey ......................................................................................................... 3 Figure 3.1: Kibuye is located in south‐central Burundi ........................................................................... 4 Figure 3.2: Existing zones on the Kibuye FMC property ......................................................................... 5 Figure 3.3: 3‐D site model of Kibuye FMC property ............................................................................... 6 Figure 3.4: Physical boundary illustrated in a site section of Kibuye FMC Property .............................. 6 Figure 3.5: Existing vehicular circulation ................................................................................................ 7 Figure 3.6: Existing pedestrian circulation .............................................................................................. 8 Figure 3.7: Average monthly rainfall for Gitega ...................................................................................... 8 Figure 3.8: Average monthly temperature for Gitega ............................................................................ 8 Figure 3.9: Accessibility problem areas on the hospital campus ............................................................ 9 Figure 5.1: Unsupported lintel at Women's Health Clinic .................................................................... 14 Figure 5.2: Crack in brick wall at southwest corner of Men's Ward ..................................................... 15 Figure 5.3: Cracking of brickwork under roof purlin in south end of north gable wall ........................ 16 Figure 5.4: Cracking of brickwork below window in east wall of the north wing ................................. 16 Figure 5.5: East wall of Morgue / Laundry ............................................................................................ 16 Figure 5.6: Stones used for foundation walls ....................................................................................... 17 Figure 5.7: Grade beam at perimeter of building. ................................................................................ 17 Figure 5.8: Masonry work underway. Note lighter‐colored, durable clay bricks used at exterior walls and darker‐colored non‐durable soil bricks used at interior walls. ............................................. 18 Figure 5.9: Area between bond beam and window header filled with screened louvers .................... 20 Figure 5.10: Bond beam located at truss bearing elevation ................................................................. 20 Figure 5.11: Roof plan for World Relief Triplex .................................................................................... 21 Figure 5.12: Truss web configurations are not modified according to panel points ............................ 21 Figure 5.13: Poorly constructed hip truss joint ..................................................................................... 21 Figure 6.1: Water supply system schematic ......................................................................................... 22 Figure 6.2: Estimated water use for the Kibuye FMC property ............................................................ 23 Figure 6.3: Estimated water use and water supply for the Kibuye FMC property ............................... 28 Figure 6.4: 9,200L main hospital water tank ........................................................................................ 28 Figure 7.1: The wastewater treatment system observed at the new Quadriplex Visitor Housing is said to be typical for wastewater treatment systems throughout the campus .................................. 30 Figure 8.1: Hospital incinerator ............................................................................................................ 31 Figure 9.1: 6.6KV Transformer on site .................................................................................................. 31 Figure 9.2: Exposed feed to Women's Health Clinic ............................................................................. 34 Figure 9.3: Maternity Building meter.................................................................................................... 35 Figure 9.4: Surgical theater backup ...................................................................................................... 35 Figure 9.5: Quadriplex meter ................................................................................................................ 37 Figure 9.6: Ogden House electrical installation .................................................................................... 38 Figure 9.7: Exposed splice at Police House ........................................................................................... 38

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APPENDICES APPENDIX A APPENDIX B APPENDIX C APPENDIX D APPENDIX E

– ARCHITECTURAL DATA – WATER SUPPLY DATA – WASTEWATER MANAGEMENT DATA – STRUCTURAL DATA – ELECTRICAL DATA

RENDERINGS

DRAWINGS

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INTRODUCTION

1.0 1.1

MINISTRY OVERVIEW

Kibuye Hospital was founded in the 1940s by Free Methodist Missionaries and has served the surrounding area continuously since its founding, with periodic interruptions due to political instability. The 110‐bed hospital serves a rural population of roughly 250,000 people, covering about one tenth of the geographical area of Burundi, and is the hospital of reference for 12 rural clinics.

Kibuye is currently staffed by 6 African medical doctors who are assisted and mentored by visiting expatriate professionals of around 20 per year. The hospital is supported by patient fees and by government subsidies for several programs, in addition to some outside help from grants, private donors and benevolent organizations. The hospital maintains a strong Christian identity, demonstrating a clear spiritual witness in the lives of staff and maintaining a regular ministry to its patients through the services of chaplains and pastors. It also operates a small cereal factory which produces a food supplement widely and charitably distributed in the country.

Hope Africa University is a Christian university, founded in the year 2000 in Nairobi and later moved to Burundi, where it opened in 2003. The school’s current student body population is over 6,000, and it offers fields of study in Business, Law, Education, Civil Engineering, Bible, and Health Sciences.

It also has a number of graduate programs including a Medical School and a Nursing School. It was founded by the Equatorial Africa Area Fellowship of the Free Methodist Church and is operated by the Free Methodist Church of Burundi.

In February 2010, Kibuye Hospital was transferred to Hope Africa University (HAU) from the Free Methodist Church of Burundi for development as a teaching facility for the clinical training of the University's nursing and medical students. HAU gave it the name Kibuye Hope Hospital and in recent years has begun providing personnel, training and administrative assistance to enable the facility to increase in capacity. Since becoming part of the University, aggressive plans have been in process for expansion of the hospital in concert with the January 2014 arrival of six expatriate career teacher‐ physicians.

Everything done in connection with Hope Africa University, including its hospital campus, has a strong Christian witness component along with the desire to train African leadership at the highest levels of excellence.

1.2

EMI TRIP AND TEAM PERSONNEL

Engineering Ministries International East Africa (EMI EA) was invited to partner with Hope Africa University to develop a master plan for the future development of Kibuye Hope Hospital. EMI EA believes strongly in the importance of providing a multi‐disciplined approach to master planning.

This approach includes in‐depth consideration of architecture, water, wastewater, drainage, electricity, agriculture, pedestrian and vehicular circulation, topography, and existing structures and infrastructure. In order to manage the scope left to right): Figure 1.1: Assessment Team of the project, it was determined that the best (from Daniel Propst, John Joiner, John Ellis, Paul Gilham, approach was to send two teams: an Assessment Anne Herron, Philip Greene, Uriah McCall, Paul Berg Team and a Master Planning Team. This report (Not pictured: Larry Bucar)

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covers the work of the EMI EA Assessment Team. This Team (see Figure 1.1 and Table 1‐1) worked with the ministry from February 17 to February 27, 2013 to complete a topographic survey, document existing building layouts, evaluate soil conditions and water supply sources, investigate and assess local construction practices, investigate and assess electrical infrastructure, and document existing facility and space‐use patterns. EMI EA’s Master Planning Team will use this assessment report to begin the master planning process when they travel to Kibuye in April of 2013.

Table 1‐1: Assessment Team TEAM MEMBER

ROLE

Philip Greene

EMI EA Team Leader/Staff Structural Engineer

John Ellis

Secretary, Friends of Hope Africa University

Paul Berg

Volunteer, Civil Engineer

John Joiner

Volunteer, Electrical Engineer

Paul Gilham

Volunteer, Structural Engineer

Larry Bucar

Volunteer, Land Surveyor

Daniel Propst

Volunteer, Mechanical Engineer

Anne Herron

EMI EA Landscape Architecture Intern

Uriah McCall

EMI EA Structural Engineering Intern

1.3

SCOPE OF WORK

The scope of work for this stage of the project includes the following:  Topographical and as‐built survey of the existing 65‐acre site;  Documentation of existing buildings, utilities, infrastructure, and vehicular and pedestrian circulation;  Documentation of existing programs, use of space and site functions;  Documentation and assessment of the structural conditions within existing buildings, and structural soils analysis;  Documentation and assessment of electrical supply and distribution, including verification of existing power demand;  Documentation and assessment of the mechanical systems and equipment within the hospital, including compressed air, medical gas and vacuum systems;  Documentation and assessment of water supply and distribution, including water quality testing and verifying existing water demand;  Documentation and assessment of wastewater and sanitary systems, including soils percolation testing and verification of existing wastewater demand;  Documentation of regional utilities and planned utilities expansion/development in coordination with local officials; and  Water, wastewater and electrical/mechanical systems feasibility reports, including initial recommendations/options for improved and/or alternate systems.

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2.0

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SITE EVALUATION

The Kibuye Free Methodist Church (FMC) property, where Kibuye Hope Hospital sits, is located approximately 34 kilometers (km), by road, south of Gitega, Burundi’s second‐largest city. It sits on 23 hectares (57 acres) immediately adjacent to the major north‐south‐running highway.

The primary survey was completed from February 19 to March 1, 2013, during and after the EMI EA Assessment Team’s stay in Burundi. The survey covered an area of 25 hectares (62 acres) and included 1,027 observations using a Sokkia SET total station and Sokkia data collector. Coordinates were based on a single point GPS positioning of Control Point “Benchmark” referenced to the WGS 84 Datum. These observations comprised of significant ground elevations including grade changes, corners of structures, roads, water courses, and the establishment of survey control points. These control points can be used for future reference for surveying and layout of structures.

The property sits on top of a knoll (see Figure 2.1), sloping downwards in three directions – north, east and south – to a series of small streams. These streams form parts of the property boundary on the north, east and south sides, and they form a flat and wide flood plain. Rising up from the plain on the steeper slopes on the north, east and south sides of the property, the land is covered in relatively dense woodland composed of native species and eucalyptus. The central portion of the property, where most of the development has occurred, is mostly flat with a gentle slope (3.6%) downward toward the east. The property slopes gradually upward toward the west and southwest, wherein there are predominately agricultural fields and scattered woodlands.

Several boundary markers delineating the property boundary were included in the survey, but the EMI EA survey was not intended to be, nor should it be used as, a legal boundary survey. A professional land surveyor registered in the region to carry out boundary surveys should be consulted to establish and/or verify this property’s boundaries and any potential encroachments.

Figure 2.1: FMC Kibuye site survey April 2013

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ARCHITECTURAL SITE ANALYSIS

3.0

The EMI EA team conducted a full architectural site analysis of the Kibuye Free Methodist Church property over an eight day period. Site analysis involves research and data collection that relates specifically to the site and how it is used. The information collected will aid in the design of the master plan for Kibuye Hope Hospital (KHH). Data was collected primarily by careful observation and by interaction with local staff, patients, and community leaders. The site analysis has been documented in the following narrative and illustrations.

3.1

GEOGRAPHIC LOCATION

Kibuye is located in central Burundi, 120km by road from the capital of Bujumbura (76km as the crow flies) and 34km from Burundi’s second‐largest city, Gitega (see Figure 3.1). The hospital is less than 1km away from a paved, well‐maintained highway (RN8) that runs north‐south through the country. While the hospital currently serves a population of roughly 250,000, its expected growth in capacity is likely to draw a much greater number from further afield and from outside of Burundi, particularly with the introduction of specialty‐level services like ophthalmology, surgery, and pediatrics. The Burundi Ministry of Health is aware of the services that KHH currently provides, and as the hospital grows in capacity, it may achieve the status of a referral hospital for its district and others in southern Burundi.

Figure 3.1: Kibuye is located in south‐central Burundi

3.2

CAMPUS ZONES

There are four primary zones that comprise the Kibuye FMC property (see Figure 3.2): the Hopsital Zone, the Staff Housing Zone, the Church/Community Zone, and the Primary School Zone. A large‐ scale zoning diagram is provided on the rendering sheets included in this report.

3.2.1

HOSPITAL ZONE

The Hospital Zone (shaded blue in Figure 3.2) is clearly defined by a perimeter fence and masonry wall. This area can be accessed by three entrances: the main entrance on the west and two side entrances on the east. The small cereal factory, called the Busoma Plant, is also located in the Hospital Zone.

3.2.2

STAFF HOUSING ZONE

The Staff Housing Zone (shaded orange in Figure 3.2) has no clear site boundary. Many of the homes at the south and east of the site are tucked away within the landscape which provides very little security. The homes on the west side of the site are interspersed among the village homes and are not clearly recogonized as hospital or church staff housing, making the security of this zone very poor.

