Innovation: Building a new kind of hospital under the sun in South Sudan

Our projects are often in remote locations with extreme weather conditions. Where there are no pre-existing buildings, our teams use tents and other temporary structures to create the life-saving medical facilities our patients need. But these are far from ideal. Construction specialist Carlos blogs from South Sudan about the challenges, and about a new project which aims to change things for the better...

It was extremely hot inside the MSF tent; doctors, logisticians and patients all sweating together.
The smell of chlorine rose up from the plastic sheeting floor. In one corner, a tap constructed from a plastic bucket over a wooden stool was leaking. 
The mamas were laying on their beds not really knowing where to go.
Mothers and children wait to be seen at the old MSF tent in Doro refugee camp.

Mothers and children wait to be treated at outside an MSF tent in Doro refugee camp. Photo: Florian Lems/MSF.

Outside, the walls of the tent were stained: three years' worth of dirt built up over time. A few baobabs and palm trees were dotted around for shade, but hardly enough to protect us from the burning sun.
It was hot, really hot - up to 50°C - and it was dusty. I could feel it inside my throat, nose, and ears all the time.
We were at the maternity ward in Doro, South Sudan - part of an MSF project within a refugee camp, providing healthcare for people in the middle of the Savannah.
The beginnings of a new type of MSF hospital...

The beginnings of a new type of MSF hospital... Photo: Carlos Cortez/MSF.


Beating the heat

MSF have been in Doro for many years. Despite our efforts, the condition of our facilities remained precarious - the same tents we installed at the beginning of the project were still there, even though they're only meant to last for emergency interventions.
Since then, a few container-type structures have been installed for housing – but like the tents, they get extremely hot.
The team managed to put up a couple of cooler brick buildings over the years, but this is a very difficult operation: materials are often not available, and the ones that are of bad quality.

The old maternity ward. Photo: Carlos Cortez/MSF.

In South Sudan, the local population mainly has experience of building mud and straw huts. Some have built small brick structures, but in general there’s a lack of skills and expertise in this kind of construction. To make matters more difficult, the sites where we work are often only accessible by air (as roads are nonexistent during rainy season) and security constraints can be harsh. This makes carrying out a proper construction project under proper MSF standards a real challenge.
Beds and sink block in the old maternity ward. Photo: Carlos Cortez / MSF
As a former MSF logistics coordinator, I’ve seen this issue arise many times: hospitals that look like a patchwork of structures - tents, brick and mud buildings, container structures, etc. all different quality, all mixed up together, responding to different needs.
But those needs are constantly changing. A disease outbreak or an increase in armed conflict means more patients than originally expected will appear, and therefore new structures are urgently needed.
We are often obliged to improvise, to urgently solve the problem - pushed to build something quickly with the locally available means. As a result, our structures are often lacking basic features: like the hot tent I was standing in in South Sudan, conditions inside are not always ideal for a medical facility.

Logistician problems

The problem for us logisticians is that in places like South Sudan, the challenges we face in construction leave our hands tied. There's often no plan B, and even if we would like to do better, there's little we can do about it.
As frustration grows and the heat rises, patients leave our hospital wards to sit outside under trees. Then the medics complain because their patients leave, the lighting is poor and it's too damn hot inside!
A young boy wisely chooses to sleep in the shade outside the field hospital.

A young boy lies in the shade outside the hot and stuffy field hospital. Photo: Florian Lems/MSF.

Numerous obstacles have a tendency to pop up while us logisticians are racing to get our structures up: we realise that the local contractors didn’t wait long enough for the cement to dry, and just painted over a freshly plastered wall; or that the door that was just installed is impossible to close; or that the transport company bringing the cement calls up to inform us that their truck broke down in the middle of the desert and “It will take another week to get the spare part there, sorry.”

Finding solutions

Because of all these problems, our medical teams often find themselves working in really challenging circumstances.
Over the past few years we have tried to find a more suitable prefabricated structure for our projects: from inflatable tents, to a hospital built from containers in Haiti, to our hospital in the Philippines built from a wood-fibre and resin composite with anti-microbial properties.
The MSF hospital in Haiti made from containers. It was a temporary measure, set up rapidly in response to the 2010 earthquake.

The MSF hospital in Haiti made from containers. It was a temporary measure, set up rapidly in response to the 2010 earthquake. Photo: Emilie Regnier/MSF.

All of these solutions present advantages and disadvantages, good things and bad things. However, the MSF operations in the field keep growing and the complexity of our interventions keep increasing - so the problems just become bigger.
In 2017 alone we are expecting to build a total of 40,000 m² of medical facilities around the world. So we needed to find a solution that is better adapted to these new challenges.

The MODUL(H)O concept

In March 2016, the MSF construction team started working on one, big, grand solution: a standardised, prefabricated, modular, good quality building adapted for different projects, needs and contexts around the world.
Taking advantage of an existing product, we developed the MODUL(H)O concept.
A 3D render of the MODUL(H)O project.

A 3D render of the MODUL(H)O project. Photo: Carlos Cortez/MSF.

This is a 90 m² aluminum building that does not require concrete foundations. It has legs that can be adjusted according to height and angle (to better adapt to uneven surfaces). It has its own self-supportive floor (500 kg/m² payload).
It’s light and modular, doesn’t need heavy machinery to be installed, and can be deployed in one week by eight unskilled labourers and one technician.
It is insulated, with washable surfaces resistant to cleaning chemicals normally used in the field.
It has a lifespan of 30 years; disassemblable and reusable, with a passive natural ventilation system to improve the temperature inside.
The product allows for wall panels and doors to be easily added and removed, adapting the building to the changing project needs.

