IUSS Health Facility Guides

IUSS HEALTH
FACILITY GUIDES
Environment and
Sustainibility
Gazetted
8 May 2015
Task Team: C:04
Supported by:
Document tracking
Version Date Name Comments
Dicussion Draft 1 06 Feb 2013 J Gibbard, W Jonker-Klunne
08 March 2013 J Gibbard, W Jonker-Klunne,
Dicussion Draft 2
T v Reenen
Dicussion Draft 2.1 10 March 2014 J Gibbard
Proposal V.1 31 March 2014 J Gibbard, T v Reenen
Proposal V.2 11 June 2014 T v Reenen Language and spelling
Gazetted 8 May 2015 National Health Act,2003(Act
no.61 of 2003)
INFORMATION NOTES
Form: Health facility guides

Status: Gazetted 8 May 2015
Title: Environment and Sustainibility

Description: “sustainability guidelines” is an overview and background to sustainability in
health care facilities.
Reference: CSIR 59C1119 – C:04 - 001
Authors: IUSS N and S task group C:04
Accessing of these guides
This publication is received by the National Department of Health (NDoH), IUSS Steering Committee
Chairman, Dr Massoud Shaker.
Use of text, figures or illustrations from this report in any future documentation, media reports,
publications, competition entries and advertising or marketing material is solely at the discretion of the
IUSS Steering Committee and Working Group and should clearly reference the source. This publication
may not be altered without the express permission of the IUSS Steering Committee and Working Group.
Feedback is welcome.
This document (or its updates) is available freely at www.iussonline.co.za
Disclaimer
This proposal guidance document has been prepared in the development of national norms and
standards for the National Department of Health for the benefit of all South Africans involved in the
procurement, design, management and commissioning of healthcare infrastructure across both public
and private sectors. Use of the guidance in this document is at the risk of the implementing party, until
endorsed by the National Health Council of the Department of Health.
Development status
The development process adopted by the IUSS team is to consolidate information from a range of sources
including local and international literature, expert opinion, practice and expert group workshop/s into a
first- level discussion status document. This will then be released for comment through the IUSS’s online
website and through the IUSS’s national and provincial channels. Feedback and further development will
be consolidated into a second-level development status document, which again will be released for
comment and more rigorous technical review. Further feedback will be incorporated into proposal status
documents for formal submission to the Department of Health’s Technical Review Committee. Once
approved, documents will be submitted for formal approval by the National Health Council, at which
stage documents will reach approved status. At all development stages, documents may go through
various drafts and the final approved document will be assigned a version number. Documents may be
used at risk – for project development at all development stages – but will only become mandatory when
they have finally reached approved status.
Acknowledgements
This publication has been funded by the National Department of Health.
IUSS Norms and Standards Task Team E06
Jeremy Gibberd with input from Judy Bell, Wim Jonker-Klunne, Andrew Cunningham and Tobias van
Reenen
Acknowledgements also to Janine Smit the editor, Sheldon Bole, Claire du Trevou, Kumirai Tichaona and
Mokete Mokete
Reviewed by:
CONTENTS
PART A - INTRODUCTION ............................................................................................................................... 9
PART B - INTEGRATING SUSTAINABILITY ..............................................................................................11
1. Introduction ............................................................................................................................................................................. 11
2. The environmental context ................................................................................................................................................ 11
3. The contribution of the built environment .................................................................................................................. 12
4. Carbon emission mitigation strategies .......................................................................................................................... 12
5. Defining sustainability ......................................................................................................................................................... 13
6. South Africa’s Ecological Footprint and Human Development Index performance...................................... 14
7. The legislative and policy context ................................................................................................................................... 14
7.1. The South African Constitution ................................................................................................................................................ 14
7.2. Environment ..................................................................................................................................................................................... 14
7.3. Sustainability policy and legislation ...................................................................................................................................... 15
8. Built environment sustainability objectives ............................................................................................................... 15
8.1. Environmental objectives ........................................................................................................................................................... 15
8.2. Economic objectives ...................................................................................................................................................................... 15
8.3. Social objectives .............................................................................................................................................................................. 15
8.4. Integrating sustainability objectives into health facilities ........................................................................................... 16
8.5. Sustainability integration plans ............................................................................................................................................... 17
PART C - ENERGY .............................................................................................................................................19
1. Objective.................................................................................................................................................................................... 19
2. Introduction ............................................................................................................................................................................. 19
3. Criteria ....................................................................................................................................................................................... 19
4. Design and operation ........................................................................................................................................................... 19
4.1. Orientation ......................................................................................................................................................................................... 20
4.2. Building shape .................................................................................................................................................................................. 20
4.3. Building depth .................................................................................................................................................................................. 20
4.4. Insulation ............................................................................................................................................................................................ 20
4.5. Solar shading and glazing ............................................................................................................................................................ 21
4.6. Opening areas ................................................................................................................................................................................... 21
4.7. Air tightness ...................................................................................................................................................................................... 21
4.8. Mechanical systems ....................................................................................................................................................................... 21
4.9. Equipment .......................................................................................................................................................................................... 22
4.10. Internal lighting ............................................................................................................................................................................... 22
4.11. External lighting .............................................................................................................................................................................. 22
4.12. Building Management System ................................................................................................................................................... 23
4.13. Sub-metering .................................................................................................................................................................................... 23
4.14. Renewable energy .......................................................................................................................................................................... 23
4.15. Energy targets .................................................................................................................................................................................. 24
PART D - WATER ..............................................................................................................................................25
1. Objective.................................................................................................................................................................................... 25
2. Introduction ............................................................................................................................................................................. 25
3. Criteria ....................................................................................................................................................................................... 25
3.1. Hand basin taps .............................................................................................................................................................................. 25
3.2. Toilets................................................................................................................................................................................................... 25
3.3. Showerheads ..................................................................................................................................................................................... 25
INFRASTRUCTURE UNIT SUPPORT SYSTEMS (IUSS) PROJECT 1