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3.2.3

Project No. 9134

CHURCH/COMMUNITY ZONE

At the center of the Kibuye FMC property stands a large rectangular church surrounded by open lawn for community use. This Church/Community Zone (shaded yellow in Figure 3.2) is defined on all four sides by a dirt roadway.

3.2.4

PRIMARY SCHOOL ZONE

On the north side of the site sits a five‐building primary school that is attended by children from the surrounding villages. The Primary School Zone (shaded green in Figure 3.2) is clearly defined by a perimeter fence which creates a phyiscal boundary between the school and the rest of the campus.

The only other zone the primary school has regular access to is the Church/Community Zone for outdoor activities. Interaction with the rest of the site is limited to cirulation.

Figure 3.2: Existing zones on the Kibuye FMC property

3.3

SITE MODEL

The three‐dimensional model of the Kibuye FMC property, presented in Figure 3.3, provides a representation of building density, topographic relationships of figure (building) and ground.

By understanding the location of the individual buildings and how they relate to each other and the surrounding area, EMI EA can better serve the current and future needs of the Hospital.

An important part of site analysis is understanding the physical boundaries of the site and how to work with and within these boundaries. Figure 2.1 depicts the property boundary that represents the full property owned by the Free Methodist Church of Burundi. The 25 hectares are determined

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by this ‘legal boundary’a. In addition to this property boundary, however, it was found that the Kibuye FMC property is marked by a very strong physical boundary. Figure 3.4 shows how the central area is relatively flat and covered by buildings and areas of small‐scale agriculture. These relatively flat areas are surrounded on three sides by steep valley slopes that then flatten out into the flood plain of a collection of small creeks. This lush flood plain is used by the church and its neighbors for additional small‐scale agricultural production.

Figure 3.3: 3‐D site model of Kibuye FMC property

Figure 3.4: Physical boundary illustrated in a site section of Kibuye FMC Property

3.4

CIRCULATION

Circulation is an essential field of study for every site. Understanding both pedestrian and vehicular circulation patterns and volume informs how the site is used and accessed. This in turn will direct the master planning process and determine ideas of development density, parking needs, patient flow, entrance locations and security needs.

3.4.1

VEHICULAR CIRCULATION

The majority of staff, patients and visitors arrive to the church, hospital and school on foot. Very little vehicular traffic enters the site on a daily basis. Vehicles that do come to the Kibuye FMC property enter at the east side from RN8, the main road to Gitega and Bujumbura. RN8 is a paved and well‐maintained two‐lane highway. The road from the highway to the FMC Kibuye property is a predominately‐private dirt road that crosses two culvert‐directed low‐flowing creeks. The traffic flow and patterns observed by the EMI EA team are represented in Figure 3.5, in which the two vehicular

a

See Section 2.0. The EMI EA survey of the property boundaries was informed by local maintenance workers. The EMI EA survey was not intended to be, nor should it be used as, a legal boundary survey.

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entrances to the hospital campus are indicated with yellow stars. The Busoma plant, at the southeast corner of the hospital campus, has regular deliveries of grains by a small truck. At present, vehicular traffic to the hospital is directed around the southern hospital boundary and then through the gate on the west edge of the hospital. There is unmarked, unpaved space to park within the western gate, and the hospital ambulance has a covered parking spot there. The rest of the site sees very minor vehicular traffic, the bulk of which is motorcycle traffic.

Figure 3.5: Existing vehicular circulation

3.4.2

PEDESTRIAN CIRCULATION

The village to the west of the property has a high residential density. The site in general is very active with pedestrian flow. Most pedestrian traffic is related to the hospital and its services, though the path to the west of the hospital sees a good deal of pass‐through traffic between homesteads and small‐scale agricultural property. See Figure 3.6 for a depiction of the different levels of pedestrian circulation. The heavy blue dashed line represents the primary circulation paths that carry the majority of pedestrian flow and provide the site’s connection to the adjacent village to the southwest. The lighter blue dashed line represents secondary paths with lower traffic flow. The orange dashed line represents circulation within the hospital campus, and the shaded areas represent areas where patients and family members are found gathering and/or waiting for medical services. The green area represents the neighborhood gathering and activity space.

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Figure 3.6: Existing pedestrian circulation

3.5

CLIMATE 3.5.1

RAINFALL

The area surrounding Gitega, Burundi, which includes Kibuye, has moderate rainfall with two wet seasons, peaking in April and November, and only one dry season from June to August . The two wet seasons are broken up by a moderate season, neither dry nor wet, which occurs between December and February (see Figure 3.7).

Figure 3.7: Average monthly rainfall for Gitega

3.5.2

Figure 3.8: Average monthly temperature for Gitega

TEMPERATURE

Because of Kibuye’s elevation (1700 meters) in the mountainous region of central Burundi and its tropical location, the area around Kibuye has very moderate and comfortable temperatures year April 2013

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round (see Figure 3.8). With the average temperature around 16 degrees Celsius, simple passive ventilation systems within existing buildings are adequate, keeping room temperatures at comfortable levels throughout the day. Even the Main Hospital Building, which has a central corridor with rooms on both sides, does not suffer from lack of cross‐ventilation.

3.5.3

PREVAILING WINDS

The prevailing winds around Kibuye come from the east to the west. When designing new outdoor spaces, a physical screen on the east side of the site should be considered to protect the space from any winds that may disrupt outdoor activities.

3.6

ACCESSIBILITY

Kibuye Hope Hospital is a campus made up of multiple, department‐specific buildings wherein patients are often transferred from building to building during the same visit. It is important to define circulation pathways that permit easy transportation of patients, who are occasionally non‐ ambulatory, to access each building and for most buildings to be handicap‐accessible. To create handicap accessible buildings, walkways and paths should be even and level, and ramps should be appropriately‐shaped to permit accessibility between areas of differing elevation. Figure 3.9 illustrates areas of poor handicap accessibility at the hospital, and the following list identifies key areas observed during the assessment:

 Location #1: All toilet and shower rooms in the Laundry/Showers Building (Building No. 16b) are accessed by a 250‐millimeter (mm) step. (Any type of step creates an inaccessible space.)  Location #2: The area at the Cook House (Building No. 14) and adjacent dining shelter is surrounded by poorly‐maintained compacted soil, creating a walking surface that is uneven with multiple tripping hazards.  Location #3: The pathway on the east side of the Emergency/Dormitories (Building No. 11) that leads to the Men’s Ward (Building No. 12) and the Main Hospital Building (Building No. 13) is broken up and uneven, creating an unsafe walking surface and tripping hazards.  Location #4: The main entry to the hospital is made up of poorly‐maintained compacted soil, creating an uneven walking surface and tripping hazards.  Location #5: The area in front of the Maternity Building (Building No. 10) and the pathway to the Isolation Ward (Building No. 2) have poor handicap accessibility. The concrete and stone walkways are broken up in most areas, creating Figure 3.9: Accessibility problem areas on tripping hazards along the path. The dirt walkways the hospital campus

b

All building numbers are keyed to the Architectural Site Plan, Sheet A0.1 in the drawing set.

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are uneven and include pot holes and protruding rocks.

Location #6: There is no handicap accessibility to the Women’s Health Clinic (Building No. 1).

A trench drain runs between the Maternity Building and the Women’s Health Clinic, separating the two buildings. Someone wanting to enter a room in the Women’s Health Clinic must step over the trench, making it difficult for anyone with a disability to access the building. While there is not currently another way around, it would be quite simple to create an accessible pathway between these two buildings.

Photographs taken at these different locations capture the varying degrees of inaccessibility (refer to the rendering sheets included in this report).

3.7

SITE VIEWS

Nestled in the mountainous region in Central Burundi, Kibuye Hope Hospital is surrounded by sloping hills and lush vegetation. This creates beautiful views from various vista points throughout the site. These views create ideal locations for community gathering spaces, hospital ‘healing gardens’, new hospital buildings, and staff and student housing.

Photographs taken at five different locations capture various views throughout the site (refer to the rendering sheets included in this report).

HOSPITAL ARCHITECTURAL PROGRAM

4.0

Through a series of detailed interviews with the hospital leadership, the EMI EA team was able to capture the following data regarding departmental structures, facilities, staff and patient load. Refer to Table 4‐1 and Appendix A for more information.

4.1

INTERNAL MEDICINE & EMERGENCY CARE

The Internal Medicine and Emergency Care Department is responsible for non‐invasive inpatient care for adults and for emergency medical care for adults and children. Based on diagnosis and treatment needs, the Emergency Care building (Building No. 11, refer to architectural floorplan on Sheet A2.5 in the drawing set) serves as one portal for admission to the hospital for inpatient care.

This building has two emergency treatment rooms and two rooms with beds for patient observation.

Internal Medicine (IM) has two rooms in the Main Hospital Building (Building No. 13, refer to architectural floorplan on Sheet A2.7) with six beds total. It also shares, as overflow space and when necessary in cases with contagious infection, the eight rooms in the Isolation Ward (Building No. 2, refer to architectural floorplan on Sheet A2.2). Staffing for these services consists of one BSNc nurse, four nurse’s aides (equivalent to LPNd) and two assistants trained through practical experience. The total bed count for IM/Emergency is 12. Both Internal Medicine and Emergency Care are services that must be staffed 24 hours per day.

Typical daily patient load is 6 inpatients and 20 visits for emergency care. Patient loads that exceed the IM/Emergency Department capacity are cared for in the Surgery Wards. Patient volume is heavily influenced by poverty and lack of preventive care. Malaria, pneumonia, tuberculosis and diabetes are common, and alcohol abuse creates emergency care needs. Government programs to combat some of these diseases will increase need for hospital services. For example, vaccinations, community health education, testing and treatment will all be increased to see the incidence and severity of these diseases decline.

c

BSN = Bachelor’s Degree in Nursing LPN = Licensed Practical Nurse

d

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Surgery and maternity services may be called upon for emergency care, and laboratory and pharmacy services are needed for both internal medicine and emergency care. Patients with communicable diseases are treated in the Isolation Ward. Ambulance service is dependent on availability of the District Health Office’s ambulances and radio‐dispatching services and equipment.

Management oversight of the IM/Emergency Department is through Medical Director Dr. Nkeshimana Désiré, Head Nurse Kadigiri Laurent and Chief Nurse Ndayesamiye David. Operational leadership is through Hospital Administrator Japhet Nsanze and Vice‐Administrator Pastor Ngenzebuhoro Luc. Table 4‐1: Hospital inpatient bed count INPATIENT BEDS FROM FLOOR PLAN ANALYSIS PT. ROOMS

IM & ER

Emergency/ Dormitories (11)

2

2

Men’s Ward (12)

6

BUILDING

2 Main Hospital Building (13)

SURG

PEDS

MATERN.

COMM. HLTH

2 19

19

6

6

4

21

4

TOTAL

21

21

21

Isolation Ward (2)

8

Maternity Building (10)

8

Outpatient Clinic (7)

0

0

Women’s Health Clinic (1)

0

0

Total

34

4.2

4

4 37

12

40

21

37

37

0

110

SURGERY DEPARTMENT

The Surgery Department serves the entire hospital by performing general, urological, and gynecological surgeries; amputations; setting of fractures; and treatment of burns for patients of all ages. The level of surgery and treatment available at any time is dependent on the skills of surgeons who might be available. As of April 2013, none of the six physicians stationed at Kibuye Hope Hospital is qualified to do more than C‐sections. Periodically, visiting physicians are available to perform a variety of surgeries, and the hospital staff works with them to meet patients’ needs.

Support staff include one MSNe nurse, two nurse’s aides (equivalent to LPN) and two assistants trained through practical experience. Surgery supports the entire hospital and must be available at all times, with special support available for Emergency and Maternity.

The Main Hospital Building (Building No. 13) houses two surgery suites with accompanying pre‐op and recovery rooms as well as a staff changing room and scrub sinks. The suites are supported by a sterile pack facility and equipment storage (refer to sheet A2.7 of the drawing set). Ten rooms with 48 beds are assigned to care for patients after surgery: six rooms are in the Men’s Ward (Building No. 12, refer to architectural floorplan on Sheet A2.6 of the drawing set) and four are in the Main Hospital Building.

