HEALTHCARE BUILDING STANDARDS
an electrical system comes over time as
modifications are made to the system,
Therefore, the best way to prolong the life of
an electrical system is to keep it simple.
Key steps include:
• Evaluation of existing site conditions,
including available electrical sources and
electrical service options.
• Analysis of the proposed new facility as it
pertains to electrical loads, and sizing of
the new electrical service to accommodate
those loads.
• Identification of critical and non-critical
loads to ensure patient care is maximised
when power supply is limited.
Selection of systems that can be simply
designed based on accepted industry
standards, efficiently installed, and readily
maintained. Furthermore, in order to ensure
a resilient facility, natural resources should be
utilised. Available power options will differ
according to location and resources, however
there are generally five electrical system
options:
• Service from a public electric utility
company.
• Diesel/gasoline-fired generator.
• Solar photovoltaic systems.
• Hydroelectric plant.
• Wind generation.
Out of these generation options, Solar PV has
proven the most desirable in Liberia. When
properly installed and operated, a PV system
should operate for at least 25 years. Because
the electrical grid is limited throughout
Liberia, PV systems are important for rural
4 IFHE DIGEST 2016
facilities. PV is very desirable for developing
nations because it has no moving parts and
requires very little maintenance. In addition
to reliable forms of generation, another
integral component to a resilient power
system is storage. Incorporating an on-site
storage system (battery plant) will allow a
facility to fully utilise all the power generated
from its renewable systems. Storage
systems also allow the facility to
remain operational beyond daytime
hours. However, available storage
systems are expensive, have limited
life, require maintenance, and are
theft targets.
Natural lighting should also be
optimised as a priority and then
supplemented by artificial lighting
where needed. Natural daylighting
design allows visible light from the
sun to enhance a building’s interior
illumination, elimination or
complementing electrical lighting,
reducing electrical energy costs and
grid reliance, and improving occupant
health and comfort. Studies have
shown that effective use of daylighting
can improve productivity, enhance
moods, boost morale, lower fatigue,
reduce eyestrain, and hasten healing.
Conclusion
International codes inherently limit
the ability to leverage opportunities
unique to a given context and
constrain innovation. In development
of the MOHSW Health Infrastructure
Standards, the goal was to be
prescriptive enough to hold responsible
parties accountable, while remaining flexible
to adapt to project specific needs and
produce optimised solutions. These standards
have provided a platform for other developing
nations to refer to that can help in the
development of context appropriate solutions
for international projects. 

healthcare facilities in developing
nations. Rainwater is well suited for non-
potable uses and with additional
treatment is adequate for potable uses.
Rainwater harvesting consists of
collection, pre-treatment, storage, final
treatment and distribution. Collection
surfaces are sloped horizontal surfaces
including roofs and concrete slabs where
rainfall lands and flows off usually as
sheet flow and is intercepted by gutters
on the downslope of edge of the
collection surface. Pretreatment takes
place in the form of a conveyance system.
This system includes the rainwater
gutters that collect the rainfall off of a
roof and typically include debris screens
and a first flush diverter that are used to
intercept organic matter and debris that is
washed from the collection surface.
For storage, cisterns are used as storm
water collection points providing a water
reservoir for later use. Cisterns should have
access to allow inspection and cleaning.
They can be installed either above or below
ground. For non-potable use, the water
should be filtered as a safeguard against
sediment or discoloration, and for proper
operation of valves or other devices.
Rainwater catchment systems for potable
water applications must use a multi-barrier
treatment system to remove pathogens,
sediment, and other potential contaminants
and the multi-barrier system should at a
minimum include filtration and disinfection
treatment systems.
Hot water only where needed: Although
potable hot water is not required at any
fixture as a standard, some facilities desire
hot water to be delivered to all or some
fixtures used for cooking, bathing, hand
washing, medical equipment washing, and/or
janitorial fixtures. It is important to note that
hot water provides no improved ability to
wash hands, as the water cannot be hot
enough without creating a scalding
hazard. Hot water systems are expensive,
energy intensive, and can encourage the
growth of pathogens within the system.
