Recapping

Everyone who has ever written on a blog, or something like it, knows that it can be hard to keep up the continuity throughout a longer period. The same goes for us and that's why you haven't been getting much updates from here recently. HOWEVER, that doesn't mean that we have been slacking off. On the contrary, the latest month has been very busy trying to find out and do everything we had to before leaving Kolandoto (and also with some well deserved vacation in the more ocean-close parts of Tanzania of course).

From an engineering point of view, the most important work the latest weeks, and perhaps for the whole stay in Kolandoto, has been to install the new water pump. As mentioned earlier in this blog, there is an urgent need for a new water pump for the hospital and village of Kolandoto. After the pump test, thorough investigations of the whole water supply system, and careful budget assessments we decided together with the hospital on a submersible Dayliff 17/10. (For the nerdy readers, read further about the pump here: https://www.davisandshirtliff.com/water-pumps/product/397-ds-17-10. For the not so nerdy readers, a submersible pump is just a device which lies on the bottom of the borehole continuously pumping up water.)

As always, a couple of issues arises. Firstly, the retailer was out of stock in whole Tanzania and had a delivery time of four weeks for this specific pump. This would have meant that the pump would arrive after we left Kolandoto. Since the actual installation would be made by the supplier and not by us, this was of course possible but nevertheless a very unfortunate option. Luckily, we found out that the company had one pump left at their main storage in Nairobi, Kenya, and if we only could collect it ourselves we could have it straight away. By the help of the very charismatic archbishop (!) of AIC (African Inland Church, the organisation which runs Kolandoto Hospital), who we met with a couple of days earlier, we could arrange for the pump to be collected and transported across the boarder and finally to Kolandoto.

Having solved that problem, there were still more to come. When the pump had arrived, a whole day was spent on installation and waiting for the correct equipment and installation material to arrive. The installation was finally completed late on a Saturday evening, but only for us to realize that the pump doesn't work as expected: the power supply from the hospital to the pump was of poor quality which resulted in too low voltage to run the pump properly. When evaluating and excluding different options (buy a diesel generator, replace old power lines etc.) it was clear that the best option was to do nothing and continue to run the new pump on the lower voltage.

Pump installation

Still, the new pump has been a great improvement for the village and hospital of Kolandoto. Even though the pump doesn't run under optimal conditions, it has been working flawless since it was installed almost four weeks ago. With the new pump, we have managed to double the water supply to the hospital and the village, an outcome for the first phase of this project that both we and the inhabitants of Kolandoto are very satisfied with.

The whole Healthy Hospitals survey team has now left Kolandoto, which means that Phase 1 of this project is coming to its end. Soon Phase 2 is to be initiated, and the aim of this phase is to implement as many of the interventions we have investigated during Phase 1 as possible. Some, but not all, of the needed interventions are:

• Water treatment system to ensure safe drinking water
• Solar powered back-up electricity system to protect the hospital against power cuts
• Further increase of the water supply through an additional borehole

However, how much and what we can do depends on the amount funds we can gather. Are you interested to help out? Please visit http://iaidafrica.eu/ and click on "Stöd oss" > "Healthy Hospital". Do you want to read more and maybe get involved in Engineers Without Boarders or I Aid Africa? Visit them at http://www.ingenjorerutangranser.se/ and http://iaidafrica.eu/.

Kolandoto Church, view from the top of the hospital's water tower

Construction is starting!

It is late Sunday evening here in Kolandoto and I have just finished the fourth revision of a budget for a construction project here at the hospital. I will tell you more about the construction, but first some background. 

This Healthy Hospital project has many parts to it. In addition to making our master theses on water and architecture at the hospital, we are also part of a larger collaborative development project between Kolandoto Hospital, and three NGOs in Sweden called Architects without Borders, Engineers without Borders and I Aid Africa. Within the set-up of this project there are also some funding available for implementing smaller interventions, which we call low-hanging-fruit projects, while we are on site here during these two months. 

About two weeks ago I made 8 architectural sketches for such low-hanging-fruit projects. The 8 sketches were presented to the officer in charge at the hospital as ideas for small projects that we could do. He took the sketches with him and discussed the ideas with staff at the hospital during a morning meeting to decide what the hospital would like to spend the available money on. One of the sketches were chosen, and in addition to that, the hospital suggested a different project as well. 

The door renovation sketch.