Patient load varies with the capabilities of physicians present. When a fully‐qualified surgeon is present, it is typical for three surgeries to be done each day and the inpatient load to be 24 to 38

e

MSN = Master’s Degree in Nursing

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patients. With only staff physicians present, the average activity is four C‐sections per week.

Inpatient care facilities are usually at maximum capacity due to long recovery times and treatment for burns and fractures. The addition of three surgeons (general, ophthalmology and gynecology) to full‐time staff in 2014 will greatly increase the level of activity and can be expected to push the patient care load to maximum capacity at all times.

In the future, more and larger surgery rooms will be needed. Ideally there would be three or four rooms with similar capabilities that would enable multiple surgeries to be performed at the same time, while the vacant room is prepared for the next case. As more equipment becomes available, and as more staff are required to support more complex surgeries, the rooms will need to be larger.

Any new surgery rooms should be designed for future equipment and staff needs. Equipment needs include electro‐cautery, auto‐suction, oxygen and an anesthesia machine, a desk and a stool.

Management oversight of the Surgery Department is through Medical Director Dr. Nkeshimana Désiré, Head Nurse Kadigiri Laurent and Chief Nurse Ndayirukiye Sophonie. Operational leadership is through Hospital Administrator Nsanze Japhet and Vice‐Administrator Pastor Ngenzebuhoro Luc.

4.3

PEDIATRICS DEPARTMENT

The Pediatrics Department provides general inpatient care around the clock for children from post‐ natal discharge through age 15. Assigned medical staff consists of one general practice physician, two BSN nurses, two trained nurse’s aides (equivalent to LPN) and two nursing assistants trained through practical experience. Four rooms for patient care in the Main Hospital Building (Building No. 13) provide space for 21 beds. There is also one staff room and one nurses’ station used by the pediatrics staff.

Typical patient loads are 5 to 10 inpatients per day which, with extended lengths of stay, may result in an inpatient census as high as 35 to 40. In these situations patients are put two in a bed, and overflow space is sought in private rooms throughout the hospital or in the Men’s Ward (Building No. 12). Increases in influenza, malaria and respiratory diseases are commonly seen during the rainy seasons. Children with communicable diseases are cared for in the Isolation Ward (Building No. 2).

Patients for pediatric care are admitted through the Outpatient Clinic (Building No. 7, see architectural floorplan on Sheet A2.3 in the drawing set) or Emergency Care (Building No. 11) based upon a determination of the need for inpatient care. The laboratory and pharmacy provide support services as needed.

Patient load for pediatrics is already beyond capacity, and the addition of a specialist in 2014 will raise the level of care and expand services. More rooms and outfitted beds will be needed as will additional nursing staff. In addition, basic equipment (e.g., otoscopes) is limited and needs to be addressed, both for quantity and storage space. The national government provides free healthcare for children up to age five, so patient load can be expected to grow.

Management oversight of the Pediatrics Department is through Medical Director Dr. Nkeshimana Désiré, Head Nurse Kadigiri Laurent and Chief Nurse Maniratunga Thimothée. Operational leadership is through Hospital Administrator Nsanze Japhet and Vice‐Administrator Pastor Ngenzebuhoro Luc.

4.4

MATERNITY DEPARTMENT

The Maternity Department provides around‐the‐clock care for women through the labor, delivery and post‐partum process of either natural or C‐section birth, as necessary. Gynecological treatments and care after surgeries are also provided. A relatively new building (opened in 2011) dedicated to April 2013

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these services has eight patient care rooms: two rooms each for cesarean recovery and post‐partum care, one room for gynecology services, one labor room, and two private rooms. In addition there are two delivery rooms, staff lounge, and one administrative office. A total of 37 beds are available for patient care (refer to architectural floor plan on Sheet A2.4 in the drawing set). Maternity is staffed by one general practice physician and five on‐call, one BSN nurse, four nurse’s aides (equivalent to LPN) and four assistants trained through practical experience.

Patients for maternity care are admitted through the Outpatient Clinic (Building No. 7) or Emergency Care (Building No. 11) based upon the need for inpatient care. Easy access to Surgery is important when C‐sections are needed, and laboratory and pharmacy provide support services as needed.

The average number of patients is eight per day and the typical length of stay is 12 hours after delivery. When patient census exceeds bed count, two women are sometimes assigned to a single bed until space is available. High and growing demand for maternity services should be expected.

The hospital has a very good reputation in the region and receives referrals from twelve outlying community health clinics. The arrival of a physician certified in obstetrics and gynecology in 2014 will increase the quality and scope of the services that can be provided. The fertility ratef in Burundi is 6.8 births per woman (which is the fourth highest national rate in the world)g, so even with family planning and improving economic conditions, future plans must account for significant growth in maternity services. National government subsidies for maternity services will also contribute to this department’s growth. These changes will require more space for patients, additional staff and more modern equipment.

Management oversight of Maternity Department is through Medical Director Dr. Nkeshimana Désiré, Head Nurse Kadigiri Laurent and Chief Nurse Ishimwe Marie Clémentine. Operational leadership is through Hospital Administrator Nsanze Japhet and Vice‐administrator Pastor Ngenzebuhoro Luc.

4.5

COMMUNITY HEALTH DEPARTMENT

The Community Health Department is responsible for outpatient services, prenatal care, family planning counseling, childhood vaccinations and HIV+ maintenance care. Medical staff for these services includes one general practice physician, two BSN nurses, two nurse’s aides (equivalent to LPN) and two assistants trained through practical experience. No inpatient beds are assigned to the Community Health Department, but in the Outpatient Clinic (Building No. 7) there are three consultation rooms for general medicine and one for HIV, a room for medical records filing and a pharmacy. In the Women’s Health Clinic (Building No. 1) there is one room with two consultation cubicles, one office, one small pharmacy store, and a room for vaccinations. Often basic consultation with mothers and vaccinations for children are conducted under the portico along the entrance walkway. In addition to these rooms for patient care there are in the same building one room dedicated to an itinerant eye clinic (not operated by the hospital) and a large assembly room used primarily by World Relief, Inc. for training seminars.

Activities among the services of Community Health are closely linked. The Women’s Health Clinic depends on the Outpatient Clinic for patient registration and records and the pharmacy for medicines. It coordinates activities with the District Health Office in fulfillment of the national health programs for mothers and children. There is also close cooperation with Maternity for prenatal health management.

f

This use of “fertility rate” is defined as: the number of children that would be born to a woman if she were to live to the end of her childbearing years and bear children in accordance with current age‐specific fertility rates. g According to a United Nations study, 2005 – 2010.

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Patient activity for Community Health services is typically very heavy, especially on Mondays. The average daily patient load is about 90 for outpatient care and 20 for other consulting services. This activity is expected to increase because of national support for programs for childhood vaccinations, prenatal care and family planning. The addition of obstetric and pediatric specialists in 2014 will also have a significant impact on patient load. More space and additional staff will be needed. Specific needs are refrigeration for medicines, a gynecological exam table, and scales to weigh infants for better efficiency and patient care.

Hours of operation for Community Health are typically 7:30 am to 3:30 pm, Monday to Saturday at the Outpatient Clinic (although no patient who arrives before 3:30 pm is turned away) and Monday to Friday at the Women’s Health Clinic. On Saturdays the clinics may close before 3:30 pm if all patients have been seen.

Management oversight of the Community Health Department is through Medical Director Dr. Nkeshimana Désiré, Head Nurse Kadigiri Laurent and Chief Nurse Mukasa Joseph. Operational leadership is through Hospital Administrator Nsanze Japhet and Vice‐Administrator Pastor Ngenzebuhoro Luc.

STRUCTURAL ASSESSMENT

5.0 5.1

STRUCTURAL CONDITION INSPECTION 5.1.1

OVERVIEW

A structural condition inspection of the Kibuye Hope Hospital campus was performed on February 20, 2013. This assessment consisted of visual observation of eight buildings. Each building is single‐ story (ground floor only) with similar construction and structural systems. The structural systems consist of stone foundation, masonry walls, steel roof trusses and corrugated roof panels. The newer buildings utilize reinforced concrete grade beams and bond beams. The inspection included observations of the walls, roof and eave lines.

The walls are unreinforced masonry (URM). Structural distress in masonry walls will be evidenced by cracking in the mortar joints. This distress can be caused by foundation settlements or by lateral loading in the plane of the wall. Distress in the roof trusses will be evidenced by non‐level or non‐ uniform ridge or eave lines. This occurs when there is deflection of one or more trusses. If a bottom chord is distressed, there may be an outward deflection of the walls at the truss bearing location.

5.1.2 WOMEN’S HEALTH CLINIC No distress was observed in the roof or wall systems of the Women’s Health Clinic (Building No. 1). Several lintels were no longer than the wall opening they spanned (see Figure 5.1), which would cause the bricks above these lintels to be supported only by arching action of the brick work. Alternatively, the age of the building would suggest that there are longer timber lintels with proper bearing that have been covered over by plaster in more recent years. There is no cracking Figure 5.1: Unsupported lintel at Women's Health in the brick walls.

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5.1.3 ISOLATION WARD No distress was observed in the roof or wall structures of the Isolation Ward (Building No. 2).

5.1.4 OUTPATIENT CLINIC No distress was observed in the roof or wall structures of the Outpatient Clinic (Building No. 7).

5.1.5

MATERNITY BUILDING

Columns on the west entrance of the Maternity Building (Building No. 10) are slightly out of plumb, and the grade beam on the north face of the building has minor sagging along its length. These are most likely due to the construction practices and are not considered structurally significant. No distress was observed in the roof or wall structures.

5.1.6 EMERGENCY / DORMITORIES The Emergency / Dormitories building (Building No. 11) has a mono‐sloped roof with cantilevered overhangs and no trusses. The purlins bear directly on the interior and exterior walls. No distress was observed in the wall structures.

5.1.7 MEN’S WARD No distress was observed in the walkway or the roof system of the Men’s Ward (Building No. 12); however, there is significant cracking at the southwest corner of the building. The crack is highest at the corner and extends downward in both the south and west exterior walls (see Figure 5.2). The crack is most likely caused by foundation settlement prior to the placement of concrete for the walkway. EMI EA recommends that this crack be monitored for movement in the next year. If additional movement is not observed, this crack can be repaired with mortar. If additional movement is observed, then the foundation should be lifted to the original position. This Figure 5.2: Crack in brick wall at southwest corner involves temporarily shoring the structure, over‐ of Men's Ward excavating the footing, thoroughly compacting the foundation soils, lifting the foundation and wall back into place, and packing new concrete or stone foundation walls to fill in the gaps.

5.1.8

MAIN HOSPITAL BUILDING

The Main Hospital Building (Building No. 13) is a non‐symmetric cross in plan view. Minor cracking was observed in the upper corners of the gable walls at the north and west wings. These cracks are located immediately below where the roof purlin penetrates the wall (see Figure 5.3). Minor cracking was also observed below the window on the east wall of the north wing (see Figure 5.4), but there is no indication of foundation settlement at this location. Spalling was observed on the north wall of the east wing. The spalling was limited to the outer face of the foundation wall and there was no indication of foundation settlement. No distress was observed in the roof structure.

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The cracking in the brick work on this building is of a minor nature. It should be observed over the next few years to see if it is propagating. If the cracks are propagating, the foundations in the area should stabilized and the cracks sealed with an epoxy grout sealer.

Figure 5.3: Cracking of brickwork under roof purlin in south end of north gable wall

5.1.9

Figure 5.4: Cracking of brickwork below window in east wall of the north wing

MORGUE / LAUNDRY

The Morgue / Laundry (Building No. 18) has minor damage on the west wall where several openings pass completely through the wall (see Figure 5.5). Pastor Luc attributed the damage to the removal of a large washing machine unit. No distress was observed in the roof system.

