Ayder Comprehensive Specialized Hospital

Localization: Ayder sub city, Mekelle City, Northern Ethiopia Tigrai Region

Number of bed-places: 500 inpatient beds, with 36 ICU

Date of opening: September, 2008

Starting then, Ayder Hospital has bee through incremental expansion and refurbishment projects; cadamic buildings, staff residence, dormitories, temporary store, and its major hospital expansion (oncology centre) in 2017.

Ethiopian health system

The National Health Policy emphasizes core principles of democratization and decentralization of the Health Care provision though its smallest administrative units (Woreda’s) as semi autonomous health care units. Through these units the core objective of the Ethiopian healthcare policy focuses on Preventive, promotive and curative approach.

Ethiopian Ministry of Health structures the public healthcare system into a three-tier health care delivery system; with a slightly different approach to its rural and urban population (refer diagram 01). In this chapter we will focus on the urban healthcare system; Level one is a woreda health system comprised of a primary hospital (for 60.000–100.000 people), health centres (for 15.000–25.000 population) and their satellite health posts (for 3.000–5.000 population), connected to each other by a referral system. The primary hospital, health centres and health posts form a primary health care unit. Level two is a general hospital for 1–1.5million people and level three is a specialized hospital for 3.5–5million people. In which Ayder comprehensive specialized hospital is positioned as tertiary level facility.

Ethiopian Health System

Brief note: Ayder Comprehensive Specialized Hospital

Ayder Comprehensive Specialized Hospital is designed in 1998 by Architect Hasen Indris, after it’s commencement in 2008 the hospital starts to render its referral and non-referral services to around 9 million population in its catchment areas of the Tigray, Afar and North-eastern parts of the Amhara Regional States including the Eritrea refugees. The hospital is built with the estimated cost of about 33 million USD by the Tigray Regional government. After many major expansions and retrofit development projects in its hospital and academic facility the hospital become relatively among the most advanced medical facility, by all accounts, in the Northern part of the country and that it stands as the second largest hospital in the nation with the total capacity of about 500 inpatient beds in all departments and other special centres (Oncology, Cardiac and Psychiatric centres) under construction. Since the Hospital is also used as a teaching hospital and research centre, it has integrated education facilities (dormitory, academic and support facilities) with the College of Health Sciences, Mekelle University.

The hospital serves divers group of people from five ethnicity with different cultural and demographic background around the north part of Ethiopia. The hospital also serves all economic ranges, people who are categorized below poverty line and middle class. These diverse user group background and need shaped the hospital during last 10 years and it was one of the factors which drives the hospital’s physical environment to its current state; how they use indoor and outdoor space affected the hospital to alter its physical premise over time in addition to the technological, economical and other changes that affect the hospitals physical environment.

With the very first hospital built in the beginning of 20th century in the capital city, in general modern healthcare facilities in Ethiopia can be considered a century old phenomenon. Modern healthcare and facility was introduced during the Italian occupation. And it remained as a new phenomenon and associated with foreign until the wake of world war II (1950-60s) the government with help of western began to construct hand full hospitals in and out of the capital cities. In the mid of 1970s after the downfall of monarchy system Ethiopia went to two decades long civil war, and the healthcare sector remained stagnant for two decades in 70s & 80s. After the beginning of 1990s, the government, as part of the new government’s reconstruction program, devoted ever-increasing amounts of funding to the social and health sectors, which brought corresponding improvements in school enrolments, adult literacy, and infant mortality rates. With 60+ million population and more than 80% population living in rural areas the government’s accelerated effort resulted tens of new hospitals around the regional cities. Ayder Hospital and other nine regional referral hospitals were developed as part of this effort. With limited experience in building such number of hospitals, these new generation of hospitals were developed in a uniform manner with similar nature of early modern hospitals of developed countries.

This case study will focus on Ayder Hospital, one of these new generation hospitals at that time, it was designed as typology of regional referral hospital for multiple secondary cities. Though the typology was developed with thinking of average climatic and environmental context from dry windy (Mekelle) to humid (Hawassa), there has been some modification to situate the facility with its context. Ayder hospital is located in middle of low-rise residential neighborhood in Mekelle city the capital region of Tigray (norther region of Ethiopia). The climatic character of Mekelle is dry windy, average temperature of 10 – 25 °C, average annual rainfall of 175 millimeters, with 2000+ meter above sea level.