Therefore, the extent of hot water
provisions and type of heating system
must be carefully considered and
determined by project stakeholders.
Source equipment may be designed
as point-of-use heaters or centralised
water heating systems utilising single or
multiple storage tanks and piping
networks distributing water to fixtures,
and pumps to circulate water through
the heater. Point-of-use water heaters
may be best if only a few fixtures are
served, however there are no
inefficiencies due to heat loss. Central
storage systems have the ability to use a
small amount of energy to heat water
over a long period of time rather than
using a large amount of energy to heat at
the rate of use. Central storage systems
also have the option of integrating a
solar water heating system which can
IFHE DIGEST 2016
HEALTHCARE BUILDING STANDARDS
‘In development of the MOHSW
Health Infrastructure Standards,
the goal was to be prescriptive
enough to hold responsible
parties accountable, while
remaining flexible to adapt to
project specific needs and
produce optimised solutions.’
offer energy savings.
Natural ventilation: The primary
objective in ventilation within healthcare
facilities is to provide air for breathing and
promoting health by diluting and removing
pollutants. The importance of adequate air
exchange where needed should not be
understated, as poor ventilations puts both
patients and staff a risk of nosocomial
infection. This is especially true of healthcare
facilities in developing nations, where
facilities are small and patients and doctors
are in close quarters.
Natural ventilation
Natural ventilation can address ventilation
needs while avoiding many of the economic
and environmental costs of mechanical
ventilation. Concepts of natural ventilation
are well-known and can be used as the basis
for design and operation of healthcare
facilities with special appeal in resource-poor
contexts. It can provide many benefits over
mechanical ventilation in developing
countries in that it typically requires lower
capital cost, has lower maintenance, and can
be more reliable under certain climatic
conditions. Furthermore, natural ventilation
provides an ability to operate in the event of
failure of power or mechanical ventilation
systems. The challenge with using natural
ventilation is that it is not always guaranteed
to work and it may not be possible to achieve
desired ventilation rates, airflow direction,
and air patterns to maintain thermal comfort
support infection control. In addition, vector
control can be problematic in many
situations.
For natural ventilation to work effectively,
specific climactic conditions must exist, staff
must be educated on its use/operation and
regular maintenance is needed to ensure its
effectiveness and reliability. Given its
advantages over purely mechanical driven
solutions, its use should be maximised
whenever appropriate climactic conditions
exist to make it possible to provide adequate
and reliable ventilation to maintain thermal
comfort and indoor air quality.
Power system (energy access is
fundamental, micro-grid power, backup,
solar): Access to energy is essential for any
healthcare facility and fundamental to the
facilities operations. Providing appropriate
lighting in health care facilities is critical for
task completion, and the health, safety, and
comfort of patients and staff. This can be
challenging in developing nations where
public electric utility service is limited in
availability and high in cost.
Healthcare electrical systems must be
properly designed and installed to prolong
the life of the facility and maintain a safe
environment for all users. For electrical
systems to perform reliably, more than one
source of power should ideally be utilised to
ensure that power is always available for
patient care. In most cases the degradation of
3
HEALTHCARE BUILDING STANDARDS
There is a need for designs that bring together the best thinking and knowledge for effective healthcare design with systems, equipment,
and designs that respect the local knowledge, skill, product, and ways of life.
simply being the setting for services. They
play an active role in determining the success
and sustainability of health improvement
measures.
Development of standards
Liberia’s National Health and Social Welfare
and Policy Plan 2011-2021 (NHSWPP)
developed by the Ministry of Health and
Social Welfare (MOHSW), recognises that the
provision of quality health infrastructure is
necessary for the effective, efficient delivery
of health services. But, until recently, no
definitions or criteria have existed for what
‘quality’ entails.