Figure 5.5: East wall of Morgue / Laundry

5.2

DESCRIPTION OF NEW ON‐SITE CONSTRUCTION METHODS 5.2.1

OVERVIEW

Newer construction standards have only a few variations to that observed in the older buildings. The structures consist of a stone foundation supporting a reinforced concrete grade beam. Two‐wythe brick masonry walls are built on top of the grade beam to the top of the door and window openings.

A reinforced concrete bond beam is then built on top of the brick walls. The brick walls continue up, on top of the bond beam, to the roof bearing elevation. Pitched steel trusses are supported on the longitudinal exterior walls and form a ridgeline running the length of the building. Most of the buildings use a gabled end wall. The Quadriplex Visitor Housing Building (Building No. 38) and the World Relief Triplex (Building No. 31, under construction at the time of the EMI visit) use a hip roof configuration such that the eave height is consistent around the end of the building. Additionally, these two buildings feature offset units and a ridge line which does not run perpendicular to the end walls. The roof consists of corrugated fiberglass sheeting, HSSh purlins and steel trusses. The following paragraphs will expand on each of these elements.

h

HSS = hollow square section

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FOUNDATIONS

Foundations are constructed below both the exterior and interior walls. Construction begins with hand excavations to firm native soil.

Moderately dense sandstone (see Figure 5.6) is then broken using a small sledge hammer before being hand placed to level, specified as the base of the grade beams. With sloping sites, the stones are mortared in place such that the foundation walls are sloped at the ground line but are level on top. The typical wall foundation is 400mm wide and 600mm deep. The excavations at non‐ sloping sites are of sufficient depth, that the finished level of foundation stones is equivalent to the existing grade. These foundation stones are Figure 5.6: Stones used for foundation walls not mortared in place.

Site soils were observed at various places on the site and were found to be relatively uniform. Red clay/loam soil was underlain by red sandy clay. Nine pocket‐penetrometer tests were taken of the soils at various places on the site at 800mm‐1200mm below grade. The average unconfined compressive strength is 1.33tsfi. Using a factor of safety of 2.0, the allowable bearing stress will then be 0.67tsf (64kPaj). The estimated bearing stress for the wall footings on the Maternity Building (Building No. 10) is 0.3844tsf, well within range of the allowable bearing stress.

5.2.3

GRADE BEAMS

The formed, reinforced concrete grade beam is 180mm wide and 220mm deep. The steel reinforcing consists of four Y8k longitudinal bars and R6l stirrups at 150‐mm spacing. The stirrups are evenly spaced along the whole length of the beam, and there is no positive tie between the grade beam and the foundation. The grade beam runs along the exterior walls only (see Figure 5.7).

The concrete is mixed on site using crushed aggregate, sand and Portland cement. Bank run aggregate (ie. smooth river rock) is not used. The crushed aggregate used appears to be sandstone.

According to engineers from the HAU Engineering department, the local governments qualify a quarry to ensure that the aggregate is of adequate hardness. For an additional cost, it is possible to get a test of the aggregate quality for each project. This test was not purchased for these projects.

The mixed concrete is transported to the forms with wheel barrows and buckets. Any vibration or consolidation, if performed, is done by hand with tamping rods and hammers. The grade beams have a smooth finish, which indicates that they received adequate consolidation during placement and that they were “patched and sacked” after the forms were removed.

i

tsf = tons per square foot j kPa = kilonewtons per square meter k Y8 = 8mm square twisted rebar l R6 = 6mm diameter round bar

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Figure 5.7: Grade beam at perimeter of building.

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BRICK WALL CONSTRUCTION

The brick walls at the Quadriplex Visitor Housing and World Relief Triplex are two wythes wide. The overall width is about 180mm, including 20‐mm grout between wythes. The bricks are approximately 80mm wide, 55mm deep and 180mm long. The brick is laid with two bricks side by side in the longitudinal direction and then one brick transverse. The pattern in adjacent courses is offset such that there is a transverse brick centered above and below the longitudinal brick.

Batter boards and string lines are used to align each course, both in plan and level.

Two grades of brick are used, including clay and soil (non‐clay) fired brick (see Figure 5.8). The material properties differ such that the exterior clay fired bricks are more durable, with slower degradation from weathering. The interior bricks are less durable and appear to be used exclusively Figure 5.8: Masonry work underway. Note lighter‐ for interior walls. The majority of the bricks colored, durable clay bricks used at exterior walls observed by the EMI EA team already had broken and darker‐colored non‐durable soil bricks used at edges from being dumped at the jobsite. interior walls.

The mortar is mixed on a circular cement‐pad at ground level. Two wheel barrows of sand are combined with one 50‐kg bag of Portland cement. Based on the size of the wheel barrows, this is approximately equivalent to a 1:4 mix design. The sand and cement are mixed with shovels and then formed into a ring on the slab. Water is then added to the center of the ring and the sand/cement mixture is stirred into the water, without letting the water flow outside of the ring. Mortar is then transported to the wall under construction with a shovel or a small container. There are no tests performed on the mortar.

5.2.5

BOND BEAM CONSTRUCTION

The continuous reinforced concrete bond beam is cast in‐situ along the exterior walls at a height immediately above window and door openings. A typical beam has a size of 180mm wide by 230mm deep, with no positive connection between the brick walls above or below. Reinforcing layout is the same as in the grade beam.

5.2.6

COLUMNS

The confining columns of the newer buildings (Medical Student Dormitory A and the Maternity Building) have non‐uniform spacing, 25‐mm thick plaster finish, unknown reinforcing details and a height equivalent to that of the adjacent wall. A typical column has a size of 230mm by 230mm and is located at an average spacing of 4000mm.

5.2.7

ROOF CONSTRUCTION

Tubular steel purlins span between top chords of the trusses and support corrugated fiberglass roofing panels. These panels are attached to the purlins with 6‐mm‐diameter J‐bolts. The bottom chords of the truss bear directly on the exterior and interior walls. The brick is then extended to the underside of the roofing panels.

All trusses were assembled in‐situ with welded connections. The majority of pitched roof trusses were constructed of HSS with typical dimensions of 40mm x 50mm x 2mm. Some trusses used steel April 2013

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pipe for the diagonal webs while others, including the Main Hospital Building (Building No. 13), used single angle sections for all truss members. The diagonal webs are arranged so that they slope downward toward the middle of the building. The roof slope at the Women’s Health Clinic (Building No. 1) measured 2.9:12 (13.6 degrees). All other roof slopes on the hospital campus appear to be close to this value.

Across the site, the trusses are very lightly loaded. For example, at the Women’s Health Clinic, the maximum force in the bottom chord is 8.4kNm (1894lbsn), while the allowable force in these members is 53.6kN (12,052lbs). The top chord and webs are also lightly loaded. Buckling in the webs is limited by the configuration. The longer diagonal webs are in tension only, and the shorter vertical webs are in compression. The welds are adequate to transfer the loads from the webs to the chords.

5.2.8

FLOOR CONSTRUCTION

The floors are made of a 150‐mm thick layer of stone laid over a 50‐mm layer of sand. A cement‐ sand screed is spread over this as a skim coat. On sites where the water table is near the surface, a plastic vapor barrier is used.

5.2.9

LATERAL FORCE RESISTING SYSTEM

There is no diaphragm capacity in the plane of the fiberglass roofing panels; therefore, there is no system for distributing lateral loads at the roof level. There are no positive connections between the different structural elements, so the only element that has lateral load resisting capacity is the masonry. However, the walls have no reinforcing and are considered Unreinforced Masonry (URM).

In most building codes, URM is not permitted in structures located in areas of moderate to high seismicity, such as central Burundi.

The newer buildings (Medical Student Dormitory A and the Maternity Building) utilize a type of confined masonry construction. This system uses reinforced concrete grade beams, columns, and bond beams. The grade beam is located on top of the foundation, the bond beam is at the top of the window and door openings, and columns are spaced at an average of 4000mm on center. These reinforced confining elements increase the ductility and sheer strength of the wall system. This wall system is becoming popular in most of East Africa.

5.2.10 RECOMMENDATIONS FOR FUTURE CONSTRUCTION Appropriate construction practices must consider the anticipated loads the structure will need to resist, the available materials, and the skill level of local craftsmen.

Design properties of materials were investigated by the EMI EA team. The information in Table 5‐1 is based upon the best available information for the region. The values in this table should be used in the structural design of future buildings.

Correct mix ratios for structural concrete and grout/mortar should be used and can be found in Table 5‐2.

There is no snow load in this region and elevation. Low lateral loading is anticipated due to wind.

Data sheets from the insurance company FM Global indicate a design wind speed of 35 m/so (78 mphp) for Burundi.

m

kN = kilonewtons lbs = pounds‐force o m/s = meters per second p mph = miles per hour n

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Table 5‐1: Material properties MATERIAL STRENGTH

BRITISH IMPERIAL UNITS

SI UNITS

q

20 MPa

r

Concrete 28-Day Strength

2,900 psi

Reinforcing Steel Yield Strength

61,600 psi

425 MPa

Structural Steel Yield Strength

36,300 psi

250 MPa

Soil Allowable Bearing Stress

1,333 psf

64 kPa

Table 5‐2: Mix ratios STRUCTURAL MATERIAL

CEMENT

SAND

AGGREGATE

Beams, Columns, Slabs

1

2

4

Grout / Mortar

1

3

Low to moderate lateral loading is anticipated due to seismic ground motion. Seventeen earthquakes with a Richter magnitude greater than 4.0 have been recorded in the last 39 years in Burundi. The largest earthquake was a magnitude 5.3 with an epicenter near Bururi, 76km (47 miles) from Kibuye. An associate professor in civil engineering at Hope Africa University indicated that there has been no building damage at the site due to wind or seismic events. See Appendix D, Table D.1 for historic earthquake records in Burundi.

The construction methods used on the Maternity Building (Building No 10) and the Medical Student Dormitory A (Building No. 37) are appropriate for the available materials and skill level of the local laborers. The walls are straight and plumb, and the brick courses and bond beams are level. The lack of diaphragms and lack of connection between building elements do not seem to be a problem in this region. However, it is recommended that the bond beam in the walls be raised up to the truss bearing elevation and that a positive tie be established between the trusses and the bond beam (see Figure 5.9 and Figure 5.10).

Figure 5.9: Area between bond beam and window header filled with screened louvers

Figure 5.10: Bond beam located at truss bearing elevation

The Quadriplex Visitor Housing and World Relief Triplex are constructed with offsets between each unit forming a sawtooth pattern in plan. The ridge and eave lines run parallel to the sawtooth pattern, while the trusses run perpendicular (see Figure 5.11). Construction drawings indicated that the webs of each truss were to be uniquely modified for specific bearing on the brick wall. However, all of the trusses were made with identical web configurations, so the truss bearings varied from one truss to the next (see Figure 5.12). Construction also deviated from the drawings at the complicated

q

psi = pounds per square inch MPa = megapascal = meganewton per square meter

r

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hip details. The haphazard framing combined hip and jack trusses at that location (see Figure 5.13).

The complexities of this roof framing scheme seem to be beyond the capabilities of the local skill level. Simplifying the building layout to avoid this type of framing would be beneficial for future projects. Rectangular buildings such as the recently‐constructed Maternity Building are more appropriate for this area.

Figure 5.11: Roof plan for World Relief Triplex

Figure 5.12: Truss web configurations are not modified according to panel points

Figure 5.13: Poorly constructed hip truss joint

WATER SUPPLY SYSTEM ASSESSMENT

6.0 6.1

OVERVIEW

The hospital and other facilities that make up the Kibuye Free Methodist Church property are served by a common water system (refer to schematic in Figure 6.1). The water is supplied from a pair of springs located about 3km southwest of the campus. Water flows by gravity from the springs to the main hospital tank about 270m west of the campus. Water then flows by gravity from the hospital tank to the campus distribution system, which feeds hospital buildings, the Busoma (cereal) plant, the primary school, and various dorms and houses. No water treatment was reported or observed, except for point‐of‐use systems at the Ogden House (Building No. 41) and the Hospital Rental Housing (Building No. 40, currently rented by World Relief).

