This paper proposes a methodology to provide a new system of area standards, driven by clinical needs, in order to give guidance to health planners, give a baseline for cost comparisons and a method of judging value for money in a given health facility design. “More clarity for less costly confusion”

1. Clarity amidst confusion
A vision for Public Sector health facilities
Infrastructure Norms and Standards in
South Africa, driven by functional and clinical
needs
Richard Hussey

2. Background
 Prior to the election of democratic
government, hospital planning was
managed using the SA Hospital Norms,
published under the Exchequer Act.
 The SAHNORM was rigidly managed by the
Treasury Committee for Building Norms and Cost
limits.
 Buildings were allocated area in departments
according to a number of norm units – e.g. beds,
examination rooms, meals served, etc.
On the face of it, the system seemed logical and
methodical…

3. AREA MANAGEMENT
 Area was rigidly managed.
New hospital projects required a detailed analysis per SAHNORM
category of the total area allowed for the intended purpose at the
level of SAHNORM units, a calculation of existing area and any
resulting shortfall.
Norm Area Needed – Norm Area existing = Norm
Area allowed (m²)
 If the existing area exceeded the Norm Area allowed for
the existing Norm Units, then a formal condoning of this
excess was required, or the excess was deducted from
the Norm Area allowed for the new project.

4. FINANCIAL MANAGEMENT 1
 Project budgets were rigidly managed using the simple equation:
Norm Area allowed x Cost per Norm Unit = Project Budget
(ZAR)
 Escalation were rigidly managed using Bureau for Economic
Research indices - starting with projected indexes.
 Final allowable construction cost was capped by final indexes
– 20-20 hindsight vision.
 Efficient management of the project budget during
planning, design and documentation and construction
was often to no avail as the final indexes for the tender
month were adjusted after the fact by persons
uninvolved in the project.

5. FINANCIAL MANAGEMENT 2
 The approved budget was often exceeded at
construction stage and design teams were frantically
instructed to either effect cost cuts on a live construction
project to prevent cost overruns, or to be penalised in
their fees for those cost overruns.
 As a result, haphazard cuts in finish standards, eng.
services or equipment were made to bring the project
back within budget
– all at the expense of service delivery.

6. APPLICATION OF SAHNORM 1
The system had inherent shortcomings in its
application.
 Aggregating building area irrespective of actual final application.
As a result, clinical areas were weighted equally with storage,
passages with operating theatres.
 Areas per norm unit were not managed per category and clinical
service was often not given the elbow room it required. Clinical
and functional space was not prescribed in allowed norm area –
only the gross allowable maximum area.
 Rooms were built too small, inflexible in design and to a low
standard of finishes to ensure that the guillotine of final cost
index was not exceeded.

7. APPLICATION OF SAHNORM 2
Ultimately this compromised service delivery and
increased maintenance costs.
 The Committee for Building Norms and Cost Limits cared little
about what happened above the line.
 Funding of departments within projects was pooled to provide a
single bottom line.
 Accountants in committee ruled on the design variables
(e.g. add-on costs for special foundations) with little or no
knowledge of the real cost drivers.
 TCBNCL cared little for health outcomes - it simplistically
counted square metres and Rands.
 Buildings could be planned as they wished and area applied at
will, with cross-subsidising of area and cost, providing Approved
Norm Area and Final Norm Cost were not exceeded.

8. THE SAHNORM IS DEAD!
The Public Finance Management Act repealed the
Exchequer Act.
 SAHNORM and its entire management structure
disappeared.
 Responsibility for managing area and cost norms was
passed about between unwilling government
departments.
 Finally, the National Department of Works was dumped
with the responsibility of setting standards – which it then
proceeded to conveniently forget about
(where health facilities were concerned, that is.)

9. THE SAHNORM IS DEAD…!
 Without a similar subsequent structure to manage complex
health infrastructure planning, a haphazard methodology of
managing health facility norms and standards came about.
 Provinces planned new projects without limits on area or cost.
 Some continued to apply SAHNORM as a guide,
others ignored it.
 Some applied the R158 regulations instead, despite these having
been set up as “bare bones minimum” requirements to licence
private facilities,
R158 is not the desirable clinical or functional space
necessary to deliver a quality public health service.