Between 2008 and 2010 prototype
drawings were developed for a series of health
facilities including clinics and health centers.
Because there was no official set of organised
building codes to use as a guideline,
contractors based designs and drawings
around US and European building standards.
While this provided some degree of
infrastructure standardisation, it did not offer
enough flexibility for a broad application.
This was primarily due to the overly complex
nature of US and European building codes as
well as the lack of both infrastructure and
financial resources available in Liberia.
In response, the National Health
Infrastructure Policy (NHIP) was developed in
acknowledgement that a one-size-fits all
approach is neither appropriate nor cost-
effective given the diversity across Liberia.
The NHIP acknowledged the importance that
these standards be ‘dynamic and flexible to
the needs of a range of conditions as they
develop over time.’ In conjunction with
various architecture and engineering firms,
the MOHSW developed a set of Standards for
Health Infrastructure in 2013. These
standards were developed under an
important premise: That to enable the design
and construction of health facilities
optimised for Liberia, building standards had
2 IFHE DIGEST 2016
to be approached not as a universal rely on onsite wells, rainwater collection,
prototype, but as a flexible tool for springs, and/or streams to meet the demands
implementing efficient, effective, and of patients and staff. In some urban areas, a
sustainable change. health facility may be connected to a
centralised water system; however, even in
Reusable ideas and practices these settings, providing an onsite supply of
Liberia’s Health Infrastructure Standards can water either as the primary or secondary
easily be adopted by other developing supply can be critical as a backup and secure
nations as a model and tool for healthcare source of water at all times.
infrastructure projects. The following The manner in which the source water is
techniques provide specific examples of supplied to the healthcare facility will depend
practices taken from the MOHSW Health on the type of source water that is available at
Infrastructure Standards that can be or near the location of the facility. Possible
implemented in various developing nations. sources of water supplied to a healthcare
Each of these methods promote the ideas of facility include:
sustainability, efficiency, and resiliency for • Pumping water from a cistern which
healthcare facilities. captures and stores rainwater into a
Water: Water is one of the most critical pipeline leading to the facility.
infrastructure needs for healthcare facilities, • Pumping water from a hand-dug well into
and is essential for medical services as well as a pipeline leading to the facility.
building functions. Clean sterile water is • Pumping from a machine-drilled well into
required within every healthcare facility for a pipeline leading to the facility.
hand washing, equipment cleaning, cleansing • Diversion of part of a stream into a
wounds, compounding medicines, and for all pipeline leading down slope to the facility.
the human uses of clean water. Water is • Diversion of the discharge of a spring box
especially critical in health facilities in into a pipeline leading down slope to the
Liberia as in most developing nations, where facility.
sources of water are not always readily • Pumping water directly from a lake and/or
available. Therefore, identifying a source of stream into a pipeline leading up or over
water, clean or requiring treatment should be to the facility.
one of the first steps in the creation of a new
health facility. In particular, rainwater harvesting can be a
In rural settings, most health facilities will supplemental and high source of water to
‘Liberia’s National Health and Social Welfare and Policy
Plan 2011recognises that the provision of quality health
infrastructure is necessary for the effective, efficient delivery
of health services. But, until recently, no definitions or
criteria have existed for what ‘quality’ entails.’

Walt Vernon, Kaylynn Rothleder, Arash Guity,
Brian Hageman, Ron Bourgault – Mazzetti
Building standards:
learning from Liberia
This article examines the new Liberian
healthcare building standards which
combine best-practice with local
requirements and suggests that there is
much to learn from them to help other
regions create suitable buildings.
In the developed world there is an estimated
one architect for every 2,000 people. In the
developing world, however, there are very few,
and the ones who are there tend to focus
their practice on the few well-funded
projects. The problem is maybe even more
acute for engineers. And so, when architects
or engineers design buildings in places with
few resources, they tend to draw upon their
knowledge and experience from more highly
resourced situations.