The first sketch that was chosen to be implemented was a renovation of the doors to the general theatre building. This is a small project idea that came to me already during my first visit here to Kolandoto last year in July. The doors are today not tightly fitted to the door frames, but instead there is an air gap that lets dust and air enter the theatre. In other words, dust can easily flow straight into an environment that need to be clean to perform safe surgeries! The door renovation sketch.

 A door with an obvious air gap leading straight into the minor theatre. 

So, last Monday me and the carpenters at the hospital went into town to get the materials for renovating three double doors.

Checking the wood quality before buying.

It went well, and now the first double door is up, although it is yet to be painted. 

A renovated door.

In addition to the door renovation project, the hospital also wished to look into constructing an extension to the current operating theatre. The hospital has a fully equipped theatre room for c-section, located next to the delivery room, so that it is easy to transport the mothers in labour to there if an emergency c-section is needed. 

The theatre for c-sections.

However, the theatre is apparently not in use at the moment. This is due to that the hospital feel they cannot guarantee the needed hygienic conditions for performing safe c-sections. What is missing is an entry room, a proper changing room, a scrub room, and a sluice room for rinsing the used equipment before taking it to the sterilization unit. 

After constructing this extension the pregnant mothers who are in delivery and need emergency c-sections will no longer have to be transported out of the building, and along an outdoor path, to go into the general operating theatre. This will of course increase the patient safety a lot!

The site for the extension.

The operating theatre is situated right inside that wall on the picture. The open area in the picture is where the extension will be. After the hospital had decided that they wanted to spend the money on this project I did a sketch of a possible layout of the extension. This was discussed during a meeting with staff in which I also physically showed the size of the rooms in order for the staff to assess if the rooms were big enough. 

So, the last week I have been working to get proper cost and time estimates from different people in preparation for the construction - the mason, the roofing guy, the carpenter, the plumber, the electrician and the painter. Tonight we arrived to a proper budget, after double checking a lot of things and having extra meetings with the workers to coordinate and discuss the best way to solve some issues concerning rainwater run off, roofing design, and wall construction techniques. 

The next thing that happens is that I will do some revision to the drawings, and make them clear to read and understand for the workers. And, tomorrow we are off to buy the material for the plumber and the mason! 

The maternity building.

Let the construction begin! 

/Annika

Why do a masterplan?

In the last blog post I wrote about only one part of what we be my master thesis - the design proposal of a new eye outpatient clinic. This time, I thought that I would write a bit about another part of my work here - making a master plan for the long-term development of Kolandoto Hospital. By masterplan, I mean a document that describes the development of the built environment at the hospital during the next 10 years. 

Background 1: The process of creating this masterplan started with mapping of the current site and site usage. Two aspects that have been important to know are the flows of people through the hospital site, and the medical zoning of the hospital. 

Six different medical zones have been categorized and identified. Those are: 

• Inpatient
• Outpatient
• Diagnostics and treatment
• Support, goods and materials
• Staff and administration
• Public and non-hospital functions

In the master plan layout, one should strive to differentiate between these zones. However, some support functions and some diagnostic functions will naturally be closely connected to functions belonging to other zones. The justification of not overlapping zones is to decrease the risk of transmission of communicable diseases and nosocomial infections, to safeguard the security and safety of patients, to differentiate between non-sterile spaces and sterile spaces, to ensure appropriate privacy to patients, to create an environment that minimizes room for errors, and to ensure a good working environment for the staff. 

Zoning illustration. 

Problems with the current zoning at the hospital include: 

• outpatient areas spread out over the whole hospital
• public access to the diagnostics and treatment functions (excluding lab)
• support, goods and materials spread out 
• unnecessary public functions inside the hospital
• inpatient and outpatient areas are overlapping

Site circulation and flows of patients, staff, materials and visitors across the hospital area plays an important part in making sure the hospital is an environment that does not cause illnesses or poor health. Just as with zoning, appropriately designed flows will decrease the risk of medical errors and nosocomial infections or diseases. Appropriate access and entrance points to the site for different types of flows need to be considered. 

The flows considered are: 

• emergency care
• inpatients
• outpatients
• delivery 
• visitors
• students
• staff
• goods and material 

Flows illustration. 