10. AND THEY’RE OFF…! 1
With the demise of the SAHNORM, the reins of the
horse were dropped and the horse leapt forward
with gusto!
 There was a real need for improved access to health
care and a political imperative to delivery to communities
that had been without equal health care for decades.
 Driven by pressure to deliver and confused by other
interests both legitimate and less than legitimate, the
capital cost of building health facilities increased
dramatically.
The horse was bolting out of control…

11. AND THEY’RE OFF…! 2
A ‘free-for-all’ came about,
 Project teams were able to pump up the cost by applying
unrealistically high specifications.
(They earned much higher fees for far less work and nobody was
complaining.)
 There were no measures in place to manage and / or moderate
political imperatives.
 To aggravate the situation, a critical shortage of skills during the
transformation from a racially skewed administration resulted in
many middle managers simply not managing – some because they
didn’t know any better and others because they just wanted to stay
below the radar until they could retire.
When they did retire, another part of the corporate memory
disappeared with them and the knowledge base atrophied even
further.

12. AND THEY’RE OFF…! 3
This inequity of standards stifled the efforts of health
planners to provide equitable access to health care.
 Service delivery was seriously compromised.
 Proper service planning was inhibited by rapidly depleting
infrastructure budgets. Instead of being able to build 10
hospitals at R1,5m per bed, provinces could only build 5 at
R3,0m per bed.
 Ignorance, ill-informed decision-making, image-seeking and
infectious greed was robbing expectant mothers of clinical care
and new-born babies of incubators.
A new nationally applicable system of area standards
and cost management was desperately needed to
replace the extinct SAHNORM.

13. IT HISTORY 101
Let’s look at what life was like
when SAHNORM was set up
… in1984
 IBM has invented a small computer– the Personal Computer.
 A young man called David Gates and another geek partner have developed
an operating system that will allow this new machine to work.
 The operating system is written on a magnetic disk that gets the name
“floppy disk” from the inability of the thin magnetic plastic medium to support
itself.
This requires the floppy disk to be contained in a cardboard envelope with a
slot in the cardboard – a “Window” ?
 The new floppy disk contains 360k of data written on one side and there are
TWO of them in the computer. It is rumoured in the industry that very soon
a disk with data on BOTH sides will be available – 720k on a single disk!

14. IT HISTORY 102
Let’s fast forward to 2011…
 The floppy disk is a quaint oddity of history.
 Portable data memory media is not measured in
kilobytes, nor megabytes, nor gigabytes – it is measured
in Terrabytes.
(If in 1984 you had given every human on this earth a single 360k
floppy disk, the total data content of all those floppies would be
720Tb)
Direct application of a 1984 SAHNORM is as
appropriate today as using floppy disks!

15. THE TECHNOLOGY TREADMILL 1
Technology is literally driving society today.
 The average car today has more computing power on
board than the first mission to the moon in 1969.
 Instead of taking your motorcar to a mechanic for a
tune-up once every six months, you are blissfully
oblivious to the fact that your car’s computer is adjusting
valve timing, fuel to air ratio and ignition timing 10 - 25
times…
…every second !

16. THE TECHNOLOGY TREADMILL 2
Technology does more in less time
 Current technology on every laptop enables skilled planners and
professionals to perform complex and laborious calculations in a
matter of seconds.
Ove Arup mailed punch cards by parcel post to their London office
to calculate the structure of the roof of the Sydney Opera House on
an IBM mainframe computer. The mainframe took 12 hrs 42 min to
calculate a single arched beam.
Arup staff recently ran that same calculation using software
presently available on every structural engineer’s laptop…
The result was produced in 3 seconds.

17. THE TECHNOLOGY TREADMILL 3
Technology exists today to totally self-control an
aircraft to the extent that it can:
 start up,
 taxi to the runway,
 take off,
 fly a complete mission,
 navigate to a destination airfield
 and then land
…all without any direct intervention by a human.

18. THE TECHNOLOGY TREADMILL 4
 Advances in medical technology have shown similar trends and
the rate of growth in this knowledge is increasing. Magnetic
Resonance Imaging, PET scanners, Gamma knife surgery,
Radiation Oncology Linear Accelerators… the list goes on.
 How do we curb the excessive space and cost overruns of the
past decade?
 How do we catch up twenty, thirty even forty years of
technology?
 The problem of technology also provides the answer. Using
commonly available spreadsheet software, we have the tools to
perform detailed analysis and management of a lot of
information.
Let us use this technology to eat this elephant…
…in byte-sized portions!

