Sustainability

Purpose

This document has been developed for the Department of Health to ensure that sustainable development is integrated into to planning and design of health facilities. The document defines sustainable development and outlines the implications of this for the built environment. It provides objectives and criteria that can be used in the development health facilities in South Africa.

Background

The Department of Health wish to support sustainable development in South Africa and ensure that there is an appropriate balance between economic development, social integration and protection of the environment. Global Warming and South African legislation and policy now make it imperative that built environment projects address sustainability. However, there is limited South African guidance on how sustainable development can be integrated with built environment projects. There is also the perception that addressing sustainability in facilities will be expensive and complicated. This document provides guidance and checklists that can be used to support the integration of sustainability into health facilities. It shows that by addressing sustainability early in projects, additional costs can be minimised and innovative, high-performance solutions that benefit society, the economy and the environment can be achieved. It also shows that achieving more sustainable facilities need not be complex but can be based on robust, sensible and simple measures.

How to use this document

This document provides a framework that can be used to inform the development of health facilities. It can be used in the following ways:

• Awareness: This document can be used to increase awareness about sustainable development and the need to address this in built environment projects. This will lead to more rigorous debate on development options and support more innovative and sustainable solutions.

• Setting sustainable development targets: This framework can be used by a development team to set explicit and challenging sustainable development targets for projects. This is done by setting quantified targets against criteria in the document and putting in place systems to ensure that these are achieved.

• Self-assessments: This framework can also be used for self-assessment and to ascertain the performance of development proposals. To carry this out refer to the Facility Recommended Compliance sheet and Compliance Checklist at the end of the document. This enables different health facility development proposals to be evaluated in terms of recommended compliance. Assessment using the criteria can also inform the design process by being used to evaluate different development options. This enables optimal solutions to be developed in an iterative and efficient way.

• Coordinated development: Some criteria in the document may appear not to be in the remit of, or possible in, a single development. These criteria however can be achieved through partnerships and local collaboration. This framework can be used bring together the key role players in order to develop integrated plans that enable key sustainable development objectives to be achieved.

Structure of the guideline

The document has the following structure:

• Implementing Sustainable Development: This section provides a description of sustainable development and translates this into specific sustainable development objectives for the built environment.

• Built Environment Sustainable Development Objectives: In this section more detailed guidance and checklists are provided for each of sustainable development objectives listed in the section above.

• Sustainability Integration Plans: This provides guidance on plans and a structure that can be used to integrated sustainability in design and operational processes.

IMPLEMENTING SUSTAINABLE DEVELOPMENT

Introduction

South Africa faces a range of social, economic and environmental challenges. HIV/AIDs has resulted in a life expectancy dropping from 67 years in 1998 years to around 47 years currently. Unemployment is estimated to be 27% and climate change is likely to lead to increasing water stress, reduced food security and loss of species and ecosystems (DEAT 2009). Sustainable development, which aims to achieve social and economic improvements while reducing negative environmental impacts, can be used to address these challenges. Sustainable development however can be difficult to achieve. This is because a holistic and integrated approach is required and the development sector and in particular, the construction industry, operates in a highly fragmented way. In addition, the concept of sustainable development is still new and has not been adequately translated into practical actions that can be readily implemented. This section defines sustainable development and translates this into key built environment objectives. It also describes the role of the built environment in creating environmental and other problems and shows how integrating sustainable development considerations into construction and the built environment can make a substantial contribution to improving the social, economic and environmental performance of the built environment.

The environmental context

Increasing carbon emissions from human activities and a reduction in the ability of the natural environment to absorb carbon dioxide is leading to an accumulation of greenhouse gases in the upper atmosphere. These gases trap more heat in the upper atmosphere leading to global warming and temperatures are predicted to increase by 2 - 6°C OC by the end of the century (IPCC, 2007). Estimates carried out for the City of Joburg indicate that temperatures in the next 50 years may increase between 2 and 3.5°C (Hewitson, Engelbrecht, Tadross, Jack, 2005) Within Africa, South Africa produces the highest CO2 emissions and has one of the highest CO2 emissions per GDP in the world. In 2002, carbon emissions per capita in South Africa were 8.4tonnes/capita - higher than Western European averages of 7.9tonnes/capita (SEA 2006). Global warming is likely to impact Africa particularly negatively. The National Climate Change Response Policy Developed by the Department of Environment and Tourism outlines the following impacts (DEAT 2009a): • Agricultural production and food security in many African countries are likely to be severely compromised by climate change and variability. Projected yields in some countries may be reduced by as much as 50% in some countries by 2020 and as much as 100% by 2100. Small scale farmers will be most severely affected. • Existing water stresses will be aggravated. About 25% o Africa’s population (about 200million people) currently experience high water stress. This is projected to increase to between 75-250 million by 2020 and 350-600 million by 2050. • Changes in ecosystems are already being detected and the proportion of arid and semi-arid lands in Africa is likely to increase by 5-8% by 2080. It is projected that between 25 and 40% of mammal species in national parks in sub-Saharan Africa will become endangered. • Projected sea-level rises will have implications for human health and the physical vulnerability of coastal cities. The cost of adaptation to sea level rise could amount to 5-10% of gross domestic product. • Human health will be negatively affected by climate change and vulnerability and incidences of Malaria, Dengue fever, Meningitis and Cholera may increase.

The contribution of the built environment

Construction and the built environment make a substantial contribution to global warming and play a significant role most economies. Environmental, social and economic impacts attributed to the built environment at a global scale are outlined below. • Consumes 40% of energy use, • Consumes 17% of fresh water use, • Consumes 25% of wood harvested, • Consumes 40% of material use • Employs 10% of the world’s work force • Construction is the largest employer of micro-firms (less than 10 people) • Facilities are typically located on the most productive land (Estimated to be 250 million hectares world wide, mostly on primary agricultural land) In South Africa the built environment is directly responsible, through electricity consumption, for over 23% of South Africa’s carbon emissions (see table below). Vehicle-based infrastructure and transport planning has resulted in transport contributing to 16% of South Africa’s CO2 emissions and an additional 18mtCO2 per year, or about 4% of South Africa’s CO2 emissions, come from the manufacture of building materials (CIDB 2009) Sector C02 Emissions Commercial 10% Residential 13% Transport 16% Industry 40% Mining 11% Other 10% Total 100%

Figure 1: South African carbon emissions per sector

Defining sustainability

Recent work by the World Wildlife Fund contributes substantially to defining sustainable development by providing quantified minimum criteria for sustainability. In the 2006 Living Planet Report, sustainability is defined as achieving an Ecological Footprint (EF) of less than 1.8 global hectares per person and an Human Development Index (HDI) value of above 0.8 (WWF 2006).

Ecological Footprint

An Ecological Footprint is an estimate of the amount of biologically productive land and sea required to provide the resources a human population consumes and absorb the corresponding waste. These estimates are based on the consumption of resources and production of waste and emissions in the following areas: • Food, measured in type and amount of food consumed • Shelter, measured in size, utilization and energy consumption • Mobility, measured in type of transport used and distances travelled • Goods, measured in type and quantity consumed • Services, measured in type and quantity consumed The area of biologically productive land and sea for each of these areas is calculated in global hectares (gha) and then added together to provide an overall ecological footprint. This measure is particularly useful as it enables the impact of infrastructure and lifestyles to be measured in relation to the earth’s carrying capacity of 1.8 global hectares (gha) per person.

The Human Development Index The Human Development Index was developed as an alternative to economic progress indicators and aimed to provide a broader measure that defined human development as a process of enlarging people’s choices and enhancing human capabilities (United Nations Development Programme 2007). The measure is based on: • A long healthy life, measured by life expectancy at birth • Knowledge, measured by the adult literacy rate and combined primary, secondary, and tertiary gross enrolment ratio • A decent standard of living, as measure by the GDP per capita in purchasing power parity (PPP) in terms of US dollars

South African EF and HDI figures The figures below show that South Africa has an ecological footprint of 2.1, above the maximum required of 1.8 gha and a human development index measure of 0.66, below the minimum of 0.8 required for sustainability.

Measure South Africa Sustainability Target Ecological Footprint (gha) 2.1 1.8 Human Development Index 0.658 0.8

For South Africa to move towards sustainability there must therefore be an improvement in both the Ecological Footprint and Human Development Index performance. The built environment has a key role in supporting this improvement. The legislative and policy context South Africa has a range of legislation and policy that aims to protect the environment and support sustainable development. Key legislation supporting sustainable development includes the South African Constitution and the National Environmental Management. These are discussed briefly below.