Health Facility Guides:
Environment and Sustainibility [Gazetted 8 May 2015]
3.4. Irrigation ............................................................................................................................................................................................. 26
3.5. Greywater systems ......................................................................................................................................................................... 26
3.6. Rainwater harvesting systems .................................................................................................................................................. 26
3.7. Stormwater systems ...................................................................................................................................................................... 27
3.8. Water consumption targets ........................................................................................................................................................ 28
PART E - WASTE ...............................................................................................................................................29
1. Objective.................................................................................................................................................................................... 29
2. Introduction ............................................................................................................................................................................. 29
3. Criteria ....................................................................................................................................................................................... 29
3.1. Provision for recycling ................................................................................................................................................................. 29
3.2. Engagement with local recyclers ............................................................................................................................................. 29
3.3. Engagement with suppliers ........................................................................................................................................................ 30
3.4. Construction waste ........................................................................................................................................................................ 30
PART F - MATERIALS ......................................................................................................................................31
1. Objective.................................................................................................................................................................................... 31
2. Introduction ............................................................................................................................................................................. 31
3. Material use in health facilities ........................................................................................................................................ 31
4. Criteria ....................................................................................................................................................................................... 31
4.1. Building reuse................................................................................................................................................................................... 31
4.2. Contribution to global warming ............................................................................................................................................... 32
4.3. Reduced material use .................................................................................................................................................................... 32
4.4. Sustainable sources........................................................................................................................................................................ 32
PART G - BIODIVERSITY ................................................................................................................................34
1. Objective.................................................................................................................................................................................... 34
2. Introduction ............................................................................................................................................................................. 34
2.1. Biodiversity in health facilities ................................................................................................................................................. 34
3. Criteria ....................................................................................................................................................................................... 34
3.1. Site location ....................................................................................................................................................................................... 34
3.2. Design for biodiversity ................................................................................................................................................................. 34
PART H - TRANSPORT ....................................................................................................................................36
1. Objective.................................................................................................................................................................................... 36
2. Introduction ............................................................................................................................................................................. 36
2.1. Transportation in health facilities ........................................................................................................................................... 36
3. Criteria ....................................................................................................................................................................................... 36
3.1. Access to public transport .......................................................................................................................................................... 36
3.2. Provision for walking .................................................................................................................................................................... 36
3.3. Provision for non-motorised transport ................................................................................................................................ 37
PART I - RESOURCE USE ...............................................................................................................................38
1. Objective.................................................................................................................................................................................... 38
2. Introduction ............................................................................................................................................................................. 38
2.1. Resource use in health facilities ............................................................................................................................................... 38
3. Criteria ....................................................................................................................................................................................... 38
3.1. Strategic planning ........................................................................................................................................................................... 38
3.2. Occupancy density .......................................................................................................................................................................... 38
3.3. Food production .............................................................................................................................................................................. 39
PART J - MANAGEMENT ................................................................................................................................40
1. Objective.................................................................................................................................................................................... 40
2. Introduction ............................................................................................................................................................................. 40