The current water supply is insufficient. It also appears that the distribution pipes serving the hospital itself have either corroded or calcified to the extent that water delivery to the hospital is severely limited even if there is water available in the main hospital tank. On three separate days, April 2013

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the water level in the hospital tank was observed to be only 0.2 meters or less, which represents only about one tenth of its capacity of 9,200 liters.

Many times during the EMI EA Assessment Team’s visit ‐ in fact, more often than not ‐ no water ran from faucet taps when tried at sinks in the Main Hospital Building (Building No. 13).

In contrast, water was generally available at the Ogden House (where several of the EMI team members stayed) at the east end of the campus. Water seemed to be available in the Ogden House even when no water was available in the hospital.

Because the water distribution system regularly runs dry (is de‐pressurized), its integrity is compromised, and the water quality is not reliably safe. The spring collection system, transmission pipe, and main Figure 6.1: Water supply system schematic hospital tank were protected and may deliver safe drinking water; however, to ensure safe drinking water, it is advisable to add point‐of‐entry chlorination.

6.2

INFORMATION SOURCES

The following individuals were consulted during the EMI EA team’s visit:

1. Engineer Manirakiza Emmanuel (manirakizaemmanuel703@gmail.com), an associate professor at Hope Africa University in Bujumbura, is knowledgeable about the new well, tank, and other aspects of the system.

2. Irakoze Pamphile, Kibuye station head of maintenance, knows a great deal of the system and its history, including buried pipe locations and sizes, the springs (which he lives nearby), services to houses off‐campus, and other system information. It is recommended that Pamphile be given the opportunity to review the completed distribution map presented in this report and have him confirm/revise the information.

3. Hatungimana Léandre (President de la Regie Communal de L’eau, translated roughly as President of Governed Municipal Water, i.e., the local minister of water; phone 77081609 or 71323151) met with the EMI EA team to discuss the status of the new well. He indicated that the Kibuye Free Methodist Church is welcome to use the new well for its water supply but that the production from the new well should also be shared with the surrounding community.s

s

Language and culture differences made it difficult for the EMI EA team to discern whether this was a requirement or a request. In any case, sharing the well with the community is a good thing for the health of people in the area and from a practical standpoint, probably just means continuing to supply the tapstands and off‐campus houses downstream of the hospital tank.

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WATER USE (WATER DEMAND) 6.3.1

DAILY WATER USE

The EMI EA team was only able to estimate the current water use on the campus since no meter data were available (and no functioning water meters were observed). The water use estimate was based on the estimated production from the springs (see Section 6.4).

The springs supply eight community tap stands upstream of the main hospital tank and two downstream of the tank, plus six off‐campus houses, in addition to supplying the hospital campus.

Table 6‐1 provides a rough estimate for water use of 11,000 liters per day (Lpd) for the off‐campus connections.

Table 6‐1: Estimated off‐campus use of springs supply SERVICE Tap Stands Houses Total

UNIT DAILY USE (Lpd)

NO. OF SERVICES

EXISTING DAILY USE (Lpd)

1,200

8

9,600

200

6

1,200 11,000 (approx.)

Current water use on the Kibuye Hope Hospital campus was estimated by subtracting the off‐ campus water use from the estimated springs production. These estimates are rough, but the important point to communicate is that water use at Kibuye (and specifically, within the hospital campus) is far less than would be expected for a typical hospital facility in East Africa. This is illustrated in Figure 6.2, which shows the current use and the potential current use for the Hospital and its campus.

Existing actual use within the hospital may be less than 4,000 liters per day (Lpd). The EMI EA team observed that hospital faucets were often dry when checked and nearly all toilets had been removed from hospital buildings. EMI personnel were told that the toilets were removed because there is

Figure 6.2: Estimated water use for the Kibuye FMC property

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often no water, and if the toilets are used and cannot be flushed, they create a mess and a health hazard. In contrast to existing actual use, the potential existing water use at the hospital could be as much as 50,000Lpdt.

Future potential water use was estimated in a similar fashion, based on the proposed number of hospital beds and projected outpatient load. The values shown in Figure 6.2 provide a reasonable approximation. As shown, the Hospital may use up to 120,000Lpd when fully developed. In addition, some growth in water use by other campus facilities and for the off‐campus services can be expected. See Appendix B for additional water supply information and data.

6.3.2

PEAK HOUR WATER USE

Peak hour demands are needed for sizing distribution and transmission pipelines. For example, the pipeline from the main hospital tank to the campus should be sized to supply the total potential peak hour demand for the hospital plus other campus buildings. It may be appropriate to size the tank transmission pipeline to meet current potential water use and then to add another pipeline in the future as warranted by growth.

Peak hour demands were estimated through the use of two approaches. One involves using fixture counts in buildings and the second applies a rule of thumb described in the EMI EA Civil Design Guideu. The resulting totals for potential current use by the Hospital and by other campus buildings are the following (with actual current use being much less because of shortages and limited fixtures):

 Hospital potential peak hour use = 200 liters per minute (Lpm)  Campus (other than hospital) potential peak hour use = 50 Lpm  Total potential peak hour use = 250 Lpm

Further details, such as peak hour use by specific building, as well as fixture (faucets, toilets, showers) counts by building, are provided in Appendix B.

6.4

SOURCES 6.4.1

EXISTING SPRINGS SOURCE

The only water source for the Kibuye FMC property is a single gravity supply line from two developed springs. The two springs are only about 400 meters (m) apart from one another, and they are located approximately 3km southwest from the property (as the crow flies). According to a motorcycle odometer, the Kibuye property is 8km from the road above the springs.

The springs are located in a rural area surrounded by cultivated and natural fields or trees. There was no evidence of a specific human contamination source uphill from either spring. Both have been developed in a similar sanitary fashion, according to what could be observed and based on Irakoze Pamphile’s description of the buried components. Water is collected using buried, perforated pipes, with the collection area fenced with barbed wire to keep out cattle and discourage other activities directly over the collection pipes. The fenced collection areas are approximately 10m square.

t

This is based on design criteria presented in the EMI EA Civil Design Guide and was determined as follows: Per bed estimate = 121 beds x 400 Lpd/bed = 48,000Lpd Per outpatient estimate = 80 outpatients per day x 15Lpd = 1200Lpd Total = 50,000Lpd (approx.) u Contact EMI EA for a copy of this guide

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Spring No. 1 (the upper elevation spring, using arbitrary numbering) has a spring box into which a 63‐mm diameter pipeline brings in flow from the collection pipes. The box is lidded and vented and has an overflow pipe. The box is formed from concrete, with approximate dimensions of 480mm x 510mm x 510mm deep. The top of the box has an approximate elevation of 1862m AMSLv. (Its coordinates are 3°40'37.68" S, 29°57'7.50" E.)

A 25‐mm diameter outlet pipe carries water from Spring No. 1 to the spring box for Spring No. 2. The inlet pipe from the collection pipes for Spring No. 2 is 50mm in size. Both these lines enter the spring box. This box is also lidded and vented, and it has an overflow pipe. The lid for this spring box was bolted in place. The box is formed from concrete, with approximate dimensions of 510mm x 540mm x 510mm deep. The EMI EA team was unable to measure the spring box’s outlet pipe size, since it was under water, but was told that it was 50mm. The elevation at the top of the spring box for Spring No. 2 is 1815m AMSL. (Its coordinates are 3°40'30.96" S, 29°57'17.76"E.)

The EMI EA team did not measure the flow in either box as it would have required climbing down in the boxes and this would have contaminated the water. An excerpt from a report by a Medical Teams International volunteer provided the following production estimates for the springs (EMI EA did not retain a copy of this report, which was dated 2012. The report did not describe the methodology used to estimate the flows.):

 Spring No. 1: 6‐8Lpmw  Spring No. 2: 8‐10Lpm

Comparing to the observations made by the EMI EA team, the above values seem reasonable. Using the mid‐range value for each spring, it is approximated that the two springs yield a total production rate of 16Lpm or 23,000Lpd. Water use by the Hospital and other campus buildings was estimated using the assumptions and calculations shown in Table 6‐2.

Table 6‐2: Calculation of Kibuye FMC water use WATER SOURCE AND DEMANDS

WATER FLOW RATE (Lpd)

ASSUMPTIONS

Total Estimated Spring Production

23,000Lpd

An educated estimate from a 2012 Medical Teams International report

Assumed 20% loss due to leakage

- 4,600Lpd

Reasonable assumption based on age and quality of installation

Public use at community tap stands

- 9,600Lpd

Eight tap stands between springs and main hospital tank; each providing 20Lpd per family for 60 families

Private use by houses connected to line

- 1,200Lpd

Six houses served downstream of main hospital tank; each providing 200Lpd

Remaining flow to Hospital and other campus buildings

7,600Lpd

23,000 – (4,600 + 9,600 + 12,000)

This is obviously a gross estimate and has several assumptions. However, even if the exact demand is unknown, what is certain is that there is inadequate water for a hospital of this size. The inadequacy of the water quantity was reported by hospital staff and was observed by the EMI team when faucets were checked at the hospital and found to be dry. In addition, it was observed that nearly all flush toilets had been removed from the hospital buildings. Site staff reported that they had been removed because of the inadequate water supply; otherwise they created a mess when they were used and there was no water available to flush them.

v

AMSL = above mean sea level Lpm = liters per minute

w

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RAINWATER COLLECTION

There is a single rainwater collection system installed on the north side of the Main Hospital Building (Building No. 13). It is used for laundry, but it appears that staff may obtain water from the tank for other purposes when the taps are dry. The tank is a black plastic tank and holds approximately 2000 liters. Rainwater is a useful, supplemental water source, and there is potential for increasing the rainwater collection although it would require not only the piping and tanks, but also installation of gutters on the buildings. Rainwater is not a suitable primary water source because of the dry seasons which may last up to three months.

6.4.3

FUTURE WELL SOURCE

A new well was recently installed on the east end of the campus, down‐gradient from all buildings, in the farmed valley. According to John Ellis, the secretary of Friends of Hope Africa University, HAU paid approximately $22,000 USD for the drilling of the well, completion of the well casing and wellhead, and purchase and installation of a submersible pump. According to Engineer Manirakiza Emmanuel and information from an email by Frank Ogden dated January 15, 2013, the well has been described as follows:

 45 ‐ 49m deep  Water strike at 18m below ground surface  Slotted screen installed (depth and length unknown)  Pump sized for 4‐5Lpsx at a head sufficient to lift water to main hospital tank

The EMI EA team observed artesian flow from the well at approximately 5Lpm. The team also observed the following about the well:

 Elevation (predicated on autonomous GPS reading) = 1712m  Steel casing of 165mm outside diameter extends to just above grade where it transitions to a heavy wall PVC plastic casing of 169mm outside diameter  An opening was cut between the steel and plastic casing pipes allowing artesian flow to exit the well  A block of concrete (approximately 500mm square) surrounds the top of the steel casing to just below the top of the casing  Top of the steel casing may be inundated during heavy rains as it is located in a low lying area and there is a seasonal stream nearby  Well pump wire (approximately 30m in length) was wound around the casing that extended above ground surface  Water temperature of artesian flow was measured as 19.7 degrees C

Emmanuel indicated that he could obtain additional information about the well and pump but as of the date of writing this report, this information has not been provided. EMI EA requested the following information:

 Well driller’s log  Well pumping rate test information  Design of well seal  Pump manufacturer and model

x

Lps = liters per second

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A concern had been expressed that the well was drilled in a poor location ‐ one that is prone to flooding and one where fertilizers may be applied to surrounding cropsy. It is possible that animal wastes are applied to crops. While the flooding concern appears to be legitimate, the top of the plastic casing appears to be sufficiently high to maintain the top of the casing above surface water, provided it is completely sealed at the base where it transitions from steel to plastic. The well casing should be sealed and finished to at least 300mm above the 100‐year flood level.