South African Constitution

The South African Constitution contains a Bill of Rights that enshrines the rights of all people in South African and affirms the democratic values of human dignity, equality and freedom. The Bill has sections covering equality, human dignity, privacy, freedom of religious belief and opinion, environment, property, housing, healthcare, food, water and social security, children, education, language and culture. Through a section on equality, the Bill requires that all people have full and equal enjoyment of these rights and freedoms:

Everyone is equal before the law and has the right to equal protection and benefit of the law. 

Equality includes the full and equal enjoyment of all rights and freedoms. To promote the achievement of equality, legislative and other measures designed to protect or advance persons or categories of persons, disadvantaged by unfair discrimination, may be taken. Environmental rights in the Bill of Rights include the right to an environment that supports health and wellbeing. It also requires legislation to be developed to ensure that the environment is protected and that development that does occur is both sustainable, and justifiable: Environment Everyone has the right ¬ a. to an environment that is not harmful to their health or well-being; and b. to have the environment protected, for the benefit of present and future generations, through reasonable legislative and other measures that ¬ i. prevent pollution and ecological degradation; ii. promote conservation; and iii. secure ecologically sustainable development and use of natural resources while promoting justifiable economic and social development Sustainable development and the protection of the environment is, therefore, a constitutional obligation and there is a requirement for ‘reasonable legislative and other measures’ to be put in place to ensure that this achieved. This document represents a measure taken by the Department of Health to achieve sustainable development.

Carbon emission mitigation strategies South Africa is a signatory to both the United Nations Framework Convention on Climate Change (UNFCC) and the Kyoto Protocol. In order to address UNFCC commitments, the Long Term Mitigation Scenarios (LTMS) process was initiated in 2006 and completed in 2008. This formulated strategies to ensure that South Africa would reduce carbon emissions. Many of the mitigation strategies identified have implications on the built environment and these are outlined below (DEAT 2009b): • Limits on less efficient vehicles • Passenger modal shift • Solar water heater subsidy • Commercial efficiency • Residential efficiency • Renewables with learning • Waste management • Land use: afforestation • Escalating CO2 tax

Following the LTMS process, key policy approaches were agreed on by the South African cabinet. These strengthen current energy efficiency and demand-side management initiatives such as environmental fiscal reform and carbon taxation which will penalize energy inefficient technology and provide for additional tax allowances of up to 15% for energy-efficient equipment. The LTMS process however also showed that although significant emission reductions could be achieved through technology-based actions, these were not sufficient for the scale of change required and that adaptations in social behaviour would be required. (DEAT 2009c).The LTMS, therefore, proposed a number of people and building orientated measures that offered low-cost large scale mitigation impacts including:

• Social adaptation and changes in human habitation, urban planning and the built environmental • Studies on the distance between work, home and other life functions • Modal shifts to public transport and moves away from individual car owners towards the operation of shared vehicles • Food production and consumption, as well as the localization of these activities

Built environment sustainable development objectives

The environmental context, legislation and potential future measures to reduce carbon measures make it clear that the built environment must change to support sustainable development. It also makes it clear that many of the conventional practices in the planning, design, construction and management of building must be substituted with improved more sustainable approaches. In order to develop practical measures that can be integrated into the built environment, it is useful to set out built environment or development objectives that, together, would support sustainable development. These objectives are outlined below and form the starting point for the next sections of this document where more detailed criteria are provided.

Environmental objectives • Energy: The building is energy efficient and uses renewable energy • Water: The building minimises the consumption of mains potable water. • Waste: The building minimizes emissions and waste directed to landfill • Materials: Construction impacts of building are minimized • Biodiversity: The building supports biodiversity Economic objectives • Transport: The building supports energy efficient transportation • Resource Use: The building makes efficient use of resources • Management: The building is managed to support sustainability • Local Economy: The building supports the local economy • Products and Services: The building supports use of more sustainable products and services

Social objectives • Access: The building supports access to facilities • Health: The building supports a healthy and productive environment • Education: The building supports education • Inclusion: The building is inclusive of diversity in population • Social Cohesion: The building supports social cohesion

Integrating sustainable development objectives into health facilities Integrating sustainable development objectives requires structured processes. These are described below in terms of design and operational processes.

Design processes Addressing sustainability in designs for new health facilities can be achieved through the following steps: 1. Target setting: Challenging sustainability targets should be set for the building and agreed with all of the key stakeholders of the project including the design team, the facilities manager and the funder or owner of the building. Targets should take into account government policy and strategies as well as local and international best practice. 2. Design principles: Strategies and design principles required to achieve these sustainability objectives should be understood and established from the outset. For instance, energy targets may require passive environmental control strategies to be well understood and established from the outset. These strategies and their implications can be understood through analysis of best practice examples and precedents. 3. Integrated design: Once targets and design principles have been established, an integrated design process should be used to ensure that all aspects of the building work together to achieve the required performance. This requires the different disciplines to work closely together. 4. Testing: Throughout the design process, checks should be carried out to ensure that targets set will be achieved. This can be done through calculations, modelling and analysis which assesses performance against targets set. Where aspects of the design are found not to meet targets a re-evaluation of the design should be carried out and in an iterative and integrated way, improved, to ensure that performance achieves, or surpasses, targets set. 5. Detailed design and implementation: It is important to ensure that the principles set out in 2 above, are carried out in to detail otherwise this may affect operational performance. This includes, for instance, details such as appropriate locations for switches, labels and instructions. 6. Handover: On completion, effective processes should be followed to ensure that design intentions are carried through into building operation. This includes effective commissioning, handover and training processes which ensure that designers, subcontractors and suppliers transfer knowledge and skills to facilities managers required to ensure effective management of the building.

Operational performance Addressing sustainability in existing or newly developed health facilities can be achieved through the following steps: 1. Data: Obtain operational performance data on your building for at least a full year. For energy, this can be obtained in the form of utility statements that indicate energy consumption in kWh. 2. Benchmark: The above data should be normalised so that it can be compared to benchmarks. This will indicate whether your facility is below or above benchmark performance. If performance is well over benchmark, further investigation should be carried out, as this indicates there is room for improvement. 3. Walkthrough assessment: A walkthrough energy assessment can be used to identify where obvious improvements can be made. Checklists are used as a basis for these assessment and they can be carried out by health facilities personnel with training or experience of the respective areas such as water and energy. 4. Audit: Where walkthrough assessments and benchmarking exercise indicate that a full audit is warranted this can be carried out. These audits provide detailed reports on interventions that can be carried out to improve sustainability performance in a facility. 5. On-going operational performance: A key component of improving sustainability operational performance, in combination with the steps above, is an on-going programme that improves performance. This includes detailed sustainability monitoring and reporting as well as day-to-day management processes required to optimise performance. Operational performance should be allocated to an individual who is required to report on this to senior management. Identified responsible persons should be provided with appropriate training, resources and incentives to achieve excellent energy performance.

Sustainability integration plans The above processes can be supported through sustainability integration plans which present targets, strategies and monitoring process for each sustainability performance areas. The simplest form of this is illustrated in the table below and can be used for both design and operational processes.

Area Targets Strategy Monitoring Sustainability performance area Sustainability targets and requirements Proposed strategy and processes Progress on achievement of targets

ENERGY

Objective The building is energy efficient and uses renewable energy

Introduction Energy is used in health facilities to operate equipment, heat water, and to ensure that required minimum lighting, ventilation and thermal comfort standards are met. In most existing South African building it is estimated that savings of up to 30% of energy consumption can be achieved at no or low cost. These savings can be considerably higher in new facilities were passive strategies, energy efficient equipment and renewable energy systems can be used.

Ensuring that health facilities are more energy efficient use renewable energy has a wide range of benefits including: • Reduced carbon emissions and therefore global warming impacts • Reduced impact of mains power outages • Reduced negative health impacts of pollution from coal-fired power stations • Reduced operational costs • Improved internal environment where passive strategies such as day lighting and natural ventilation lead to improved internal conditions relative to mechanical ventilation and artificial lighting.