Current problems with the flows at the hospital include:

- 500 college students passing the site there times per day to get food in the kitchen and social hall

- the emergency flow of patients is too inefficient and delays the treatment of acute patients 

• the outpatient flow is too spread out and crossing inpatient flows
• the visitors flow is unnecessarily long and crossing other crucial flows

Reason 1: The two aspects of appropriate medical zoning and design of flows through a hospital is part of one reason as to why it is important to have a masterplan - to decrease the risk of mistakes and spread of infections. This has to do with the human right to health which includes patient safety and access to health care in an environment free from factors causing illness or poor health. 

Background 2: In the process of making a masterplan, we decided to identify what building/room/space needs there are at the hospital for the next 10 years. I organized a programming workshop attended by the heads of departments at the hospital in which we together created a list of construction needs for the the coming 10 years.

Reason 2: This relates to another reason for making a masterplan -  a reason that has more to do with the vision for the future than with the problems of today. The hospital is in the process of becoming a designated district hospital, but to fully become that some services and hence buildings need to be added. So, for the hospital to be able to lobby for full implementation of being a designated district hospital - a masterplan identifying the new constructions, renovations and extension needed can help smoothen and also speed up the process. Which then also helps the community around to get access to appropriate healthcare, and their human right to health to be fulfilled. 

Background 3: The hospital is set in a relatively resource scarce setting. And by resources I mean both money, materials and staff. When making plans for the future expansion of the hospital, it is important to consider this. To deal with the limited resources priorities need to be clarified. To do this, the hospital management and I had a meeting in which I facilitated a discussion regarding what out of all the different building needs they have during the next 10 years that should be prioritized. Decisions were made by the management team, and now they have a comprehensive list of priorities. 

I will use this list of priorities when I continue to develop the masterplan, and consider the order and timing of different constructions. The masterplan will also include a little bit more details about spatial needs, medical justifications and tentative budgets for around 8-10 of the first entities on the list. 

Reason 3: This relates to the third reason of creating a masterplan which has to do with funding of implementations and ownership of the development process. A proper masterplan in with agreed priorities, medical justifications constructions, and tentative construction budgets can be used as a base for resource prioritization within the hospital, and resource mobilization from possible donors for implementation of the identified building projects. It also provides better possibilities for the hospital management to really have ownership over the development process at the hospital, and especially in relation to the international development sector and possible donors.

MASS Design Group summarizes the need for a masterplan in a very good way: 

”A masterplan is necessary for buildings and services to operate as a unified system for efficient and effective healthcare delivery. Designing sites to accommodate programmatic, contextual, and climatic needs involves the strategic placement of spaces and services, well-designed site circulation, and provisions for future growth, while limiting risk factors that can confound infection control and service delivery.”

With greetings from a very warm Kolandoto in which we had 39 degrees C in the shade today,

/Annika

Pump test

During this weekend a nine hour long pump test was made in the existing borehole by the company Wedeco Ltd. The pumping started at 13 and finished around 22. Also a recovery test was made by me and Daniel for one hour after the pumping was finalized. Conducting the pump test during a weekend was the best solution since the water supply will be very limited. The hospitals need of water is less in the weekend compared to a normal weekday. 

A meeting with the company is planned on Thursday to discuss the results. Wedeco Ltd also works with fluoride removal from drinking water in other regions in Tanzania and a possible study visit will be discussed on Thursday.

Picture from the pump test

Unfortunately one of the pipes broke when the old pump was inserted into the borehole again, causing a limited water supply for the past few days. However, spare parts were obtained from Shinyanga yesterday and the pump was back running by the evening.

Our plan for this week is to start with the electricity-part of the project. On Wednesday, Dr. Katani will show us the Eye Theatre, including machines which have a need for an uninterrupted power supply. A more extensive inventory will be on-going during the following weeks.

Also, on Wednesday there is a football game between Shinyanga – Kolandoto which we will attend to, and this weekend we will visit the Ngorogoro crater together with our neighbor, Lotta.

Advances in the water issue

So, the last week the work has been pretty hectic for me and Andrea (yes for most of the time that is his name here, the “s” doesn’t really come through for the Swahili speakers). Almost from the day we arrived, it was clear that the hospital was in need of a new pump for the drilled well that supplies the hospital and parts of the village with water. The current pump is old, ineffective and often breaks, which results in water shortages for the users. A new pump could for the short term ensure a more stable (and hopefully increased) water supply, even though a further increase in the supplied volume has to be established for the long term. Therefore, the recent work has mainly focused on finding an entrepreneur that can carry out the tests we need to be able to decide on the specifics for a new pump.