The manner in which the below ground well seal was installed is the primary construction feature that is necessary to prevent surface water from traveling down the casing to the depth from which water is pumped. The well was allegedly installed with such a below‐ground sanitary seal. The driller’s log should be consulted to confirm details of the well construction. Additionally, the final completion of the well should include a full concrete slab that extends above the surrounding ground (by as much as 500mm or more, if possible), with an outward slope to shed water away from the well casing. The area surrounding the well should be fenced to keep animals away.

The well will also require that the opening between the steel and PVC casings be sealed. Both piping and electrical connections are needed to put it into operation.

The EMI EA team roughly calculated the necessary pumping head, assuming a flow of 4Lpm:

 Static lift, from well to existing tank = 52m  Dynamic head = 67m (This will require larger transmission pipeline than is currently installed along the east‐west road toward the hospital, in addition to extending a pipelie east to connect the well; the new pipeline will probably need to be 100mm in diameter although this size should be confirmed in the next project phase.)  Pump efficiency = 65%  Pump motor draw = 4.9hpz  Electricity cost per day = 3000 BIFaa (for 5 hours operation/day, at 140 BIF/kWhbb

As summarized in Figure 6.3, it appears that the well (if the production rate is 4Lps) can meet nearly all of the long‐term demands for Kibuye Hope Hospital as well as other facilities served by the water system. In combination with the springs and rainwater collection, it appears that the full long‐term needs can be met. The well production of 110,000Lpd assumes operation of the well for eight hours per day.

Additional storage will also be required to balance supply with demand. A sufficiently large storage tank would also allow the well to be manually started and stopped, because it could be operated for one or two long periods each day. A smaller storage volume would necessitate more frequent starting and stopping of the pump. This could be acceptable if there was an automatic system based on a level control in the tank, but this type of control system is not common and could be both expensive and difficult to maintain.

y

Dr. Frank Ogden, familiar with the area and local farming practices, suggested the concern about fertilizers. hp = horse power aa BIF = Burundian francs bb BIF/kWh = Burundian francs per kilowatt‐hour z

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Figure 6.3: Estimated water use and water supply for the Kibuye FMC property

6.5

STORAGE

There are two water storage tanks for the hospital: the main hospital tank (on the hillside above the campus) and the attic tank in the Main Hospital Building (Building No. 13).

The main hospital tank appears to be in good condition (see Figure 6.4). It is constructed of metal (aluminum) and sits on concrete supports. Its dimensions are 3580mm x 1600mm x 1600mm deep, yielding a volume of 9.2 cubic meters (m3) or 9,200L. It is equipped with a lid, vent, drain, and overflow. The outlet line connects to the bottom of the tank. Its level gauge (an interior float with a wire or rope over a pulley to an outside marker along the side) was not connected at the time of the EMI EA team’s visit. It has a bottom elevation of approximately 1768m AMSL.

Engineer Manirakiza Emmanuel showed the EMI EA team a proposed location for a new, larger tank. It would be located about 200m farther from campus than the existing tank, to the west. The elevation of the ground surface at this location is approximately 1799m AMSL. Emmanuel explained that the higher elevation was desirable for supplying other houses between the tank and the hospital and because the additional head would improve service to the hospital. A tank at the new location would increase pressures in the system, but the existing tank has adequate head to serve the hospital. In addition, using the new location would eliminate the value of the existing tank (unless it can be relocated), would increase the pumping head for the new well (and depending on the pump sizing, would severely decrease the well production rate) and would significantly increase pressures in the distribution system which would likely increase water loss Figure 6.4: 9,200L main hospital water tank through leakage.

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There is a 2,000‐L tank in the hospital attic. This tank was full but not active during EMI EA’s visit, as evidenced by a layer of dust on the surface of the water. The EMI EA team could not determine whether the float valve was working. Irakoze Pamphile said that the tank was disconnected from the system by means of an isolation valve on a line outside of the building, but it was unclear where this valve was located and why it was shut off.

6.6

WATER QUALITY AND TREATMENT

The EMI EA team was not able to collect reliable biological test data on the water on site. Regardless of this lack of specific data, the fact that the water distribution system regularly runs dry (is de‐ pressurized) indicates that its integrity is compromised and the water quality is not reliably safe.

There is no centralized (point‐of‐entry) water treatment. Point‐of‐use treatment is practiced in at least two buildings. A Sawyer 0.1 micron filter is used at the Ogden House (Building No 41). World Relief staff occupying the Hospital Rental Housing (Building No. 40) indicated that they either boil or chlorinate their drinking water. According to the cook at the Ogden House (Ezechiel), most community members use water from the system (whether from the hospital campus or in the community outside of the campus) without boiling or other treatment.

6.7

DISTRIBUTION SYSTEM

A map of the distribution system was prepared based on input from Pamphile and other hospital staff (see Drawing Sheet C1.1). The hospital campus is fed by a 63‐mm plastic pipe from the main hospital tank, which transitions to a 40‐mm plastic pipe. An autonomous GPS elevation measurement of the hospital finished floor indicated an elevation of 1742m AMSL. The bottom of the main hospital tank at 1768m is sufficiently high enough for gravity flow. Therefore, the fact that the hospital taps were dry, even during times when water was available at Ogden House, suggest that there may be a problem with the pipes feeding the hospital. However, it was also noted that the outdoor tap at the Busoma plant was dry on occasion, and it appears to be fed off the main line that serves the Ogden House. Replacement of some or all of the distribution piping around the hospital may be necessary to obtain reliable service. Additionally, it would be worth learning whether service to other connections (such as to the pastor’s houses, Kuhn House and others) receive water more or less often than at the hospital.

WASTEWATER SYSTEM ASSESSMENT

7.0 7.1

DESCRIPTION OF EXISTING FACILITIES

Wastewater is handled on the hospital campus through the use of septic tanks and soak pits. In some cases, the septic lids were observable on the ground surface but in other cases, they were apparently covered by a layer of dirt. There were no reports or observations of problems with existing systems but it should be recognized that at the hospital, for example, nearly all toilets have been removed. Therefore, the current actual waste flows may be much lower than the potential waste flows assumed by the EMI EA assessment team in the design of adequate septic tanks and soak pits.

The best example of the standard design practice was obtained by viewing the wastewater handling facilities for the new Quadriplex Visitor Housing (Building No. 38) because many of these facilities were still under construction and thus, not yet covered. Figure 7.1 illustrates this system. It separates gray water from black water. Black water is run through a two‐compartment septic tank and then to a soak pit. Gray water (from the kitchen and bath sinks and from the shower) is routed through junction boxes and then to separate soak pits. Units 1 and 2 (with the numbering April 2013

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progresssing from the north, neaar the road, tto the south) have indiviidual septic ttanks, with tthe flows then rou uted to a co ommon soakk pit. The black water from f Units 3 3 and 4 is routed to a common junction n box, then a common seeptic tank, an nd then to a ccommon soaak pit. The se ection (refer to Sheet C2.1 in tthe Drawings section inccluded in this report) of the soak pitt appears to be typical fo or all the soak pitss for the Quaadriplex.

Figure 7..1: The wastewater treatm ment system o observed at th he new Quad driplex Visitorr Housing is saaid to be typical fo or wastewate er treatment ssystems throu ughout the campus

7.2

PERCO OLATION TTESTS

Percolattion tests weere performeed at the following threee locations. TThe detailed results are provided in Appen ndix C.

o the campus, a short distance d sou utheast of th he new Worrld Relief 1. Along the south edge of building thatt is under co onstruction (aat the time o of the EMI EA A visit). n property th hat is curren ntly farmed but is beingg considered for new 2. West of thee hospital on hospital builldings b the fence, f on faarmed land that t may alsso be consid dered for 3. North of thee hospital, beyond new buildinggs.

SOLID W WASTE M MANAGEM MENT ASSSESSMEENT

8.0 8.1

OVERV VIEW

Kibuye Hope Hospittal has a fairly well‐deffined system m for managging solid waste. w Most waste is n corner of th he site. Com mpostable waste w is se eparated fro om non‐ managed in the northwest o a walled co ompost pit. TThe compostt does not ap ppear to be regularly composttable and is thrown into turned, and there w was no evideence that thee compost iss being used d for agriculttural purposses. Non‐ April 2013 3

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compostable waste is further separated into burnable waste and non‐burnable. Burnable waste is thrown into an active incinerator (see Figure 8.1) that is lit regularly with the aid of kerosene or petrol.

The ash from the incinerator is thrown into a separate chain‐link‐fenced ash pit. Non‐burnable waste – primarily glass medicine bottles, but also including some metallic waste – is thrown into a separate narrow pit. The hospital is in the practice of incinerating needles, believing that the fire gets hot enough to melt the needles down and neutralize the contamination threat. Another concrete‐lidded pit is provided for placentas, but the staff believes that it is nearly full and will need to be sealed and another pit provided.

Figure 8.1: Hospital incinerator

There was relatively little rubbish seen on the property, particularly within the hospital walls. This is a testimony to the hard work of the grounds‐keeping staff, but also a reflection of the hospital’s remote location, where packaged goods are rare.

8.2

RECOMMENDATIONS

Solid waste that cannot be reused, recycled, or composted will need to be dealt with in a healthy manner. The typical practice in East Africa for dealing with refuse is burning. Kibuye’s current incinerator is one step up from the most common practice of free burning, which does much to harm the environment and reduces air quality, but it lacks the heat and efficiency of more modern medical incinerators. Cancer‐causing chemicals are generated by the incomplete combustion of plastics and other waste products, and they put the surrounding community at risk.

ELECTRICAL ASSESSMENT

9.0 9.1

CAMPUS ELECTRICAL SURVEY 9.1.1

POWER UTILITY

The government‐owned power utility, REGIDESO, has a 6.6kVcc line passing through the site. The line supplies a three‐phase transformer (see Figure 9.1) with 380VACdd secondary. The transformer has no visible primary or secondary protection (fuses may be internal and not visible). The transformer appears to have a solidly‐grounded secondary neutral. The utility has built 100‐200 meters of secondary distribution to service the hospital campus and the community to the west. The transformer capacity is not known but is estimated to be 150kVAee.

cc

kV = kilovolt dd VAC = volt in alternating current ee kVA = kilovolt‐ampere

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Figure 9.1: 6.6KV Transformer on site

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POWER COST

Power cost to the hospital was 149 BIFff per kWHgg (approximately $0.11 USD per kWH) in February 2013. At this price, many potentially‐desirable appliances may not make economic sense for the hospital. The high price of fuel does not favor local diesel‐electric generation. It is difficult to predict what level of infrastructure will be appropriate in the future.

9.1.3

POWER DEMAND

Power demand data is based solely on utility billing records (refer to Table 9‐1). The amount of data available varied from one month (Busoma plant) to several months (Hospital campus): Table 9‐1: Electrical demand according to utility billing records ELECTRICAL DEMAND (KWH/day)

BUILDINGS SERVED BY METER Hospital, Outpatient Clinic and various wards

70.70

Most station houses

42.88

Busoma Plant

8.98

Maternity Building and Emergency / Dormitories

5.74

Distric Health Office

3.66

Hospital Rental Housing (Building No. 29)

3.46

Shop and Church

0.88

Total

136.30

9.1.4

POWER RELIABILITY

The utility power at present has poor reliability. Back‐up systems must be a part of plans for the foreseeable future. The hospital must decide to move toward a large centralized capability or small distributed back‐up systems. This is a key unresolved issue. Current practice around the campus leans toward small distributed back‐up systems. Installation and operating cost also favors distributed systems.

9.1.5

COMMUNICATIONS

There does not seem to be any support or desire for hardwired communications infrastructure (phone, alarm system, intercom, PA). This seems like a reasonable choice in an increasingly mobile wireless world.