Energy consumption in health facilities Energy in South African health facilities is largely sourced from electricity, however gas and coal may also be used in larger hospitals and some rural clinics rely on local renewable energy systems such as photovoltaic panels and solar water heaters. The proportions of energy use in a conventional South African hospital and clinic are shown in the pie charts below:

Proportions of energy consumption in a typical South African hospital Proportions of energy consumption in a typical South African clinic Data on energy consumption and demand in South African facilities is not readily available. However the following table provides a number of benchmarks 1 Energy benchmark type Typical Good practice Clinics Energy consumption (kWh/m2.a) 1 1 Maximum demand (VA/m2) 1 Renewable energy (kWh/m2.a) 0 Hospitals Energy consumption (kWh/m2.a) 395 2 1 Maximum demand (VA/m2) 1 Renewable energy (kWh/m2.a) 0

Design Criteria Highly energy efficient facilities are optimised and integrated solutions that respond closely to the local site, climate and required internal functions. It is therefore difficult to prescribe this in a set of specific design criteria; however a series of questions are outlined below which can be used to check that key energy considerations have been addressed.

Design and operation Improving energy performance in health facilities requires plans, procedures and processes that ensure that sustainability is integrated effectively into design and operations of a health facility. This can be achieved through setting challenging targets and effective monitoring processes. 1. Have challenging sustainability targets been set for energy? 2. Have effective procedures been established to model and test performance throughout the design process to ensure that these targets are achieved? 3. Have the effective monitoring and evaluation systems, including regular reporting to the client, been put in place to ensure targets are achieved? 4. Have capacity and systems in the form of staffing, training, manuals, commissioning and monitoring processes been planned for and put in place to ensure that design targets are achieved in operation.

Orientation Orienting facilities so that the long facades face North – South helps to reduce unwanted heat gains from low angle sunlight early in the morning and late in afternoon. Where there is no alternative but to have facades face East and West, appropriate solar shading should be provided to avoid glare and control solar heat gain.

1. Are the long facades of facilities orientated to face within 15 degrees of a North – South orientation? 2. Is glazing on West and East facades minimised?

Building shape While building shape and form may generally be determined by the functions accommodated, building form can also be shaped to minimise energy consumption. Shaping built form to limit building depth (see below) ensures that interior spaces can be naturally ventilated and day lit. Built form can also direct prevailing breezes through the facilities, supporting cooling and ventilation. It can also be used to create comfortable external spaces.

1. Does the form of the building respond to local climate and topography? 2. Does the building shape support reduced energy consumption and help create comfortable internal and external spaces?

Building depth Limiting building depth enables internal space to be day lit and naturally ventilated. This ensures that internal space may not need artificial lighting or mechanical ventilation for much of the day, reducing energy consumption. 1. Are building depths less than 15m?

Insulation Insulation, especially when combined with thermal mass can be used to maintain comfortable indoor conditions without significant use of mechanical equipment. Insulation can ensure that valuable heat gains from people, equipment and the sun can be retained in the building to support comfort during winter. It can also reduce unwanted heat gains from ambient conditions in summer.

1. Do the building envelope U-values achieve or surpass minimum values outlined in SANS 204 (SABS 2008)?

Solar shading and glazing Glazing is usually the most vulnerable area of a building envelope and high heat losses and gains can be experienced through this component. It is therefore important to design glazing and devices which enable light and heat flow to be controlled.

1. Is the glazing to wall ratio compliant with SANS 204 (SABS 2008)? 2. Is solar shading compliant with SANS 204 (SABS 2008)? 3. Has glazing with appropriate U-values, visual transmittance and solar heat gain coefficients been selected?

Opening areas Opening areas within the building envelope such as doors and windows can be used to naturally ventilate the building. In general, it is advisable to provide for openings even in facilities that are mechanically ventilated and cooled as this enables them to be occupied and used in the event of a power cut.

1. Are opening areas located to support effective natural ventilation? 2. Is the area of openings provided compliant with SANS 10400?

Air tightness Uncontrolled infiltration and airflow through the building envelope can affect comfort and increase heating and cooling loads in the building.

1. Has careful detailing and specification been used to minimise infiltration in the building. 2. Has a plan for rigorous construction supervision been put in place to ensure that building envelopes are air tight?

Mechanical systems As far as possible mechanical cooling, heating and ventilation should be avoided. If this is not possible, a mixed mode operation should be selected. Mixed mode operation use mechanical system when ambient and internal conditions require this, but otherwise rely on passive systems to maintain thermal comfort and meet ventilation rate requirements. In particular circumstances mechanical cooling, heating and ventilation may be required for much of the year.

1. Can the building or most of the spaces be passively cooled, heated and ventilated without the requirement for mechanical systems? 2. If the application of passive systems will not achieve an acceptable number of annual comfort hours, can complementary mechanical systems be introduced to meet the comfort and ventilation requirements? 3. Where zones exist within a facility that are not tolerant of passive ventilation and comfort systems, can a zoned mixed mode ventilation strategy be adopted? 4. Where mechanical systems have been used has a rigorous exercise been undertaken to identify the most appropriate and energy efficient system? 5. Where mechanical systems have been used do these include features that help reduce energy consumption such as:

a. An economy cycle b. Controls that enable easy systems adjustments in order to benefit for seasonal and occupancy changes.

Equipment As equipment used in building can consume large amounts of energy, the energy efficiency of equipment and energy ratings should be a key consideration. In addition, controls that ensure equipment is switched off when not in use should be specified.

1. Is energy efficiency a key consideration in the selection of equipment? 2. Is benchmarking energy consumption or energy rating used to support the selection of equipment? 3. Are the controls provided for equipment easy to use and do they ensure that equipment is off when not required?

Internal lighting Ensuring adequate lighting levels may be a key consideration in many spaces within health building. This should however be achieved in the most energy efficient way. Lighting is rapidly becoming more energy efficient and there are increasingly sophisticated controls.

1. Is energy efficiency a key consideration in the selection of lighting? 2. Has a rigorous evaluation process, including lighting power density calculations, been undertaken to ensure that the selected lighting system is highly energy efficient? 3. Have appropriately sized lighting zones (ie under 100m2) been designed to avoid lighting being on where it is not required. 4. Are lighting switching arrangements easy to use and encourage users to switch off lighting when not required? 5. Are motion sensors used to switch lighting off in areas such as store rooms and meeting rooms when these are not used? 6. Are daylight sensors used to switch lighting off in areas where these is adequate daylight? Areas with good daylight are usually found within a zone of about 6 m from external windows. 7. Can light harvesting techniques and systems be incorporated in the design solution?

External lighting Concerns about security often result in highly lit external areas. While security and building access requirements must be met, external lighting should be designed to be as energy efficient as possible. 1. Are only areas that specifically require external lighting included? 2. Has external lighting been provided as close to the area that requires lighting as possible and directed in order to avoid losses and light pollution? 3. Are photo sensors, motion sensors or timers used to ensure that lighting is only on when required?

BMS system Building Management Systems (BMS) should be used in complex building with complex equipment and systems. A BMS enables different systems to integrated and controlled and can support energy efficiency 1. Has a BMS been used to coordinate and integrate systems, where complex systems are used in a large building? 2. Is the BMS easy to use and understand? 3. Is there local training and support for the BMS 4. Does the BMS include features that support energy efficiency such as: a. Easy access to equipment schedules so that these can easily be changed to suite occupancy patterns. b. Reminders to ensure that BMS operator tune building systems for greatest energy efficiency. For instance the system may provide a reminder to change air conditioning set points to match seasonal changes. c. Reporting on water and energy sub metering and related equipment schedules. Is the BMS system developed to open protocols and standards? Sub metering An appropriate sub-metering system enables effective energy management. A facilities manager can see how much energy is used in different areas or uses in the facility. Sub-meters also show when and how energy is used through for instance energy profiles which show energy consumption and demand over time. 1. Has an energy sub metering design been developed that will monitor all of the main energy uses in the facility? 2. Is energy management data provided in formats and reports that can be easily understood and analysed to support improved energy management? 3. Does the system provide energy management report that can be used by both facilities managers and senior managers to improve energy efficiency in the facility?

Renewable energy Increasingly renewable energy is becoming a competitive alterative to ESKOM supplied power. It also has the advantage that it increases the energy autonomy and independence of facilities, allowing these to operate even when there are mains power cuts. 1. Are solar water heaters used to heat water in the facility? 2. In areas with high quality, reliable sunlight, are photovoltaic systems used to reduce the reliance on ESKOM power? 3. In areas with high quality, reliable wind, are wind turbines used to supplement to reduce the reliance on ESKOM power? WATER

Objective The building minimises the consumption of mains potable water.