Standardising MSF health structures

These ‘basic modules’ can be connected to one another, forming larger structures which can be adapted to create any MSF health structure.
We standardised all of these structures to adapt them to this solution, creating a catalogue of standard prefabricated MSF facilities. We needed the attention of several different MSF projects before we could even get this tested.
Come mid-July 2016, the logistics department received an official request to have a full blown maternity installed in Doro before the next rainy season started in May 2017.
Doro maternity ward floor plan.

Doro maternity ward floor plan. Photo: Carlos Cortez/MSF.

We needed nine basic modules to assemble four buildings: an obstetric department, an inpatient maternity department, a neonatal intensive care unit, and an emergency consultation ward.
This request would give us approximately 10 months to: 
1. Produce and test a prototype; 
2. Solve and or improve any possible problems with it; 
3. Develop adequate WASTAN (water and sanitation) and electrical solutions (as none of them were addressed during the first phase of the project); 
4. Agree on a plan with the team in Doro, taking into account their needs and existing hospital setup; 
5. Deal with the packaging and transport to one of the most isolated projects MSF has (only reachable by air because of lack of proper roads and also because of security reasons); 
6. Physically produce the modules and the spare parts needed;
7. Put together tool kits to assemble them: in a place where there are literally not available tools, this was essential - the nearest shop is two hours away by plane!; 
8. Develop and produce standard sinks and WATSAN appliances; 
9. Put all of that into containers and send it from Barcelona to Mombasa by boat, from Mombasa to Juba by truck, and from Juba to Doro by air (25 x 20 foot containers by plane!);
10. Actually build the whole thing!
All before the rain arrived.
Piece of cake, right? 


Right, how do we do this now?

All of a sudden the entire LOG department was rushing to try and find solutions to the hundreds of problems that started popping up.
Checking assembly details, making sure all the tools were available, preparing trainings for the team which will participate in the construction, signing contracts, creating codes for the new items, making detailed plans, figuring out supply possibilities and packaging solutions  etc. 
Finally, after several months of preparations, the cargo arrived at the site on March 2017: 25 x 20 foot containers worth of material.
Laying the foundations!

Laying the foundations! Photo: Carlos Cortez /MSF.

The existing hospital was entirely moved into tents, and all of the existing semi-permanent structures had been taken apart.
The construction team started with the preparatory work: demolishing old foundations, levelling the ground, building stock capacity for materials and tools, and hiring local staff.
The challenge in front of us was enormous: because of the delicate security situation, we were not allowed to have more than 12 international staff members on site at the same time, nevermind any local staff at all. This made supervision a big issue.
Thus, we had to modify our original plan of getting several teams to work in parallel (to save on construction time).
The local staff didn’t have building expertise. In fact, most of them had never held a drilling machine before in their life. Almost none of them spoke English (and not all of them spoke the same local language), and no one had ever seen a structure like this one before. We had to explain with gestures, as translators were not an option.
The South Sudanese team hard at work.

The South Sudanese team hard at work. Photo: Carlos Cortez /MSF.

Temperatures oscillated between 40 to 50°C in the shade. At 1pm it was impossible to touch the structure without gloves.
Because of some last-minute orders and supply complications, some essential items didn’t make it on time, and we had to improvise.
Water and sanitation was the biggest part of the project; we had around 80 daily workers digging up trenches to install a brand new water system around the compound: septic tanks, manholes, grease traps, hundreds of cubic meters of earth had to be dug up by hand, as no machine was locally available.
We were carrying material, filling trucks, and assembling the buildings. Some of the workers were natural handymen, some others less skilled, but they learned fast. Since it was repetitive work, once they assembled the first module, the rest was easier and faster. And for us in the logistics team, it was the same: we were learning by doing.
Taking a break.

Taking a break. Photo: Carlos Cortez /MSF.

Working on a project like this requires being very methodic and organised.
In the beginning we made some mistakes. If we skipped one phase, we would have troubles during the next one. Every single bolt, nut, and washer counts.
Getting electricity installed was fast and smooth; it fitted perfectly with the assembly sequence of the structure. The water and sanitation implementation however, was heavier and it took us some time to figure out the right approach.
However. once we found it, we fell into a smoother groove.
Taking shape!

Taking shape! Photo: Carlos Cortez/MSF.


Better hospitals = better quality of care!

After exactly three months of work, the buildings were ready! Right on time before the rainy season started.
The medical team was very happy with the outcome – some of them even wanted to extend their assignments so they could work in the new structures. 
The finished hospital!

The finished hospital! Photo: Carlos Cortez/MSF.

The spaces are appropriate now, the comfort inside the structures has dramatically improved, they are cooler, the cleaning and infection control measures are now easier to attain, and the conditions for our patients and for the medical team are much better.
Therefore, the quality of care will greatly improve.
This is the goal of this project: to ensure MSF standards even in the most isolated places on earth and to improve quality of care.
The challenge is great and the costs involved are quite high, but that’s the price we have to pay to get the job done the way it should be done.

Inside. Photo: Carlos Cortez/MSF.

Of course, there are still details to be improved: the integration of the electrical and water and sanitation installations through pre-made kits, the finishing of the floor, the simplification of certain solutions. We need to correct some mistake, but in general the outcome is very positive.
A mother smiles with her baby in the new hospital
The first baby born in the new hospital! Photo: Viviane Mastrangelo
We finished the construction 12 weeks after we started the first module (instead of the nine weeks we set time for) - but taking into account that it was our first implementation, that the labour was totally unskilled, that some of the tools and materials were not there on time, and all of the other constraints I already mentioned, I think this is quite good timing for a 1350 m² health facility!
If we managed to pull this one out in Doro, I think the rest will be easier, faster and cheaper.  

Carlos and some of the dream team! Photo: MSF.

Our next challenges include a trauma outpatient department in Haiti which is currently under construction, and an operating theatre facility in Mauritania to start in July.
Bring them on!