19. AREA MANAGEMENT
 Managing area is a proven manner of positively
influencing capital costs.
Dept of Public Works Office Standards –
Govt Gazette 27985 of 2 September 2005.
This space planning logic used need as the driver for
space – not merely averaging previous practice.
 If you don’t build what you don’t need, you don’t waste
money.
After all, SAHNORM methodology worked in
theory, it was only the practical application was
flawed, wasn’t it…?

20. “FIT FOR PURPOSE”
SPACE DESIGN
Form forever follows function – Louis Sullivan, Architect.
Let us look at a very simple space for example
– the space to park a motorcar.
 “Traditional” space guidelines such as say a parking garage is 3m
wide and 6m long =18 square metres. (Neufert, AJ Metric)
This space will fit any motor car, except a Rolls Royce Silver Spirit
at 6,05m long. A good standard, one might think, at a 99,999
percentile accommodation.
 South African National Building Regulations requirements for a
public parking space are 2,5x5,5m = 13.75m² - a 24% reduction in
this requirement.
Is this also a good standard?
Which of the two is appropriate?

21. “FIT FOR PURPOSE” SPACE
DESIGN 1
Form forever follows function – Louis Sullivan, Architect.
 Users of public parking areas know how frustrating and costly it
is to return to your car to find that your car door has small vertical
dents in the paintwork due to your neighbour opening their car
door just a little too far, causing their open door to bang against
your car.
 This experience, therefore, tells one that the ergonomics of
entering and exiting the car were not taken into account in sizing
that public parking space.
 Also, there is an increase in the number of two-door coupés such
as a BMW C1, Toyota Yaris or a Volkswagen Beetle. Doors on
coupés are wider in order to give access to the rear seats and so
the space required to fully open the two-door is wider than that of
a four-door family sedan.

22. “FIT FOR PURPOSE” SPACE
DESIGN 2
Form forever follows function – Louis Sullivan, Architect.
 Present day cars are somewhat smaller than the vehicles that
gave rise to the standards of the 1950’s, 60’s and 70’s.
Yet these reference space
standards still are applied
religiously half a century later.

23. “FIT FOR PURPOSE” SPACE
DESIGN 3
Form forever follows function – Louis Sullivan, Architect.
 ‘Fit for purpose’ design for today’s requirements would indicate
that parking spaces should be shorter and wider to allow proper
ergonomic exiting from both sides of a two door vehicle.
 Theoretically in public parking spaces, such ergonomic space
can be shared – providing drivers park their cars in the centre of
the space.
(We all know how many times this does not happen.)
 Between walls though, wider space is definitely required for
effective ergonomics, and shorter space is possible for cost
reduction to balance these spatial requirements.

24. ESCALATING COMPLEXITY
Traditional logic for a simple space such as a garage is
not reliable enough to apply directly to current
requirements.
Do we simply extrapolate this same deficient historical space
requirement logic to a far more complex space such as an operating
theatre?
comatose patient on a life support system,
several clinical staff members
simultaneous activities
complex sterile medical equip.
with service umbilicals
instrument trolleys and tables…?

25.  I contend that one has a far more exhaustive space
requirement analysis to do in order to come up with a
present day ‘fit for purpose’ standard.
 Anything less is just a ‘we’ll make do’ solution.
Is this how we want to invest scarce
capital in health facilities?

26. CLARITY IN DEFINING NEEDS
First we shape our buildings, then our buildings shape
us. [Winston Churchill 1943]
 Users have an inherent problem in communicating
their clinical needs to physical planners. More often
than most, they will introduce as their need a copy
of what they were trained in, what they currently
work in or something they saw somewhere else.
This is in fact the solution offered to another user’s
needs, not an analysis of their own needs.