Introduction Water is used in health facilities for cleaning equipment, utensils and facilities, laundry, irrigation, food preparation and for drinking. In most existing South African health facility it is possible to reduce mains potable water consumption at no or low cost. These savings can be considerably higher in new facilities where water efficient technologies, grey water and rainwater systems can be used.

Ensuring that health facilities are more water efficient has a wide range of benefits including: • Reduced water consumption and associated negative environmental impacts • Reduced impact of mains water shortages or outages • Reduced operational costs

Water consumption in health facilities Water in South African health facilities is largely sourced from municipal potable water supply, however in some areas water may come from a rain water tanks or a borehole. The proportions of water use in a conventional South African hospital and clinic are shown in the pie charts below:

Proportions of water consumption in a typical South African hospital Proportions of water consumption in a typical South African clinic Data on energy consumption and demand in South African facilities is not readily available. However the following table provides a number of benchmarks 1 Water benchmark type Typical Good practice Clinics Water consumption (kl/m2.a) 1 1 Hospitals Water consumption (kl/m2.a) 70 2 1

Criteria The consumption of mains potable water in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective performance requirements within the health facility; however a series of questions can be used to check that key water considerations have been addressed. These are outlined below.

Wash Hand Basin Taps Controlling and reducing water flows in wash hand basin taps can be used to reduce water consumption. 1. Are wash-handbasin tap flow rates should not exceed 6L/minutes? 2. Are passive infra-red (PIRs) or push-button controls used to limit the duration of flows? 3. Has legionella control been considered when designing for low flow and systems and where existing system are made redundant?

Toilets Reducing flush rates in water-borne sanitation can be used to reduce water consumption.

1. Have WC flush rates been specified that do not exceed 6L/flush? 2. Have dual flush controls can be used to ensure that reduced flush rates can be used when full flushes are not required?

Showerheads Controlling and reducing water flows in showers can be used to reduce water consumption. The following measures can be considered: 1. Have shower head flow rates been specified to not exceed 10L/minute? 2. Are push-button type controls used to limit the duration of flows? 3. Has legionella control been considered when designing for low flow and systems and where existing system are made redundant?

Irrigation Minimising irrigation water requirements can be used to reduce water consumption. The following measures can be considered: 1. Are locally indigenous species (species found in the local area) used to minimise irrigation requirements? 2. If irrigation is required, are highly efficient water delivery systems, such as a drip irrigation linked to soil moisture probes, used to minimise irrigation requirements. 3. Has grey water been used to avoid the use of potable water for irrigation?

Grey water systems Grey water systems reduce mains potable water consumption by reusing lower quality water within the facility. Examples of this are where waste water from showers and wash hand basins is captured and reused to flush toilets. Other sources of grey water include waste water from laundries and HVAC systems. Grey water systems however are potentially hazardous to human health, particularly in health facility environments. In particular, grey water which is left to stand for over 36 hours or is contaminated by food or similar waste is considered as blackwater and requires the same treatment as sewage. Therefore, grey water systems should only be designed, implemented and operated by appropriately competent people. Potential grey water applications in health facility environments are described below: • Wash hand basin and shower waste water: Waste water from wash hand basins and showers can be directed to a grey water system and then used to flush toilets or for landscape irrigation. • Vehicle wash: Waste water from vehicle waste can be reused to wash vehicles for up to 3 or 4 times. After this it can be disposed of or used for irrigation. • HVAC plant: It may be possible to use waste water from HVAC systems for irrigation or to flush toilets. To ascertain if this is possible investigations should be carried out with the HVAC manufacturer and grey water specialists. The following considerations in relation to grey water systems should be made: 1. Have significant sources of grey water from, for instance, showers and wash-handbasins, been captured in a grey water system? 2. Are grey water usage points appropriately labelled to prevent unsafe consumption. 3. Will this grey water be used for irrigation or to flush toilets in order to significantly reduce portable water consumption? 4. Is the proposed grey water system easy and cost effective to maintain? 5. Have as many of the potential health hazards associated with the system been eliminated?

Rain water systems Rain water systems store water captured from roofs or hard landscape surfaces. This water is then available for irrigation, to flush toilets or for cleaning. In large facilities very substantial amounts of water can be captured and used to reduce mains potable water consumption. A number of different types of systems are described below: • Roof rainwater harvesting: Rainwater from roofs is directed to tanks and stores. Usually a proportion of initial run-off is directed to waste as it may have picked up dust and other debris. This system is the most common and generally has the lowest cost as rainwater tanks can be installed above ground surface. • Hard surface rain water: This system captures storm water run-off from hard surfaces such as game pitches, paths and car parking. This type of system generally requires some form of filtration to remove debris, and in the case of car parking, oil wastes. Tanks are usually sub-surface. • Landscape surface run-off capture: Surface run-off from soft landscaping can be captured and reused. This is sometimes used as part of an onsite storm water retention strategy. The disadvantage of this system is that the resulting water quality can be poor as debris and silt may be picked up. The filtration and maintenance requirements are therefore more stringent. The following considerations in relation to rain water systems should be made: 1. Have significant sources of rain water from roof and hard surfaces been captured in a rainwater harvesting system? 2. Will this rain water be used in functions such as irrigation or to flush toilets in order to significantly reduce portable water consumption? 3. Is the proposed rainwater harvesting system easy and cost effective to maintain? Have as many of the potential health hazards associated with the system been eliminated? WASTE

Objective The building minimizes waste directed to landfills.

Introduction Waste in South African health facilities is largely directed to landfill sites. Not only does this use up valuable land, but can also lead to air, soil and water pollution if not waste is not disposed of correctly. In addition, this waste also consists of valuable resources that could be easily reused and recycled. Recycling and reusing materials not only reduces energy and resource consumption but can also create jobs and additional revenue streams. Ensuring that health facilities minimise waste and reuse and recycle waste products are as follows: • Reduced loss of land area to landfill • Reduced energy and resource consumption • Potential to create jobs and small enterprises

Waste production in health facilities Waste in South African health facilities is largely directed to landfill sites. However in some area waste may be disposed of by local recyclers. The proportions of waste generated use in a conventional South African hospital and clinic are shown in the pie charts below:

Proportions of waste in a typical South African hospital Proportions of waste in a typical South African clinic

Data on waste in South African facilities is not readily available. However the following table provides a number of benchmarks 1 Waste benchmark type Typical Good practice Clinics Waste production (kg/m2.a) 1 1 Proportion of waste recycled or reused 10% Hospitals Waste production (kg/m2.a) 1 1 Proportion of waste recycled or reused 10%

Criteria Waste in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health facility; however a series of questions can be used to check that key waste considerations have been addressed. These are outlined below.

Provision for recycling Recycling can be encouraged by developing systems that make this easy. This includes providing easy-to-use receptacles for different types of waste and providing space in the right locations so that waste can be stockpiled into worthwhile quantities for a recycler to collect. 1. Are there appropriate waste receptacles at the waste source to enable waste to be disposed of easily? 2. Are there adequate number and type of waste receptacles at source to ensure that the value of waste is not reduced as a result of wastage or mixing of waste? For instance, clean waste paper can be spoilt if mixed with food waste. 3. Has adequate storage space been provided in an appropriate location for the different recycling waste streams so that this waste can be stockpiled and easily accessed recycling contractors?

Engagement with local recyclers Engaging with local recyclers earlier in the development of a new or refurbished facility can be used to understand the recycling process and the key requirements to make this effective. 1. Have all the potential waste streams been identified? These include paper, cardboard, tin, glass, plastic, timber, electrical appliances etc? 2. Have appropriate associations and local recyclers related to each of these waste streams been engaged with a view to ensuring that appropriate provision and systems are put in place to maximised recycling.

Engagement with suppliers Engaging with suppliers can be used to reduce waste and transportation impacts. Waste and transportation impacts can be reduced through reduced use of packaging, use of reusable containers and optimised logistic supply chains. 1. Have all suppliers of substantial goods and services to the health facilities been identified? Have these been engaged in relation to transportation and packaging with a view to minimising impacts in these areas? 2. Has provision been made to reduce packaging waste and transport impacts through aspects such as increased space allowances for releasable containers and storage of products?