Ayder hospital is characterized as utilitarian design organized along central courtyard without or less emphasis for contextual parameters like social values and traditions. The base design was G+1 treatment and diagnostic unit and G+6 inpatient facility. Though similar to most hospitals developed at that time, like what most hospitals in the world are facing, there are extensions here and there in all direction as the byproduct of continual and evolution of decades of development in size and service.

Since there was less attention to the end users at the time where Ayder hospital was developed, this case study will try to investigate and discuss the contextual situation of open spaces, their purpose and how they are interacting with their users. As the hospital is considered one of modern generation hospitals in Ethiopia, this case study can be considered representative of its generation and can give glimpse of modern Ethiopian healthcare facilities and their open spaces’ interaction with users.

Background

Most Ethiopians are still connected to their deep-rooted culture and belief, in understanding health and healthcare which is immensely associated with spirituality and religion. Religious centres and traditional physicians are considered as physical and psychological healthcare providers, who widely use herbal and holy water as medication. The orthodox churches are the centre of these activities, concurrently churches are usually with ample open space for religious services and widely vegetated with herbal and big trees as sanctuary of nature. Conventionally both factors made churches and their natural setting a healing centre for the general population.

More than 80% of Ethiopians live in rural areas and they are deeply connected to the traditional notions of physical and spiritual health interconnectedness with the natural environment. The most accepted way of treatment is still considered to be holy water (natural spring water) in churches and monasteries, physical and spiritual patients get treatment by residing for weeks. Sometimes months long treatments in these facilities. Thus, the assessment of symptom and the decision where to seek a treatment is embedded in the overall socioeconomic and cultural contexts of the society. Which usually prefer to these places than modern hospitals.

Ethiopian Demographic and Epidemiological Profile

Estimated population – 115million (2020); Urban Population counts only 20.9 % of the total population (23.376.340 people in 2019)

Adult literacy rate of 51.77%; 59.24% male literacy rate, and 44.42% females (2019)

Per capita income: $1,890 (2017)

A Total Fertility Rate (TFR) of 2.1 (2020)

Life expectancy at birth: F 69.8 /M 65.9 yrs (2020)

Infant mortality rate: 29.5/1,000 live births (2020)

Deaths of Children under 5 Years Old: 44.0/1000 live births (2020)

Hospital beds ratio (per 1,000 people): 0.33 (2016) Physicians (per 1,000 people): 0.1 (2018)

Local Context of the hospital and its surrounding,

Ayder Comprehensive Specialized Hospital is located in Mekelle city, the capital of Tigray Regional State, which was founded in the 13th Century. During the time of Emperor Yohannes IV, it became the capital of Ethiopia. This very tiny town, which had only seven hectares of urban land, was expanded to 2.4 km2 in the 1960s (MCPPO, 2008). Currently, this figure has exponentially grown to 259.9 km2 (ibid). The city is located 783 kms to the north of Addis Ababa at an altitude and longitude of 13029’N 39028’E respectively with an elevation of 2084 meters above sea level.

The Case Study

Based on a questionnaire designed for the purpose of this book, modifications to the Aider Hospital (ACSH) case questionnaire included overlapping two subjective assessments. The first part focuses on the different user groups: patients, visitors, staff members and students. All user group interviewees with their unique emotional experience and behavioural pattern have been asked with due care not to mislead their answers regarding subjective experience, limit their response regarding emotional experience and extract information about their behaviour, attitudes, opinions, preferences, experiences, interests and feelings. The second part of the questioner was intended for experts to evaluate the exact place where the users interviewed. Accordingly, the second part of the questionnaire requires skills to understand how people perceive open spaces, explaining and evaluating places and open spaces, and observation and understanding people’s opinion on their interaction with the open spaces. The questioner, which was composed of four questions, focuses on type and spatial characteristic of an open space in the specific area of the hospital where they conducted the survey, for every participating user interviewee. In addition to that basic categorization, like space dimensions, pathways, greenery, building condition and urban furniture, they described peoples’ presence, behaviour, activities and emotional look, as well as their own opinion (feelings) about space design, accessibility, orientation and emotional impact.

Physical Environment

The hospital (26.1 hectares) is located in the mid-northern part of the city in a predominantly residential area with neighbouring school and city park. The hospital is organized in ‘Tower on base’ with a spacious courtyard in the middle. Rest of expansions on the hospital and facilities surrounds the hospital and formulated campus (Ayder master plan revision report 2012), with green open spaces 31%, road, parking and pedestrian 23.1%. Built footprint (14.88 %) of the existing campus currently includes different buildings, infrastructure etc. the remaining 31.02% of expansion area (in accessible open space).