27. CLARITY IN DEFINING NEEDS
“First we shape our buildings, then they shape us, then we shape
them again - ad infinitum” [Stewart Brand, 1994] writer, Editor of
Whole Earth Catalogue
 Perpetuation of this solution-based needs definition for clinical
and functional spaces is as appropriate as applying Neufert’s
1960 solution for a parking garage to house Sir Alec Issigonis
1959 design for the Mini.
 We need to be able to define the user’s requirements more
fundamentally from the actual need for space.
A proven methodology in determining this comprehensive
analysis of need is the application of six questions…

28. Six Questions
WHAT? HOW? WHO? WHERE? WHEN? WITH?
 Users focus their needs establishment by answering
the questions about the activities they perform in the
spaces they need.
 This narrative is then interpreted by physical
planners into three-dimensional space requirements
that are sufficient to provide for the activities where
they occur.
I’ll refer to the information output of this process as
the WHoW.

29. WHAT CAN I DERIVE FROM
WHoW?
Question Aspect of need
WHAT? ACTIVITIES TO BE ACCOMMODATED
HOW? METHODOLOGY
WHO? PEOPLE INVOLVED
WHERE? LOCATION
WHEN? TIME SIGNATURE + PROCESS ORDER
WITH? LINKS, CO-PROCESSES CO-LOCATIONS

30. Service solution comparison =
standards comparison 1
The rendering of a health service is tailored around the
WHoW. Different countries use different methodologies
for every procedure and so the WHoW differs.
 Simple bed space, for example, is defined by the processes and
methodologies appropriate to that country. In some countries,
much use is made of mobile patient lifting apparatus, the bed-
head space is increased to permit this apparatus to be brought to
either side of the bed.
 Eliminate the use of mobile lifting apparatus, or merely turn the
bed slightly and the lifting apparatus can be used efficiently
without requiring this multiple permanent free space for a very
occasional process.
Remaining within functional limits,
less space = less cost.

31. Service solution comparison =
standards comparison 2
 It is the differences in WHoW that result in other health
facility norms and standards having varying degrees of
appropriateness to the South African situation.
 This does not mean that we have to rethink absolutely
everything from scratch, but we have to take due
cognisance of the matching WHoW when reviewing any
standard from anywhere else.

32. Service solution comparison =
standards comparison 3
Having compared the operational narrative and the
equipment list and the services and the personnel and
the processes, we are left with four choices to make
around other standards presented for comparison;
 Adopt WHoW aligns perfectly and no change is needed.
 Adapt WHoW is very similar, slight changes easily made.
 Assimilate WHoW is not that similar, but some aspects are
easily incorporated in our standard.
 Annihilate WHoW is so different that nothing is transferable.
Mere adoption of isolated external standards constitutes a fifth
unacceptable path – abdicate.

33. BOTTOM-UP BUILDING BLOCKS
 This bottom-up clinical / functional needs analysis is the
proposed knowledge foundation for a new national Health Facility
Norms and Standards system.
 It provides clarity around the problem of defining what the user
needs in small enough bites of information to enable them to
focus on what they do.
 It enables physical infrastructure planners to similarly extract
understanding of the needs and to translate this need into
building functional units so the user can do what they do.
 With appropriate yardsticks available from defined clinical area
standards and ‘fit for purpose’ standards for associated support
space, the other drivers of design sprawl can easily be
addressed - because they become glaringly obvious.

34. PIAZZAS, PASSAGES AND
PARK-OFF PLACES
 Circulation Space and Waiting Space can be managed by a
defined allowance over and above the clinical / functional space
standards.
With the SAHNORM, add-on space allowance was contentious and
never enough to provide for proper circulation space management.
This meant that circulation space was often provided by stealing
from functional space.
 By separately measuring circulation and similar general space
under Core Space allowance, planners are given the ability to
apply this within the building functional units and between units.
 Because it is separately measured, this space is separately
managed and any overprovision becomes obvious.

35. MEASUREMENT IN LOCATIONS
 The standard methodology of measuring Bills of Quantities as
used by South African Quantity Surveyors allows the software
used to be set up to measure by localities.
 It costs no more and provides much more useful information to
the user. For example, the cost of providing an additional
operating theatre can be easily determined as the net effect on
the Operating Department building functional unit can be
measured, without having to search for snippets of data from the
whole health facility.
It is therefore proposed that this method be mandated
as an extension of the space standard management
methodology right through into the final building on all
public health facilities.

36. ELEMENTAL METHODOLOGY
 Further to measurement by location, elemental measurement
methodology can be used when calculating building costs.
 This method will provide both user and implementing agent with
the tool to better manage the cost of construction by identifying
the main cost drivers of any particular design.
 This will also permit effective analysis and decision-making when
it comes to choices of materials, increasing or decreasing ceiling
heights and comparing construction methods such as load-
bearing brickwork against column and slab.
It is also proposed that measuring by building elements
be mandated for health sector building cost
management.