Construction waste Construction is a major source of landfill waste. Waste from construction however can usually be easily reduced through explicit planning and monitoring processes. 1. Has was construction waste minimisation and recycling been included as specific requirement within tender and contract documents? 2. Has the contractor been asked to develop a construction waste management plan in order to minimise waste? Does this plan include specific construction waste management targets ie 50% of all waste on site will be recycled? Have the parties responsible for implementing the plan been identified clearly and have they been given the mandate and resources to implement the plan? Has an appropriate monitoring and evaluation systems been put in place to ensure targets are achieved?

MATERIALS

Objective Construction impacts of building are minimized

Introduction Materials used in new facilities and the refurbishment of facilities can have significant impacts. Materials may be mined, processed, manufactured and transported before being incorporated in facilities. The extent and nature of the impacts of these stages varies widely depending on the material. The selection of materials and products to be used in facilities therefore is important in reducing negative environmental impacts. Careful selection of construction materials used in health facilities has the following benefits: • Reduced land and mining impacts • Reduced environmental and health impacts from manufacturing processes • Reduced transportation impacts • Reduced material use • Increased use of local sustainable materials

Material use in health facilities Materials are used to construct South African health facilities and largely found in the building structure and envelope. More specialist materials and products such as refrigerants are found in equipment and systems within the building. The source and processes associated with construction materials and products have a wide range of impacts. It is therefore important to understand and confirm these with respective suppliers in order to select and specify materials and components with the least negative impacts.

Criteria Material and component selection in health facilities can be addressed developing criteria list, communicating this to suppliers, and using this as a basis for specification and design. The nature of these criteria will depend on local circumstances and the respective requirements of the health facility; however a series of questions can be used to check that key material and component considerations have been addressed. These are outlined below.

Building reuse Using existing facilities instead of building new avoids or reduces the requirements for construction materials and therefore the impacts associated with extracting, manufacturing and transporting these. In addition, existing facilities are usually part of the urban fabric and already serviced with electricity, water, roads and public transport. Increasing the intensity of use of this fabric increases its efficiency and avoids the requirement to replicate this elsewhere. Therefore, in most circumstances it is preferable to reuse and refurbish existing facilities rather than build new facilities. 1. Can the existing facilities continue to be used? If necessary, can these be refurbished and expanded rather than building a new facility? 2. Are there other existing facilities that can be used? Can these be readily adapted for health use rather than constructing new facilities?

Contribution to Global Warming Construction materials can contribute to global warming through carbon emissions associated with large amounts of energy used in their extraction, processing and transportation. This is referred to as embodied energy. Other materials such as refrigerant can contribute directly to global warming if they are released or leak into the atmosphere. Using existing facilities instead of building new avoids or reduces the requirements for construction materials and therefore the impacts associated with extracting, manufacturing and transporting these. In addition, existing facilities are usually part of the urban fabric and already serviced with electricity, water, roads and public transport. Increasing the intensity of use of this fabric increases its efficiency and avoids the requirement to replicate this elsewhere. Therefore, in most circumstances it is preferable to reuse and refurbish existing facilities rather than build new facilities. 1. Refrigerants: Where refrigerants are being used in HVAC systems, cold rooms or in fire suppressions sytems have refrigerants with the lowest Global Warming Potential (GWP) and Ozone Depleting Potential (ODP) impacts been selected? 2. High embodied energy materials: As far as possible, have construction materials with low embodied energy such as timber been selected? Where it is not possible to use these type of materials and high embodied energy materials such as cement and aluminium have to be use have the quantities of these materials been minimised?

Reused materials or materials with recycled content Construction materials that are reused or have recycled content have less energy associated with their manufacture than equivalent new materials. Where possible, it is therefore preferable to reuse materials that may have already been used in another building or to select materials with recycled content. 1. Are there materials from another building that is being demolished that could be reused? Aspects that can be reused include structure steel elements, facades, demountable structures such as carports, and building components such as windows and doors. Crushed concrete from demolished structures can also be used as aggregate in new construction. 2. Have materials with recycled content been specified in preference to materials without any recycled content? Can the supplier / manufacture confirm the reduced environmental impacts of their recycled content product relative to new products?

Reduced material use The quantity of construction materials used in facilities can be reduced through avoiding material use, using materials more intelligently and using materials for more than one use.

1. Avoided material use: Have materials been avoided where these are not required? For instance, can ceilings and plastering be avoided through better concrete finishes? Can improved floor finishes be used to avoid the requirement for carpets and tiling? Can the use of passive systems reduce the requirement for ducting and plant? 2. Intelligent material use: Can quantities of materials be reduced through different designs and specifications? For instance, can structural strategies such as pre-tensioning concrete slabs and waffle slabs be used to reduce concrete requirements? Can material use and wastage be reduced through use of precast elements? 3. Dual plus use: Can materials be used for more than one purpose? For instance, can photovoltaic panels be used as a roofing material as well as to generate material?

Material source The quantity of construction materials used in facilities can be reduced through avoiding material use, using materials more intelligently and using materials for more than one use.

1. Avoided material use: Have materials been avoided where these are not required? For instance, can ceilings and plastering be avoided through better concrete finishes? Can improved floor finishes be used to avoid the requirement for carpets and tiling? Can the use of passive systems reduce the requirement for ducting and plant? 2. Intelligent material use: Can quantities of materials be reduced through different designs and specifications? For instance, can structural strategies such as pre-tensioning concrete slabs and waffle slabs be used to reduce concrete requirements? Can material use and wastage be reduced through use of precast elements? 3. Dual plus use: Can materials be used for more than one purpose? For instance, can photovoltaic panels be used as a roofing material as well as to generate material?

Sustainable sources Materials can be defined in terms of whether they are from sustainable or non-sustainable sources. Materials from sustainable sources include timber, cork, wool that are grown and therefore can be harvested on an on-going materials. Other materials such as plastics and metals are mined and therefore once these sources are depleted will not be available. 1. Where possible, have materials from sustainable sources been specified? For example, have timber, and plant-based products been used in preference to materials that have to be mined and processed? 2. Are materials from sustainable sources actually being grown and harvested on a sustainable on-going basis? For instance, has timber specified been certified by the Forest Stewardship Council (FSC) as being from a sustainable source? It is important to note that there are still timber products available, in particular hardwoods, that are harvested from tropical rainforests which are not being replanted and therefore are notconsidered sustainable sources.

BIODIVERSITY

Objective The building supports biodiversity

Introduction Biodiversity plays a very important role for man through providing ecosystem services. Ecosystem services include the production of food and water, the control of climate and disease, supporting nutrient cycles and crop pollination and spiritual and recreational benefits. Ensuring that health facilities take into account biodiversity has a wide range of benefits including: • Maintaining local ecosystem services • Providing an natural amenity such as gardens which would could support recuperation.

Biodiversity in health facilities Health facilities affect biodiversity through their location and in the way that site planning and landscaping is carried out. New facilities can minimise negative impacts on biodiversity by avoiding green field sites and building outside municipal boundaries. Biodiversity within health facility sites can be supported through considered site planning and landscaping strategies.

Criteria Biodiversity in health facilities can be addressed in a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key biodiversity considerations have been addressed. These are outlined below.

Site location Biodiversity is being lost at a rapid rate through urban sprawl. Preserving existing biodiversity can therefore be achieved by avoiding green field site and building only within urban boundaries. 1. Has the health facility been planned for a brown field (already built-on) sites? 2. Has the health facility been planned for a location within an urban boundary so that this does not take up land that supports agriculture and or biodiversity.

Design for biodiversity Biodiversity can be supported through site layouts and landscaping that retains existing biodiversity and enhances this. 1. Has planning of the health facility ensured that existing valuable biodiversity on site is preserved? 2. Have valuable links and wildlife corridors between biodiversity on the health facility and adjacent sites been preserved? 3. Has the landscaping strategy enhanced existing biodiversity? Does this include the introduction of appropriate loc TRANSPORT

Objective The building supports energy efficient transportation

Introduction Ensuring that health facilities support energy efficient transportation has a wide range of benefits including: • Reduced air pollution and noise from vehicles • Health benefits from increased opportunities for exercise • More affordable transport for health facility users • Reduced space requirements as a result of reduced parking and road requirements.