2.1. Building management in health facilities ............................................................................................................................. 40
3. Criteria ....................................................................................................................................................................................... 40
3.1. Energy and water sub-metering .............................................................................................................................................. 40
3.2. Facilities management manual ................................................................................................................................................. 41
3.3. Senior management commitment ........................................................................................................................................... 41
PART K - LOCAL ECONOMY ...........................................................................................................................42
1. Objective.................................................................................................................................................................................... 42
2. Introduction ............................................................................................................................................................................. 42
2.1. Local economy in health facilities ........................................................................................................................................... 42
3. Criteria ....................................................................................................................................................................................... 42
3.1. Small enterprise support ............................................................................................................................................................. 42
3.2. Material and component procurement ................................................................................................................................. 42
3.3. Construction employment .......................................................................................................................................................... 43
PART L - PRODUCTS AND SERVICES .........................................................................................................44
1. Objective.................................................................................................................................................................................... 44
2. Introduction ............................................................................................................................................................................. 44
2.1. Products and services in health facilities ............................................................................................................................. 44
3. Criteria ....................................................................................................................................................................................... 44
3.1. Local produce ................................................................................................................................................................................... 44
3.2. Vegetarian options ......................................................................................................................................................................... 44
3.3. Drinking water ................................................................................................................................................................................. 45
3.4. Reusable vessels .............................................................................................................................................................................. 45
PART M - ACCESS ..........................................................................................................................................46
1. Objective.................................................................................................................................................................................... 46
2. Introduction ............................................................................................................................................................................. 46
2.1. Access to facilities in health facilities ..................................................................................................................................... 46
3. Criteria ....................................................................................................................................................................................... 46
3.1. Banking ................................................................................................................................................................................................ 46
3.2. Grocery retail .................................................................................................................................................................................... 46
3.3. Communication ................................................................................................................................................................................ 46
3.4. Cafés and canteens ......................................................................................................................................................................... 47
3.5. Childcare ............................................................................................................................................................................................. 47
PART N - HEALTH.............................................................................................................................................48
1. Objective.................................................................................................................................................................................... 48
2. Introduction ............................................................................................................................................................................. 48
3. Criteria ....................................................................................................................................................................................... 48
3.1. External views .................................................................................................................................................................................. 48
3.2. Daylight ............................................................................................................................................................................................... 48
3.3. Ventilation .......................................................................................................................................................................................... 49
3.4. Building materials .......................................................................................................................................................................... 49
3.5. Contractor health and safety ..................................................................................................................................................... 49
3.6. Community health education .................................................................................................................................................... 50
PART O - EDUCATION .....................................................................................................................................51
1. Objective.................................................................................................................................................................................... 51
2. Introduction ............................................................................................................................................................................. 51
3. Criteria ....................................................................................................................................................................................... 51
3.1. Contractor education .................................................................................................................................................................... 51
3.2. Notice boards .................................................................................................................................................................................... 51

3.3. Space for learning ........................................................................................................................................................................... 52
3.4. Employee induction ....................................................................................................................................................................... 52
3.5. Building user manual .................................................................................................................................................................... 52
3.6. Community health education .................................................................................................................................................... 52
PART P - INCLUSION .......................................................................................................................................54
1. Objective.................................................................................................................................................................................... 54
2. Introduction ............................................................................................................................................................................. 54
3. Criteria ....................................................................................................................................................................................... 54
3.1. Environmental access ................................................................................................................................................................... 54
3.2. Accessible transport ...................................................................................................................................................................... 55
3.3. Access to affordable accommodation .................................................................................................................................... 55
PART Q - SOCIAL COHESION .........................................................................................................................56
1. Objective.................................................................................................................................................................................... 56
2. Introduction ............................................................................................................................................................................. 56
3. Criteria ....................................................................................................................................................................................... 56
3.1. Shared used of facilities ............................................................................................................................................................... 56
3.2. Social spaces ...................................................................................................................................................................................... 57
3.3. Stakeholder involvement ............................................................................................................................................................ 57
PART R - REFERENCES ...................................................................................................................................58
PART S - APPENDIX A: SUSTAINABILITY INTEGRATION PLANS .....................................................59