There does not seem to be any interest or support for hardwired data network infrastructure. There is a wireless server located in the Outpatient Clinic (Building No. 7) that was not operating during EMI EA’s visit. Data services through cellular phone are currently unreliable at the hospital campus, but this situation is likely to improve over time.

9.1.6

110 VAC SYSTEMS

Burundi uses French (Belgium) electrical standards including 220VAC, 50‐Hertz (Hz) service outlets.

Equipment brought in from North America is typically designed for 110VAC, 60Hz, which is not easily compatible with the infrastructure. The EMI EA team’s electrical engineer recommends that hospital

ff

BIF = Burundian Francs kWH = kilowatt hour

gg

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buildings not be wired for 110VAC. Most modern equipment can be configured for 220VAC and the plug changed to fit the standard outlet. American equipment that cannot be configured should be modified with a transformer and plug to operate on 220VAC. In no case should "special" outlets that will accept both North American (parallel blade) and French (round post) plugs be installed in any hospital building. If every outlet is a standard 220VAC outlet, there is less chance for confusion and subsequent equipment damage.

9.1.7

POWER DISTRIBUTION AND WIRING

The current methods and level of quality in installation of electrical infrastructure is unsafe, unreliable and wasteful of materials and labor. How to improve this situation is a pivotal unresolved issue. Some possible strategies that could be used individually or in combination include:

 Utilize a knowledgeable contractor and more complete specifications for new installations.  Hire a knowledgeable electrician as a permanent site employee.  Create training documents and provide site training for existing employees.  Utilize expertise resident at HAU to supervise installation at Kibuye (specifically, Engineer Ndikumana Gaspard).  Utilize pictorial "wiring diagram" type engineering drawings to better convey the exact intent.  Specify and develop local sources for quality material at reasonable cost.

Some specific wiring problems that were observed (and their potential hazards) include:

 Inadequate, or most often a complete lack of, safety ground (potentially fatal electrocution hazard).  Exposed energized electrical conductors (potentially fatal electrocution hazard especially to children).  No ground fault circuit interruption protection in wet locations (potentially fatal electrocution hazard).  Circuit switches, fuses or breakers in the neutral conductor without a downstream bond to ground (hazard to electrician).  Conductor color code not followed (hazard to electrician).  Circuit protection, fixtures and devices not labeled with what they feed and where they are fed from (difficult to isolate equipment).  Grounds and neutrals not mustered each at a single bus for each building (hazard to electrician).  Current carrying conductors for each circuit are not run together (creates inductive loops).  Unprotected and/or inaccessible terminations and splices (fire hazard, difficult to service).  Unprotected conductors not rated for environment such as wet location or sunlight (insulation failure).  Indoor‐rated fixtures and devices installed in outdoor locations (equipment failure).  Inadequate circuit protection (arc‐flash burn hazard and fire hazard).  No means of disconnecting and securing circuit (lock‐out) for servicing equipment (mechanical or electrical hazard).  Inadequate conductor ampacity (size) creating heating and voltage drop (fire hazard, equipment failure, wasted energy).

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No positive, foolproof transfer method for back‐up generators (electrocution hazard for utility employees).

Wiring not neat and orderly (pride of workmanship, reliability and ease of troubleshooting).

9.2

EXISTING BUILDINGS ELECTRICAL INSPECTION 9.2.1

OVERVIEW

During the EMI EA assessment team’s visit, a cursory inspection was performed on all existing facilities and is summarized here. Only buildings with electrical service are included in this documented list. Electrical layouts in individual hospital buildings have been catalogued and are available on request.

9.2.2

WOMEN’S HEALTH CLINIC (1hh)

Single phase power is fed from a brick splice box east of the hospital campus wall near the north end of the building. The feed consists of two light wires strung over the wall with no support or protection. There is one hand twisted splice within easy reach of children, which the EMI EA team covered with tape (see Figure 9.2). The original feeder near the southeast corner of the building is abandoned. Only one 20‐amp (A) breaker remains in the original breaker box. Ampacity of the feed and quality of the wiring in this building is poor. There is no safety ground.

9.2.3

ISOLATION WARD (2)

Figure 9.2: Exposed feed to Women's Health Clinic

Lighting for this building is simply scabbed onto the Women’s Health Clinic with a pair of wires strung from eve to eve.

9.2.4

DISTRICT HEALTH OFFICE (4)

Three‐phase power is fed directly from the utility by aerial feeder to a meter located on the outside of the building. The meter did not appear to have any line side protection, but it was equipped with a four‐pole load side breaker. It is assumed that the neutral is switched. No safety ground was observed. No internal building observation was performed.

9.2.5

TOILETS (5)

Lighting is fed by a pair of wires scabbed from the west Gate House.

9.2.6

OUTPATIENT CLINIC (7)

The clinic is fed underground from the Main Hospital Building via a brick splice box in the lawn northwest of the building. There are two breakers (10A, 6A) located in the northwest corner of the building. Wiring quality is poor. No safety ground was observed.

9.2.7

LAUNDRY/SHOWERS (9)

Lighting power is scabbed from the Main Hospital Building via aerial lines.

hh

Building number in parentheses; similar throughout.

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MATERNITY BUILDING (10)

Three phase power is fed directly from the utility by aerial feeder to a meter located on the Emergency/Dormitories building (see Figure 9.3). The meter is equipped with 40‐amp line side phase fuses. The meter is not labeled and is housed in a site‐made wooden enclosure that provides mechanical protection only (not weather rated). A 30‐amp single‐phase breaker protects a branch circuit to the Emergency/Dormitories building. The Maternity Building feeder continues underground to the northwest corner of the building. There are two breaker panels located at the west end of the central hall. Each panel has a bus to muster the neutral conductors. There was no visible ground bus. There is no panel schedule to indicate what loads are served by what breakers. There is a ground wire in plastic conduit at the east end of the building. The conduit is exposed to damage where Figure 9.3: Maternity Building meter it crosses the walkway. This building has the most professional electrical installation on campus by far.

9.2.9

EMERGENCY / DORMITORIES (11)

Single phase power branches from the Maternity Building meter via a 30‐amp breaker. The feed is aerial. An old feed from the Main Hospital Building has been cut. No additional circuit protection or grounding was observed.

9.2.10 MEN'S WARD (12) Power is scabbed from the Main Hospital Building. There is no visible circuit protection or ground.

9.2.11 MAIN HOSPITAL BUILDING (13) Power is fed underground from a splice box fixed to the east side of the security wall near the southeast corner of the Outpatient Clinic. The feeder enters the Main Hospital Building mid‐way along the east side of the south wing.

Hospital power distribution is centered in the minor surgery room. There is a four‐pole, 63‐amp main breaker. A recently‐ installed transfer switch connects to a generator located near the west door. A separate 10‐amp breaker is labeled "sterilizer”. There is a sterilizer located in the surgical suite that is not in use. There is a 110VAC distribution system protected by four 10‐amp breakers and fed from a 1.0‐kVA transformer. The Outpatient Clinic and several out‐buildings are supplied from this building. There are two refrigerators in the lab with a backup system based on batteries, a charger and an inverter. There are two x‐ray machines. There is bright lighting in the surgical theaters. There are a few 12VDC Figure 9.4: Surgical theater backup lighting systems in various wards and the surgical theaters, which are based on batteries and chargers (see Figure 9.4).

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9.2.12 LAUNDRY/SHOWERS (16) Lighting power is scabbed from the Main Hospital Building. No circuit protection or ground was observed.

9.2.13 TOILETS (17) Lighting power is scabbed from the Laundry/Showers building (Building No. 16).

9.2.14 MORGUE/LAUNDRY (18) Power is fed underground from the Main Hospital Building. The feed is located on the east side of the north hospital door. No ground or circuit protection was observed. There do not appear to be any loads other than lighting.

9.2.15 GATE HOUSE (19) Lighting is scabbed from the Maternity Building meter located on the Emergency/Dormitories building.

9.2.16 NORTHWEST RENTAL HOUSING (20 THROUGH 23) These homes were recently acquired by the hospital and are occupied. None of these homes were approached, nor were electrical observations made. Utility service is close by.

9.2.17 SOUTHWEST RENTAL HOUSING (24, 25 AND 28) None of these homes were approached closer than the street, and none were observed to have electric service.

9.2.18 BUSOMA MILL (26) Three‐phase power is fed to a meter located on the building exterior at the northeast corner. The meter has line side fuses and a four‐pole, 32‐amp load side breaker. It appears that the neutral is switched by the breaker. No other circuit protection was observed. No ground was observed. There is an abandoned engine for driving a grain mill in the southwest corner of the building.

Two 10‐HP mills are used to grind feed stocks. The three‐phase (380VAC) motors have manual starters. No overload protection was observed (manual starters were not opened, overload protection could be present). The motors are not grounded. There are no belt guards on these mills.

The room was clear of furniture, storage or clutter to collect combustible dust. It appears that housekeeping for combustible (possibly explosive) dust is routine.

9.2.19 HOSPITAL RENTAL HOUSING (29) An aerial line feeds power from the utility to a single phase meter located on the porch. The meter is protected with line side fuses and a load side 32‐amp breaker. No internal observations were made.

9.2.20 GENERATOR HOUSE (30) The utility feed included five conductors thought to be three phases, neutral and ground. All five conductors showed current. The building ground consists of a few feet of buried bare copper wire.

There are two non‐functional generators, one in each of the two small rooms. Only one generator remains wired. The generator is protected by two mechanically‐interlocked 30‐amp breakers acting

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Engineering Ministries International ‐ East Africa

Project No. 9134

as a transfer switch. There is a separate tie switch, which could inadvertently cross‐tie the utility and the generator (should be removed if generator is replaced). There are three meters:

 Three‐phase meter with four‐pole line side fuses and four‐pole, 32‐amp load side breaker feeding two‐pole, 25‐amp breaker protecting a single phase aerial feed to the Shop (Building No. 32) and the Church (Building No. 45).  Three‐phase meter with three‐pole, 63‐amp line side fuses and four‐pole, 32‐amp load side breaker. This breaker is damaged and now functioning as a one‐pole breaker protecting a single‐phase underground feed to the Women's Health Clinic (Building No. 1) and the Main Hospital Building (Building No. 13).  Single‐phase meter with two‐pole line side fuses and two‐pole, 10‐amp load side breaker protecting an underground feed to several station houses. It is not clear how this breaker supports the station houses’ load.

9.2.21 WORLD RELIEF TRIPLEX (31) This building is under construction (no electric service yet). Direct aerial metered feed from the utility is recommended.

9.2.22 SHOP (32) No ground or circuit protection was observed in this building. A welder and other power tools are in use. An underground feeder continues to the Church.

9.2.23 KUHN HOUSE (34) Power is scabbed aerially from the Cox house. No internal observations were made.

9.2.24 COX HOUSE (35) Power is fed from a brick splice box on the station houses’ underground feed to the south of the building. No internal observations were made.

9.2.25 DOLL HOUSE (36) Power is fed from the Cox house splice box to the northwest of the building. No internal observations were made.

9.2.26 MEDICAL STUDENT DORMITORY A (37) Power is fed from a brick splice box on the station houses feeder northeast of the building. There is a single‐phase meter without protection and four distribution breakers located in the pantry near the northeast corner of the building. There is no visible ground.

9.2.27 QUADRIPLEX VISITOR HOUSING (38) Power is fed from a brick splice box on the station houses feeder west of the building. There is a single phase meter without protection located on the porch (see Figure 9.5).

There is a ground at the north and south ends of the building, each reported to consist of a few feet of buried bare copper Figure 9.5: Quadriplex meter April 2013

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Engineering Ministries International ‐ East Africa

Project No. 9134

wire. This building is only partially wired. The north unit was reportedly wired with steel wire and has four 10‐amp distribution breakers. One of these breakers tripped off frequently during the EMI EA visit. The second unit has four 32‐amp distribution breakers. Each of these four units is equipped with a small water heater. A brief look in the attic revealed poor wiring practices with unprotected splices and no mustering of grounds or neutrals. The station houses feeder appears to continue under the Quadriplex Visitor Housing building.