Transportation in health facilities Transportation is important in health facilities as large numbers of people and goods need access to these facilities everyday. This includes health facilities staff who commute and health facilities users. The right location and provision of facilities help ensure that the transport impacts associated with this access is minimised and potential health benefits such as exercise are supported.

Criteria The transportation in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health facility; however a series of questions can be used to check that transportation considerations have been addressed. These are outlined below.

Access to public transport Locating health facilities near public transport facilities and enabling good access to these encourage people to use these in preference to personal vehicles. The use of public transport can be encouraged by ensuring that health facilities are located near well used public transport nodes and that there are good walking routes between these and key locations within the health facility. 1. Is the health facilities located near good public transport nodes such as minibuses, buses, trains and bus rapid transport systems? 2. Are there safe, direct and easy-to-use routes between public transport nodes and key locations within the health facility? (see also provision for walking criteria)

Provision for walking

Making provision that encourages walking helps to ensure that people walk to health facilities instead of using vehicles. Walking can be encouraged through safe, direct and easy-to-use routes.  

1. Are there safe direct pedestrian routes to and around the health facilities site from neighbouring areas and public transport nodes? (see also criteria 4 for detail) 2. Are there safe direct pedestrian routes from neighbouring areas to key locations within the health facility such as the main reception? (see also criteria 4 for detail) 3. Are there safe direct pedestrian routes within the health facilities between all locations within the health facility? (see also criteria 4 for detail) 4. Does pedestrian provision include safe road crossings such as bridges, underpasses and zebra crossings? Are routes wide enough and have appropriate finishes and other required characteristics to enable them to be easily used by people with disabilities and by predicted pedestrian numbers? Are routes safe and benefit from visual supervision by surrounding facilities and other pedestrians? Have lighting and appropriate security safety mechanisms been put in place if routes will be used at night?

Provision for cycling

Making provision that encourages cycling helps to ensure that people cycle to health facilities instead of using motorised vehicles. Cycling can be encouraged by providing secure cycle storage, changing or showering facilities and safe, easy-to-use local routes.  

1. Are there safe direct cycle routes to and around the health facilities site from neighbouring areas? (see also criteria 4 for detail) 2. Are there safe direct cycle routes from neighbouring areas to key locations within the health facility such as the main reception? (see also criteria 4 below for detail) 3. Are there safe direct cycle routes within the health facilities between all locations within the health facility? (see also criteria 4 for detail) 4. Does this cycle provision include designated, separate routes and safe road crossings and junctions? Are routes wide enough and have appropriate finishes and other required characteristics to enable them to be easily used by predicted numbers of cyclists? Are routes safe and benefit from visual supervision by surrounding facilities and other cyclists? Have lighting and appropriate security safety mechanisms been put in place if routes will be used at night?

RESOURCE USE

Objective The building makes efficient use of resources

Introduction There are limited resources in the form of land, finance and raw materials to construct and maintain facilities. It is therefore important to use these resourced carefully. Benefits associated with careful resource use include: • Avoiding waste • Ensuring effective and efficient use of resources • Ensuring that resources are available for other uses where these are not required

Resource use in health facilities Health facilities use financial resources to enable construction and maintenance. They also consume materials and energy in their construction. Finally health facilities use land. Careful use of these resources enables waste to be avoided and these resources to be available for other uses where this is required.

Criteria Resource in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health facility; however a series of questions can be used to check that key resource considerations have been addressed. These are outlined below.

Site density

Detailed long term strategic plans for health facilities should be developed that take into account future projections. These should ensure that expansion or changes that are envisaged can be accommodated. However care should be taken that unnecessarily large areas are allocated for health facilities to avoid land being unused. 1. Has a long term strategic site plan been developed for the health facility that addresses changes that may occur in the future, such as expansion or contraction? 2. Has the over allocation of space for health facility sites been avoided?

Occupancy density Robust sustainable facilities accommodate change through flexible and adaptable allocation and configuration of space. While this is important over provision of space should be avoided as this space will need to be serviced and maintained even if it is not used. Health facilities should therefore be designed to support spatial efficiency and effective use. 1. Is the overall space allowance in the health facility in line or below health facilities norms, for instance, in terms of gross area per bed? 2. Are the proportions of spaces use in the health facility in line with good practice health facilities design? For instance is the space allocated for circulation, support and ancillary services as a proportion of the total area in line with best practice norms? Food production Food production in the form of orchards or vegetable gardens are a productive way of using land that leads to both environmental and health benefits. Where land is available in health facility sites and there is water and appropriate capacity, food production should be encouraged and produce made available to be consumed within the health facility or by local communities. 1. Has available land within the health facility site been developed for local food production? 2. Has appropriate provision in the form of irrigation, fencing, organisational and capacity requirements been made to ensure that food production will be effective and sustained?

MANAGEMENT

Objective

The building is managed to support sustainability 

Introduction Facilities can be designed to support effective management. Systems can also be developed to ensure that facilities are effectively and efficiently used and maintained. In health facilities this is particularly important because of the stringent environmental requirements for health care and the high operating costs of the facility. Ensuring that health facilities are effectively managed has a wide range of benefits including: • Ensuring that operating costs are controlled and reduced • Minimising disruption to health care as result of maintained and repairs • Ensuring that maintenance is planned for and effective carried out

Building management in health facilities Building management aims to ensure that health facilities are effectively operated and maintained in order to support healthcare services that they accommodate. Personnel with appropriate capacity, mandate and resources should be allocated to this function.

Criteria Building management in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that building management considerations have been addressed. These are outlined below.

Energy and water sub metering Energy and water sub metering enables the manager of a health facility to manage the consumption of energy and water and reduce costs associated with these services. 1. Has energy sub metering been installed which enables energy consumption in all areas with substantial loads to be measured and monitored? Do energy meters support assessment of energy consumption trends, profiles and comparison with benchmarks? 2. Has water sub metering been installed which enables water consumption in all areas with substantial consumption to be measured and monitored? Do water meters support assessment of water consumption trends, profiles and comparison with benchmarks? 3. Is water and energy consumption monitored and reported to senior management on a regular basis?

Facilities management manual A facilities management manual provides technical detail on all aspects of the building and how they should be maintained and managed. It is useful because it provides a repository of knowledge and information that can be used by facilities managers and their staff to ensure that health facilities are effectively managed and maintained. 1. Has a detailed facilities management manual been developed for the health facilities? Does this include a detailed schedule for maintenance and other checks on equipment such as lighting, pluming fittings and HVAC 2. Does the facilities management manual refer to a full set of as-built drawings and equipment manuals? Have a full set of hard copy and electronic copy as-built drawings and manuals been provided? 3. Have facilities managers in the building had a full induction on the building’s systems and the facilities management manual? 4. Does the facilities management manual get regularly reviewed and updated to reflect upgrade and renovations details.

Senior management commitment Effective management of facilities can be supported by senior management commitment. Regular reporting on facilities performance such as energy and water consumption serve to ensure that management is aware of these issues and are likely to ensure that the appropriate mandate and resources are in place to improve this. 1. Have facilities management policies in relation to sustainability been developed? For instance, are there policies or guidance on how energy and water consumption will monitored and managed? 2. Have facilities management policies or guidelines been endorsed by senior management? Is there are requirement for facilities management to report on facilities performance on a regular basis to senior management?

LOCAL ECONOMY

Objective The building supports the local economy

Introduction The construction and maintenance health facilities are a significant investment by government. This investment, if considered carefully, can be used to support the local economy and employment. This is done by specifying local products and services from the local area. Ensuring that health facilities support the local economy has a wide range of benefits including: • Increased local employment • Increased local capacity for new construction and maintenance of facilities

Local economy in health facilities Supporting the local economy can be achieved in new facilities by understanding the nature and type of local building product suppliers and where appropriate specifying these in the building. Similarly understanding the capacity and skills of local contractors can be used to ensure that these are developed and enhanced by being engaged in the construction and maintenance of health facilities.

Criteria Supporting the local economy in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key waste considerations have been addressed. These are outlined below.

Small enterprise support The waste and emissions in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key waste considerations have been addressed. These are outlined below. Minimising irrigation water requirements can be used to reduce water consumption. The following measures can be considered: 1. Are small enterprises provided with opportunities to tender for relevant construction and maintenance contracts? Can local, small enterprises be given preference in the awarding of work? 2. Where local small enterprises have limited capacity and experience, can they be supported by encouraging partnerships with more established and larger enterprises?