Yesterday we reached a conclusion regarding which company to work with, and in the end the choice was fairly simple. Out of three entrepreneurs found, one company did not have a pump of sufficient capacity, and another (a governmental agency for drilling and dam construction) gave a sloppy and unprofessional appearance. Needless to say we decided to work together with a third option, a local water and environmental developing company based in the regional capital Shinyanga (only 15 km from our village Kolandoto) called Wedeco. At the moment we are waiting for Wedeco to confirm the details in the contract we proposed to them. Then we will find Dr. Katani, the medical doctor in charge, to sign the contract before we have a ride arranged by the hospital for us to visit Wedeco a fourth time this week to finalize the deal. If everything goes according to the plans, the pump test will be done tomorrow, updates on that later.

In other news, the recent two days has been some of the hottest yet, well over 30 degrees at midday. Also, our next door neighbour has one or several roosters that remind us – load and clear – once ever other minute that it is still there. The lust for Coq au Vin has never been greater...

A need for a new eye clinic

A new exciting development of my task here in Kolandoto has happened! During the first day almost two weeks ago, we were showed around at the hospital and also had a meeting with some of the management and the people working with water. At that meeting it turned out that the hospital is planning to extend its eye department with a new building containing an eye clinic. The hospital was looking for funding to be able to construct this building, and were supposed to write a justification document showing why this eye clinic building is needed, and then pass the document on to an NGO that will start fundraising. So, I did a short and intense consultancy task of improving a draft of this justification document with more illustrations, pictures and texts over the weekend. This whole situation of a donor asking for a convincing and illustrative document justifying a need, is to me a clear example of that an architectural masterplan would be of great use for the hospital management to have ownership over the long-term development of the hospital. 

The eye ward and clinic building. 

Anatomy of the eye.

Part of the problem is that the inpatient ward and the outpatient clinic for eyes currently are located within the same building. First, this causes a severe shortage of space to be able to accommodate all the eye health care services and it causes a lot of congestion in the entrance to the building. Second, the layout compromises infection control due to that inpatient and outpatient flows meet which could lead to easy transmission of diseases and infections among patients. 

The current building layout with zones and flows. 

Two inpatients walking towards the entrance. 

In the beginning of the following week we had a meeting with the whole management team at Kolandoto Hospital and Kolandoto College, where we discussed the whole collaboration project concerning infrastructure of water, buildings and electricity. The project was very well received among the management team. Matters ranging from the set-up of the project, to details of installing a new pump, and to concerns for the design of the new eye clinic building were adressed. 

The management team meeting. 

After some more in-depth discussions that has taken place the last few days, I have been asked to make a proposal for the design of the new eye clinic building. I am very happy to do this. And with a bit of luck there might even be available funding for constructing the building, depending on how the fundraising goes. Exciting times! 

A preliminary site plan identifying a possible site for the new building. 

/Annika

Studying local building methods

Now its been almost two weeks since I came to Tanzania - time goes fast when there is a lot to do! The first couple of days where spent in Mwanza. We took the opportunity to go to visit a site where they used a press to make interlocking stabilized soil blocks. Four people are needed to operate the machines, but at this production and building site they were many more to speed up the process. We got to see how the soil and cement are mixed, how the machine is operated, how the blocks are watered and cured, and also a finished example of a small building on site. 

We have also been here in Kolandoto village for some time now. I have been trying to better understand the local building traditions and techniques. At the hospital the buildings are mainly made out of concrete blocks with a plaster finish on the outside. The roofs are often made out of corrugated metal sheets laid on wooden trusses. The bricks are made by putting a cement and sand mixture in a wooden frame, and then letting the blocks slowly cure outside while watering them daily for a while. Piles of ready made concrete blocks are spread out at the hospital area. 

Yesterday I visited a more rural home and looked at other building methods. The older walls were made out of sun cured mud bricks, and they were quite visibly starting to fall apart from the outside. The roofs were made of wooded sticks and some plant material to cover. The owner of this home had started to produce mud bricks in a wooden form and then cured by burning them. However that seemed to be a tricky process since some of the burnt bricks did not get the same high quality. This was visible in the color of the bricks being more black instead of red, and it was possible to hear a clear difference in the sound of the blocks when nocking on them. The foundation on this site was made of stones and soil. 

Now I am going to leave this sofa at the guesthouse where most of the writing has happened so far and head up to the administration building where I got my own desk. 

/Annika