9.2.28 MEDICAL DIRECTOR’S HOUSE (39) Power is fed from a brick splice box on the station houses feeder to the north of the building. No internal observations were made.

9.2.29 HOSPITAL RENTAL HOUSING ‐ WORD RELIEF (40) Power is fed from the splice box north of the neighboring Medical Director’s House (Building No. 39) to an unprotected single‐phase meter on the south side of the building. There is a transfer switch for the small generator located in an out‐ building to the southwest of the building. There is no visible ground. No internal observations were made.

9.2.30 OGDEN HOUSE AND SHED (41 AND 42) Power is fed from a brick splice box on the station houses feeder located south of Medical Student Dormitory B (Building No. 43) to an unprotected single‐phase meter. There is no visible ground. This dwelling has 220VAC power distribution, 110VAC power distribution using a 1.5‐kVA transformer, and 12VDC power distribution using two automobile batteries, a battery charger and solar collector panels (see Figure 9.6). The home has a refrigerator and water heater. The wiring practices are poor.

Figure 9.6: Ogden House electrical installation

9.2.31 MEDICAL STUDENT DORMITORY B (43) Power is fed from a brick splice box on the station houses feeder to the south of the building. No internal observations were made.

9.2.32 POLICE HOUSE (44) Power is fed from an unprotected splice (open in the lawn, see Figure 9.7) on the station houses feeder near the southwest corner of the building. No internal observations were made.

9.2.33 CHURCH (45) Power is fed underground from the Shop (Building No. 32). Figure 9.7: Exposed splice at Police House There is no visible ground.

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10.0 CONCLUSION Our prayer is that this report and the attached drawings and calculations will provide the direction and information needed to continue developing the Kibuye Hope Hospital Master Plan, and that lives will be changed and impacted for Christ through the facilities and programs of this campus.

It has been our privilege to work with Kibuye Hope Hospital, Hope Africa University, and the Free Methodist Church of Burundi in preparing these documents. EMI EA staff, interns, and volunteers have donated more than 1,700 hours, valued at over $117,000 USD, to complete this assessment report and drawings. We look forward to continuing the relationship between EMI EA and Kibuye Hope Hospital through further involvement – not just in the master planning effort in 2013, but as Kibuye begins to implement the master plan in years to come. Please do not hesitate to contact us as we would appreciate the opportunity to serve with you again.

Though very competent architects and engineers have compiled this design, many of whom are registered professionals in their respective home countries, as staff and volunteers of EMI EA, we are not licensed architects or engineers in the country of Burundi and therefore cannot meet the requirements for having your drawings sealed by a local professional. We recommend that you discuss with your local government officials as soon as possible their particular requirements for the design and construction of your project. If construction documents require a signature from a local architect or engineer, EMI EA can still be involved. However, we recommend that you also secure the services of local professionals to review and sign the final documents.

Furthermore, EMI EA takes no responsibility for the adequacy or construction of the finished structures. Many changes can and do occur during the construction process which can adversely affect the design. The volunteers and staff of EMI EA have provided a thorough multi‐disciplinary analysis for your project in support of our goal to provide affordable, safe, and functional facility designs for our ministry partners.

As Paul stated in Philippians 1:6 “He who began a good work in you will carry it on to completion until the day of Christ Jesus,” we also pray that God would continue to prosper the vision of Kibuye Hope Hospital and pave the way for the spread of the gospel through high‐quality medical care in the name of Jesus.

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Kibuye Hope Hospital Assessment – Kibuye, Burundi

Page 39

BUILDING KEY WOODLAND

WOODLAND

WOODLAND

AGRICULTURE

LAWN

AGRICULTURE

AGRICULTURE

LAWN

LAWN AGRICULTURE

AGRICULTURE

WOODLAND

AGRICULTURE

WOODLAND

SCALE 1:1500

EXISTING SITE PLAN KIBUYE HOPE HOSPITAL

A1

BUILDING KEY

SITE PERSPECTIVE KIBUYE HOPE HOSPITAL

A2

SITE PERSPECTIVE - HOSPITAL AREA KIBUYE HOPE HOSPITAL

A3

1

SITE SECTION - NORTH/SOUTH

2

SITE SECTION - EAST/WEST

1

2

SITE SECTIONS KIBUYE HOPE HOSPITAL

A4

LEGEND

E

RTY LIN

STAFF/VISITOR HOUSING

PROPE

HOSPITAL CHURCH/NEIGHBORHOOD GREEN PRIMARY SCHOOL

PROPERTY LINE

SCALE 1:2500

EXISTING ZONING PLAN KIBUYE HOPE HOSPITAL

A5

ROAD TO MAIN VEHICULAR ENTRANCE FROM RN8

LEGEND RN8 - MAIN ROAD TO GITEGA/BUJUMBURA

MAIN TRAFFIC ROUTES

MINOR TRAFFIC ROUTES

ROAD TO NEARBY HOUSES

HOSPITAL AMBULANCE ENTRANCE

BUSOMA PLANT TRUCK ACCESS

ROAD TO NEARBY HOUSES

SCALE 1:2500

EXISTING VEHICULAR CIRCULATION PLAN KIBUYE HOPE HOSPITAL

A6

LEGEND ROAD TO MAIN VEHICULAR ENTRANCE FROM RN8

MAIN PEDESTRIAN CONNECTION

SECONDARY PEDESTRIAN CONNECTION

ROAD TO NEARBY HOUSES

TERTIARY PEDESTRIAN CONNECTION HOSPITAL ENTRANCE HOSPITAL GATHERING/ WAITING AREAS

SECONDARY ENTRY

HOSPITAL CIRCULATION NEIGHBORHOOD GATHERING/ACTIVITY AREA

ROAD TO NEARBY HOUSES

MAIN ENTRY

SECONDARY ENTRY

ROAD TO NEARBY HOUSES

SCALE 1:2500

EXISTING PEDESTRIAN CIRCULATION PLAN KIBUYE HOPE HOSPITAL

A7

LAUNDRY/SHOWERS

LAUNDRY/SHOWERS - 250mm STEP MAKES SHOWERS AND TOILETS INACCESSIBLE

COOK HOUSE/SHELTER- UNEVEN COMPACTED SOIL COOK HOUSE/SHELTER

WALKWAY TO MEN’S WARD AND HOSPITAL MATERNITY BUILDING WALKWAY MAIN ENTRY

WOMEN’S HEALTH CLINIC

MEN’S WARD/HOSPITAL PATHWAY - BROKEN AND UNEVEN WALKING SURFACE

MATERNITY BUILDING/ISOLATION WARD - BROKEN AND UNEVEN WALKING SURFACE

MAIN ENTRY - POORLY MAINTAINED AND UNEVEN COMPACTED SOIL

WOMEN’S HEALTH CLINIC - TRENCH DRAIN PROHIBITS HANDICAP ACCESSIBILTY

SCALE 1:1000

HANDICAP ACCESSIBILITY PROBLEM AREAS KIBUYE HOPE HOSPITAL

A8

1

2

3

KEY

2 1 3

4

5

EXISTING SITE VIEWS KIBUYE HOPE HOSPITAL

A9

4

5

KEY

2 1 3

4

5

EXISTING SITE VIEWS KIBUYE HOPE HOSPITAL

A10

NOT FOR CONSTRUCTION

6.6kV TRANSFORMER 150kVA 6.6kV x 380VAC

AERIAL UNDERBUILD 380VAC

32amp 1 POLE DAMAGED

32amp 4 POLE

10amp 2 POLE

32amp 4 POLE

380VAC, 30

30 kWh

4 POLE

30 kWh

10 kWh

12 DROPS TO VILLAGE

40amp

DISTRICT HEALTH OFFICE (4)

32amp 2 POLE

3 PHASE

32amp 32amp G

MANUAL STARTER

2 POLE 25amp 1 PHASE

1 PHASE

1 PHASE

OVERHEAD PROTECTION UNKNOWN

10HP 7.5kW 15.4amp

M

MANUAL STARTER

M

GATE HOUSE (19)

THERE ARE MECHANICALLY INTERLOCKED CIRCUIT BREAKERS NEAR THE GENERATOR AT THE GENERATOR HOUSE

MEN’S WARD (12)

OTHER 220 VAC LOADS 16amp x 6 10amp x 3

10HP 7.5kW 15.4amp

220VAC NORTH MATERNITY

TWIN GRAIN MILLS, MOTORS ARE NOT GROUNDED

NOTE

10 kWh

30amp

EMERGENCY/ DORMITORIES (11)

HOSPITAL RENTAL HOUSING (29)

16amp x 4 10amp x 4

220VAC SOUTH MATERNITY

MATERNITY BUILDING (10)

SHOP (32) STATION HOUSE FEEDER (BURIED)

COX HOUSE (35)

CHURCH (45)

DOLL HOUSE (36)

220VAC, 10

POLICE HOUSE (44)

10 kWh 32amp x 1 10amp x 3

KUHN HOUSE (34)

MEDICAL STUDENT DORMITORY B (43)

MEDICAL STUDENT DORMITORY A (37)

OGDEN HOUSE (41)

MEDICAL DIRECTOR’S HOUSE (39)

10 kWh

1500 VA 110VAC TRANSFORMER HOT WATER TANK 12VDC BACKUP BATTERY/CHARGER/SOLAR

10amp x 4

32amp x 4

FUTURE

10 kWh

FUTURE G

UNIT 1 NORTH

UNIT 2

UNIT 3

UNIT 4 SOUTH

4 HOT WATER HEATERS

HOSPITAL FEEDER (1 PHASE) 220 VAC

HOSPITAL RENTAL HOUSING (40)

QUADRIPLEX VISITOR HOUSING (38)

MAIN HOSPITAL BUILDING (13) 63amp 4 POLE

20amp WOMEN’S HEALTH CLINIC (1)

THREE PHASE TRANSFORMER WITH DELTA PRIMARY AND SOLIDLY GROUNDED WYE SECONDARY

IN PARALLEL (252amp)

3 BACK UP SYSTEMS 12VDC BATTERY / CHARGER / SOLAR 1 BACK UP SYSTEM 110V LAB REFRIGERATOR

CENTER OFF TRANSFER SWITCH ISOLATION WARD (2)

25amp 32amp N.O. G

10amp STERILIZER

6amp x 3 40amp x 1 10amp x 3 32amp x 1

N.O.

FUSE

CONNECTION

(HOSPITAL, UNKNOWN WHAT COMES OFF WHICH BREAKER)

CIRCUIT BREAKER

TRANSFORMER

Plotted: Mon, 15 Apr 2013 − 11:39am Filename: Y:\9134 − Kibuye Hospital\Drawings\Electrical\Wiring Diagram.dwg

1kVA 220/ 110VAC

NORMALLY OPEN

BURIED FEEDER

BURIED FEEDER

ELECTRICAL ONE−LINE DIAGRAM

30 kWh

30 kWh

30 kWh

2 POLE

KIBUYE HOPE HOSPITAL − ASSESSMENT

3 POLE 63amp

4 POLE

Engineering Ministries International

BUSOMA MILL (26)

GENERATOR HOUSE (30)

BUS 30 kWh

METER

10amp x 4 G

HOSPITAL 110V OUTLETS

GENERATOR

TWO POSITION TRANSFER SWITCH 6amp x 1 10amp x 1 OUTPATIENT CLINIC (7)

MEN’S WARD (12)

LAUNDRY / SHOWERS (9)

COOK HOUSE (14)

MORGUE / LAUNDRY (18)

PROJECT:

9134 M

MOTOR

DATE ISSUED:

APRIL 2013 LAUNDRY / SHOWERS (16)

CENTER OFF TRANSFER SWITCH

REVISIONS:

CONTACTOR

A E2.1

ELECTRICAL ONE−LINE DIAGRAM

TOILETS (17)

SWITCH SHEET NUMBER CONNECTION TO GROUND

E2.1