37. SO,
HOW DOES THIS ALL
WORK TOGETHER…?

38. AREA MANAGEMENT
WHoW will be developed from the clinical and
functional needs
 for each individual building functional unit
 for every level of health facility
(as defined by the National Health Council, using the Feb 2007 version as
departure framework.)
 The narrative will help to clarify differences in approach
and needs, where such differences are applicable.
 A translation table will allow the user and the planner to
define where the space is appropriately required,
according to the building’s functional units or blocks.

39. AREA MANAGEMENT
 Functional / clinical space (e.g. bed, theatre, delivery room) will
form the Norm Unit for defining the required nett floor space.
 Support Space for associated rooms and Core Space for
circulation / shared facilities are managed by separate
allowances on top of the Clinical Space.
 Using methods similar to the Office Norms, each schedule of
accommodation will contain clinical / functional area standards,
with Support Space allocated as a variable factor over and above
the clinical / functional space to allow for any slight variances per
level of care or per clinical discipline.
 Core Space will be a fixed allowance as it is pooled for the whole
facility.
 Because all of these are defined in nett clear floor area, a final
fixed allowance for structural elements is needed.

40. AREA MANAGEMENT
 The norm unit area standard and the other allowances will
aggregate upwards into a total allowable area standard per building
functional unit – e.g. wards / nursing units, radiology departments.
 All functional areas will be allocated area standards based on their
WHoW – e.g. Nursing Units for medical, surgical, orthopaedic, ICU /
High Care, step-down, maternity, psychiatric, TB…
The nett effect is that every functional unit in any health facility will be
defined by an area standard per clinical space, variable area for
support spaces and a fixed allowance for core space and structural
space.
 This will easily allow detailed total area analysis as designed against
area required per functional unit. The functional units will roll up into
a total area per health facility.
 Clinical or functional need will no longer cross-subsidise any other
space.

41. ROOM REQUIREMENTS
 The Area Standards will be refined and supported
by detailed room requirements, which in turn are
supported by documented building standards and
materials, in order to fully articulate user
requirements.
 These will provide the user with a detailed drawing
of what to expect in the final product.
 The detailed room requirements will require regular
revision within the health sector in order to
accommodate any technological or functional
changes to the WHoW.

42. COST MANAGEMENT 1
 From a cost perspective, the cost of building health
facilities will be analysed per building functional unit
and per level of care.
This will enable Departments of Health to arrive at a cost
per square meter range per building functional unit.
 The cost range will take into account such factors as the
province concerned, inland / coastal variations, and
distance from materials markets, etc.
 This cost management tool will provide the tools
necessary to budget forwards, to manage budget during
design / documentation and to feed back real project
information from every project into regularly refining the
cost range for future projects.

43. COST MANAGEMENT 2
 Initial breakdown of area studies indicate individual
building functional units vary between 1-5 percent of the
total area of a district or regional hospital.
 The proposed system enables effective management of
area and cost per building functional unit to provide the
public health sector with the detail analysis necessary to
manage service definition and service delivery
standards.
 It will provide the framework necessary to ensure
efficiency of planning, design and documentation, using
simple-to-operate, spreadsheet-based tools.

44. COST MANAGEMENT 3
 The proposed system relies on efficiency of
knowledge management, co-operation between
client, implementing agents and professional service
providers – particularly Quantity Surveyors…!
 Contracting models should not be affected at all.
 Data from various contracts can be directly
integrated into the database that derives the cost
model per building functional unit to broaden the
number of records on which the cost range per
building functional unit is founded.

45. INVITATION
I invite you to take up the challenge and to work
with my team in this endeavour to establish a
sound, solid and sustainable system of
standards that will enable us to hand over to our
children and grandchildren effective and efficient
health facilities, built on the basis of the right
thing in the right place at the right place at the
right time and at the right cost...
Thank you for your attention and time.

46. Enquiries:
 Richard Hussey
Director: Facilities + Planning
 National Department of Health
Private Bag X828
Pretoria 0001
 E-mail: Hussey @ health.gov.za
 Work: 012 395 8284
 Cell: 078 456 5267