Material and component procurement The specification of local materials and components in the construction of health facilities can provide a significant incentive to local suppliers and manufacturer to develop appropriate products and capacity. This in turn provides local employment and can ensure that maintenance and repairs at the facilities can be carried out more quickly and cost effectively. 1. Has a review of local materials and components been carried out? 2. Have local materials and components been specified?

Construction employment The construction industry can employ significant numbers of people. This can be supported through designs, specifications and labour intensive construction techniques which can be used to construct facilities without significant cost or time implications. Local construction employment improves the local economic impact of projects and ensures that there is local capacity to undertake repairs and maintenance of facilities. 1. Is construction employment a key consideration in the design, specification and construction of the facility? 2. Have opportunities to create local employment been sought and developed through the project?

PRODUCTS AND SERVICES

Objective

The building supports use of more sustainable products and services 

Introduction Products and services used in health facilities have a range of impacts and planning can be used to maximise beneficial impacts and avoid negative impacts. The construction and maintenance health facilities are a significant investment by government. This investment, if considered carefully, can be used to support the local economy and employment. This is done by specifying local products and services from the local area. Ensuring that health facilities support the more sustainable products and services has a wide range of benefits including: • Reduced waste • Increased support for sustainable choices and options for health facility users

Products and services in health facilities Supporting the local economy can be achieved in new facilities by understanding the nature and type of local building product suppliers and where appropriate specifying these in the building. Similarly understanding the capacity and skills of local contractors can be used to ensure that these are developed and enhanced by being engaged in the construction and maintenance of health facilities.

Criteria Supporting the more sustainable products and services in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key product and service considerations have been addressed. These are outlined below.

Local produce Impacts associated with transport and storage / refrigeration mean that produce imported from some distance away generally has significantly higher ecological footprints than local produce. Health facilities can therefore reduce ecological footprints associated with food through using local produce as far as possible. 1. Is local produce used in preference to produce imported some distance away? 2. Has the use of local produce been made a requirement in outsourced catering contracts?

Vegetarian options Meat-based meals generally have significantly higher ecological food print requirements relative to vegetarian meals. Providing vegetarian options can therefore support reduced food impacts within health facilities. 3. Are vegetarian options provided in catering establishments within the health facility? 4. Has the provision of vegetarian options been made a requirement for outsourced catering contracts?

Drinking water Waste streams can be reduced by providing alternatives to bottled drinking water. Drinking water can be provided through strategically located drinking fountains, as well as being supplied in reusable containers. A ready supply of drinking water also has health benefits. 1. Is non-bottled drinking water readily and freely available throughout the health facility?

Reuseable vessels Significant waste streams can be avoided through the use of reusable vessels. In particular disposable food and drink vessels can be avoided by providing reusable vessels. This option can be supported through provision of required storage and washing and facilities. 1. Have reusable vessels been specified in preference to disposable containers, for services such as catering? 2. Has adequate provision been made for reusable vessels in the form of storage and washing facilities?

ACCESS

Objective The building supports access to facilities

Introduction Current work patterns and lifestyles mean that many people have to access facilities such as banking, retail, childcare and communications on a regular basis. Ensuring that these facilities are within the health facility or within easy walking distance helps to avoid or reduce associated time and transport impacts. Ensuring that health facilities support access to facilities has a wide range of benefits including: • Reduced transport impacts • Reduced time spent travelling to and from facilities

Access to facilities in health facilities Supporting access to local facilities can be achieved through incorporating these into the health facility. Alternatively the health facility can be located near where these exist. It may also be possible to work with relevant service providers in order to provide these locally.

Criteria Supporting access to facilities in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key access considerations have been addressed. These are outlined below.

Banking Access to banking can be provided through formal banking facilities or through bank ATMs. This can be provided within the health facility or within easy walking distance of this. 1. Are banking facilities available within the health facilities or within the local area?

Grocery retail Grocery retail can be provided through local shops, supermarkets and markets. This can be provided within the health facility or within easy walking distance of this. 1. Are grocery retail facilities available within the health facility or within the local area?

Communication Access to telephone and internet can be provided through internet cafes or at stand alone kiosks. This can be provided within the health facility or within easy walking distance of this. 1. Are internet and telephone facilities available within the health facility or in the local area?

Café Access to catering facilities can be provided through cafes, restaurants or canteens. Refreshments should be affordable and accessible to both staff and health facility users. This can be provided within the health facility or within easy walking distance of this. 1. Is there an accessible, affordable café, restaurant or canteen within the health facility or in the local area?

Childcare Significant waste streams can be avoided through the use of reusable vessels. In particular disposable food and drink vessels can be avoided by providing reusable vessels. This option can be supported through provision of required storage and washing and facilities. 1. Is there a childcare facility within the health facility or in the local area?

HEALTH Objective

The building supports a healthy and productive environment 

Introduction Health facilities by their definition aim to support health and well being in their users. In addition to medical care health can be promoted through beneficial environmental conditions including a plentiful supply of fresh air, views and optimum thermal comfort conditions. It is particularly important to avoid conditions and situations that may be harmful to human health. Ensuring that health facilities support the health in facility users and construction workers services has a wide range of benefits including: • Improved recovery rates for patients • Reduced absenteeism associated with environmental conditions by health facility staff • Reduce injury and absenteeism rates associated with dangerous or harmful working construction environments

Criteria Ensuring construction and health facilities promote health can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that health promotion considerations have been addressed. These are outlined below.

External views Views and a connection to the external environment improve internal environmental conditions and can help improve recovery rates and reduce employee absenteeism. 1. Do health facility staff working areas have views to the external environment 2. Do patient areas have views of the external environment?

Daylight Day lighting can help reduce energy consumption associated with artificial lighting. It also improves internal environmental conditions for patients and health facility employees. 1. Are health facility staff working areas well day lit? 2. Are patient areas well day lit?

Ventilation High levels of fresh air are important for human health and productivity. This can be provided through natural or mechanical ventilation. Where mechanical ventilation is used sufficiently high levels of external, fresh air should be provided and recirculated air should be avoided or minimised. 1. If the condition of outside air makes it unfit for direct ventilation use, is it appropriately pre-treated and filtered by the ventilation system? 2. Are health facility staff working areas well supplied with good quality outside air? 3. Are patient areas well supplied with good quality outside air?

Building materials Building materials can have negative impacts for human health associated with their extraction and manufacture. They may affect health in facilities, through for instance offgassing hazardous chemicals. Construction materials should therefore be screened to avoid products being used in health facilities that have negative impacts on human health. 1. Has criteria been developed and applied for the selection and screening of building materials? 2. Have all building materials that may offgas substances such as formaldehyde and volatiles organic components that may be harmful to human health been avoided?

Contractor health and safety There are considerable health and safety risks in the construction industry. Considering health and safety in the design of health facilities can be used to reduce health and safety risks associated with construction and maintenance. Making provision for safe access to glass facades or to high level lighting helps to ensure that this can be installed, cleaned and maintained without undue health and safety risks. In addition, addressing health and safety comprehensively in contract and construction planning, procedures and processes can be used to eliminate many construction health and safety risks. 1. Has contractor health and safety been considered as a key issue in the design of the building? Have construction risks been minimised through appropriate design risk assessments and mitigation? 2. Have detailed construction plans, procedures and processes been developed to minimise risks where these may occur during construction? 3. Has appropriate health and safety procedures been put in place to ensure that plans are implemented and monitored?

EDUCATION Objective

The building supports education

Introduction Education and on-going learning is increasingly been seen as an essential component of sustainable development and a competitive economy. This is recognised in health care through the requirement for health care professionals to under continued professional development (CPD). Education and on-going learning can be supported through technology and spaces within facilities that support this. Examples of this include training rooms and access to ICT and reading material. In addition well packaged Ensuring that health facilities support the education has a wide range of benefits including: • Improve ability by health facilities staff to keep up-to-date with new developments in health care • Ability to attract and retain staff Criteria Ensuring construction and health facilities promote education and on-going learning can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that education and on-going learning considerations have been addressed. These are outlined below.