As such, the buildings they design can be
less than ideal for the people who will
inhabit, operate, and maintain them. This
challenge is especially acute in the design
and construction of healthcare facilities, with
their complex needs for infection control,
sanitation, and supportive environments.
On the other hand, when people with
little expertise and experience – such as many
of the available designers in low-resourced
areas – design buildings, they can miss some
Walter Vernon
Walter Vernon is CEO for Mazzetti, an
international program management,
strategic advisory services, consulting
and engineering firm headquartered
in San Francisco, USA. He still serves
on, and is the former chair for, the
NFPA99 Electrical Systems Technical
Committee. He is the former
Electrical Engineer for the California
Hospital Building Safety Board. He
also served as a coordinator for the
Green Guide for Healthcare, the nation’s first Green Healthcare
rating system. He co-authored the IEEE/ANSI White Book, the
international standard for Electrical Systems in Healthcare Facilities.
He also co-chairs the ASHRAE 189.3 committee, and chairs the
Research and Development Committee for the Facilities Guideline
Institute (FGI), the body that writes the Guidelines for Healthcare
Construction, which is the model licensing code for most states in
the US. He represents the US to the International Federation of
Healthcare Engineering. He also served as principal author for the
World Health Organization’s (WHO) Health in the Green Economy.
IFHE DIGEST 2016
‘Liberia recently developed a new set of standards for its
healthcare buildings. These standards incorporated
learnings from successful architecture and knowledgeable
practitioners in this country with the international
perspective of best practices from the developed world
to create an inspired blend of thinking.’
of the best thinking accumulated around the
world.
There is, therefore, a need for designs that
bring together the best thinking and
knowledge for effective healthcare design
with systems, equipment, and designs that
respect the local knowledge, skills, products,
and ways of life. Finding this vernacular is not
easy.
The country of Liberia recently developed
a new set of standards for its healthcare
buildings. These standards, developed by an
American-led team, incorporated learnings
from successful architecture and
knowledgeable practitioners in this country
with the international perspective of best
Arash Guity
Arash Guity focuses on sustainability
consulting, directing, research, and
designing high performance facilities for
healthcare and institutional facilities. In
addition he has expertise in strategic
energy and sustainability planning and
securing funding for energy/renewable
projects. He has also supervised analysis projects as part of Mazzetti’s
MEPT design work, and manages resource limited setting design
projects with a primary emphasis on Africa and Haiti.
Brian Hageman
Brian Hageman is an Associate Principal
with Mazzetti, designing and managing the
integration of MEP systems to support
healthcare organisations. He has over
25 years of experience in design and
construction of water, medical gas and
other systems for healthcare facilities
and is a LEED Accredited Professional.
HEALTHCARE BUILDING STANDARDS
practices from the developed world to create
an inspired blend of thinking that, to date,
appears to have appropriately knitted
together these two imperatives. This set of
standards shows what can be done, and is a
resource to other, similar countries around
the world.
Over the past decade, the developing
nation of Liberia has taken great strides to
rebuild its social and physical infrastructure.
The Government of Liberia (GOL) has
established a national vision to become a
middle-income country by 2030-and
recognises that health and a strengthened
network of health facilities, is integral to that
goal. However, health facilities are more than
Ron Bourgault
Ron Bourgault is the Chief Electrical Engineer
for Mazzetti. His work has included the
development of the healthcare design and
construction guidelines for the Ministry of
Health in Liberia as well as the design of
facilities in East Africa, Saudi Arabia, Dubai
and Abu Dhabi. He is a licensed Master
Electrician and has installed Solar PV systems in Milot, Haiti
and electrical distribution systems for Shalom University of Bunia,
Democratic Republic of the Congo.
Kaylynn Rothleder
Kaylynn Rothleder is an electrical engineering
undergraduate at California Polytechnic State
University in San Luis Obispo. She also works
as an electrical designer for sustainable
healthcare projects. Kaylynn is also actively
involved with Engineers Without Borders,
which provides sustainable engineering
projects to communities in need.
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