Contractor education There are considerable health and safety risks in the construction industry. Considering health and safety in the design of health facilities can be used to reduce health and safety risks associated with construction and maintenance. Making provision for safe access to glass facades or to high level lighting helps to ensure that this can be installed, cleaned and maintained without undue health and safety risks. In addition, addressing health and safety comprehensively in contract and construction planning, procedures and processes can be used to eliminate many construction health and safety risks. 1. Has contractor health and safety been considered as a key issue in the design of the building? Have construction risks been minimised through appropriate design risk assessments and mitigation? 2. Have detailed construction plans, procedures and processes been developed to minimise risks where these may occur during construction? 3. Has appropriate health and safety procedures been put in place to ensure that plans are implemented and monitored?

Notice boards Notices are very easy and cost effective way of communicating information. They can be used to support education and awareness by drawing attention to new or important education. For instance, awareness and reminders about new health care policy, procedures and processes can be communicated. Notice boards have the benefit that they can be located where they will be seen by all personnel on a regular basis and are not reliant on a particular technology, such as email. This helps to ensure information can be communicated to all levels of staff within a health facility. 1. Have notice boards been located in key locations in the health facility where they can be used to communicate key information to facility staff and users? 2. Have communication and education plans been developed that will ensure that notice boards will be updated throughout the year with relevant notices and information?

Space for learning Formal training can be supported through access to training rooms. More informal on-going learning can be provided through access to resource centres where learning material, computers and the internet can be accessed. 1. Are there appropriately sized and equipped facilities to accommodate formal training? 2. Are there appropriately sized and equipped facilities to support informal on-going learning by staff?

Employee induction Employee induction refers to awareness training provided to new employees. This can be used to support sustainability by developing awareness in health facility staff about sustainable building systems and how they should be used. This may include aspects such as lighting and HVAC operation as well as recycling procedures. 1. Have employee induction processes been developed? 2. Do these include detailed information on systems in the building that aim to support sustainability? Building user manual Building user manuals aim to complement employee induction processes by providing easily accessible and understanding information related to a facility in order to support user behaviour that support sustainability. 1. Has a building user manual been developed? 2. Is this readily accessible and easy to use?

INCLUSION Objective The building is inclusive of diversity in population

Introduction Design for inclusion helps to ensure that facilities can be used by all users including older people, sick people, people with children and people with disabilities. Inclusive design also often means that facilities are safer and easier to use. In health facilities both of these aspects are particularly important. Ensuring that health facilities are inclusive has a wide range of benefits including: • Less requirement to replicate facilities • Facilities that are easier and safer to use

Criteria Ensuring health facilities are inclusive can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key inclusion considerations have been addressed. These are outlined below.

Accessible transport Inclusive access to health facilities is an important consideration. This means ensuring that people who may be ill, infirm, old or have disabilities are able to access health facilities easily. This requires accessible routes from places for work and accommodation to the facilities and often requires easily accessible local public transport systems. This can be p Ensuring that health facilities support the education has a wide range of benefits including: 1. Are there regular, affordable and efficient local transport systems? 2. Can these be accessed readily from health facility users’ accommodation and places of work? 3. Can the health facility be accessed readily from public transport? 4. Is public transport provision inclusive?

Environmental access Facility design and management for environmental access can be used to ensure that health facilities are inclusive. This requires a comprehensive approach that ensures that access consideration are effectively integrated into all aspects of health facility design. Guidance on this aspect is provided in the IUSS d 1. Does the facility design fully comply with the IUSS environmental access requirements? 2. Are systems and management in place to ensure that environmental access standards are maintained during operation?

Access to affordable accommodation There is an increasing shortage of affordable accommodation in many South African cities. This can have a range of negative impacts including the requirement for long distance commuting, disrupted family life, and reduced family budgets for non-transport related costs such as education and health. Increasing local affordable accommodation can be achieved through partnership agreements with local developers and social housing organisations. 1. Is there affordable local accommodation for health facility staff? 2. If this does not exist, have initiative been taken to develop this with developers and or social housing institutions?

SOCIAL COHESION Objective The building supports social cohesion Introduction Social cohesion refers to the extent to which individuals within a community understand, collaborate, trust and work together. It is valuable because it enables collective knowledge and resources to be used more effectively and efficiently to support common goals. Within a health facility improved social cohesion can support improved healthcare with fewer resources by sharing and using these more effectively. It can also support improved communication and cooperation within health teams and therefore improving levels of service and reducing wastage and mistakes. Ensuring that health facilities support social cohesion has a wide range of benefits including: • More efficient and effective use of resources • Improved communication and coordination • Reduced wastage Criteria Ensuring health facilities support social cohesion can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key social cohesion considerations have been addressed. These are outlined below.

Shared used of facilities Shared use of facilities helps to ensure that valuable facilities are well used and beneficial impacts are experienced across a wider range of people. Capital and operating costs of the facility may also be reduced as these are shared between a larger number of organisations or individuals. This concept can be applied to health facilities in a range of different ways. For instance, sharing arrangements with a local sport club or fitness centre can be used to enable a health facility to use swimming pools and other facilities for rehabilitation without having the ongoing costs and management of this facility. 1. Have shared use, and possibly development, of facilities been explored with local organisations? 2. Have appropriate design considerations been put in place to ensure effective shared use of facilities? 3. Have appropriate management considerations been put in place to ensure effective shared use of facilities?

Social spaces Social spaces, such as canteens, cafes and common rooms can play an important role in the life of organisation. They not only provide a respite from work environments they also provide a space for relaxed social interaction. This interaction and the relationships and communication networks created can may a significant impact in improving organisational effectiveness and responsiveness. In health care facilities this is a valuable resource which helps to motivate individuals and build strong teams that are able to provide effective and responsive health care. 1. Have an appropriate number and type of social spaces been provided within the health facility? 2. Will these facilities support easy social interaction within and between health teams, as well as cross health facility staff structures?

Stakeholder involvement Involving people in decisions on issues will have an impact on them is a useful way of helping ensure that there is support for an initiative or a process. Structured involvement of stakeholder helps to ensure a shared understanding can be developed, joint decisions made and there is efficient and effective implementation. For instance, within a health facility, effective involvement of key stakeholders can help goals such as improved energy efficiency through ensuring that managers, building technical staff and health services staff understand the goal, the means that this will be achieved and can see their role in supporting this. 1. Has there been appropriate stakeholder involvement in the design of health facilities? 2. Has there been appropriate stakeholder involvement in the management of health facilities?

REFERENCES

1. CIDB, 2009. South African Report on Greenhouse Gas Emission Reduction, Potentials from Facilities, A Discussion Document. Construction Industry Development Board. Page 22. 2. DEAT, 1995. Urban Open Space: Guidelines for effective management. Discussion document based on Agenda 21 and the RDP 3. DEAT, 1998. National Environmental Management Act. Department of Environment and Tourism, Pretoria. Chapter 1. 4. DEAT 2009, State of the Environment Report Accessible from http://soer.deat.gov.za/themes.aspx?m=387 5. DEAT, 2009a, The National Climate Change Response Policy. Department of Environment and Tourism, Pretoria. Page 8. 6. DEAT, 2009b, The National Climate Change Response Policy. Department of Environment and Tourism, Pretoria. Page 14 7. DEAT, 2009c, The National Climate Change Response Policy. Policy Department of Environment and Tourism, Pretoria. Page 20. 8. EMM and GDACE, 2007. Environmental Management Framework for Ekurhuleni. Ekurhuleni Metropolitan Municipality and Gauteng Department of Agriculture, Conservation and the Environment 9. Hewitson, B. Engelbrecht, F Tadross, M. and Jack, C., 2005. General conclusions on development of plausible climate change scenarios for southern Africa, in: R. E. Schulze (ed.), Climate Change and Water Resources in Southern Africa: Studies on Scenarios, Impacts, Vulnerabilities and Adaptation, Water Research Commission, WRC Report 1430/1/05, Pretoria, South Africa. 10. IPCC, 2007. Climate Change 2007, Synthesis Report. Inter Governmental Panel on Climate Change. 2007.Page 7 11. SEA 2006, State of Energy in South African Cities. Sustainable Energy Africa. Cape Town. 12. South African Bureau of Standards. 2007. SANS 204 Energy Efficiency in Facilities 13. WWF 2006. Living Planet Report 2006.World Wildlife Fund. Accessed from www.panda.org.

  APPENDIX A: SUSTAINABILITY INTEGRATION PLANS

Area Targets Strategy Monitoring Sustainability performance area Sustainability targets and requirements Proposed strategy and process Progress on achievement of targets