DEFINITIONS
Air-conditioning: A mechanical system installed in a building to control the temperature and humidity of the air by
heating or cooling.
Black water: Waste water with food waste or sewage from toilets.
Construction worker: Employees of construction firms or the main contractor(s) involved in the construction of a
building.
Envelope: The external elements of the building such as the walls, windows and roofs.
Glazing: Windows, glazed doors or other transparent and translucent elements including their frames (such as glass
bricks, glazed doors, etc.) located in the building fabric.
Grey water: The relatively clean waste water from baths, sinks, washing machines, and other kitchen appliances.
Gross floor area: The total floor area of the building protected from the elements but excluding parking.
HVAC: Heating, ventilation and air-conditioning.
Local community: People and organisations that work and live near the building (does not include occupants). Near
the building is defined as being within 4 km of building.
Mixed-mode ventilation: A hybrid solution where natural ventilation systems are assisted by mechanical systems to
achieve improved ventilation and comfort criteria. Complementary and zone-mixed strategies are most commonly
adopted.
Natural ventilation: Ventilation provided by thermal, wind, or diffusion effects through doors windows or other
intentional openings in the building." ASHRAE Standard 62.1-2007, Section 3
Occupants: People who occupy the building on a normal working day.
R-value: Used in the construction industry to denote the measurement of the thermal resistance of a material.
The R-value can be described as the ratio between the temperature difference across an insulator and the heat flux of
that material(𝑅 = ∆𝑇⁄ ̇ ). Alternatively, it is the effectiveness of the material to resist the flow of heat, i.e. the thermal
𝑄𝐴
2
resistance of a component is calculated by dividing its thickness by its thermal conductivity(𝑅 = 𝐾. 𝑚 ⁄𝑊 ).
Shading coefficient: A measure of the solar gain performance of windows. It is the ratio of the solar energy
transmitted and convected by the window to the solar energy transmitted and convected by clear 3 mm glass.
Solar heat gain coefficient (SHGC): A measure of the amount of solar radiation (heat) passing through the entire
window, including the frame. SHGC is expressed as a number between 0 and 1.0. The lower the SHGC the better.
Thermal mass: A term to describe the ability of building materials to store heat.
Thermal resistance: The resistance to heat transfer across a material. Thermal resistance is measured as an R-value.
The higher the R-value the better the ability of the material to resist heat flow.
Useable area: The area of floor in a building capable of occupation. This excludes areas such as toilets, bathrooms,
storage, ducts and vertical circulation.

Ventilation opening: An opening in the external wall, floor or roof of a building designed to allow air movement into
or out of the building by naturally-driven ventilation through a permanent opening, an openable part of a window, a
door or other device which can be held open.
Ventilation: The process of supplying air to or removing air from a space for the purpose of controlling air
contaminant levels, humidity or temperature within the space.”. ASHRAE Standard 62.1-2007, Section 3
Watt (W): A unit for power (P) or the rate at which work is performed.

LIST OF ACRONYMS
BMS: Building Management System
CIDB: Construction Industry Development Board
DEAT: Department of Environmental Affairs and Tourism
EF: Ecological Footprint
FSC: Forest Stewardship Council
GDP: Gross Domestic Product
GWP: Global warming potential
HDI: Human Development Index
HVAC: Heating, ventilation and air-conditioning
IPCC: Intergovernmental Panel on Climate Change
LTMS: Long-term Mitigation Scenario
NEMA: National Environmental Management Act
ODP: Ozone depleting potential
PIR: Passive infrared
PPP: Purchasing power parity
SABS: South African Bureau of Standards
SEA: Sustainable Energy Africa
UNFCCC: United Nations Framework Convention on Climate Change
WC: Water closet
WWF: World Wildlife Fund

Table 1 : IUSS:GNS Reference Documents
CLINICAL SERVICES SUPPORT HEALTHCARE PROCUREMENT &
Recommended
Recommended
Recommended
Recommended
SERVICES ENVIRONMENT/ OPERATION
CROSS-CUTTING ISSUES
Essential
Essential
Essential
Essential
Adult inpatient Administration Generic Room X Integrated X
Services and Related Requirements Infrastructure
Services Planning
Clinical and General Hospital Hospital Design Principles X Briefing Manual X
Specialised Diagnostic Support Services
Laboratory Guidelines
Mental Health Catering Services Building Engineering X Space Guidelines X
for Hospitals Services
Adult Critical Care Laundry and Environment and Cost Guidelines
Linen Sustainability
Department
Emergency Centres Hospital Materials and Finishes X Procurement X
Mortuary
Services
Maternity Care Nursing Future Healthcare Commissioning X
Facilities Education Environments Health Facilities
Institutions
Adult Oncology Health Facility X Healthcare Technology Maintenance
Facilities Residential
Outpatient Facilities Central Sterile Inclusive Environments X Decommissioning X
Service
Department
Paediatrics and Training and Infection Prevention and X Capacity
Neonatal Facilities Resource Centre Control Development
Pharmacy Waste Disposal X Information Technology
and Infrastructure
Primary Healthcare Regulations
Facilities
Diagnostic Radiology
Adult Physical
Rehabilitation
Adult Post-acute
Services
Facilities for Surgical
Procedures
TB Services
Colours Legend
Consultants
Administrators
Related documents

PART A - INTRODUCTION
1. Purpose
These guidelines have been developed to support the integration of sustainability into planning, design and operation
of health facilities. The document defines sustainability and outlines the implications of this for the built environment.
Sustainability objectives and criteria are defined to inform the development of health facilities in South Africa. The
document provides a framework for addressing sustainability in health facilities; greater detail on referenced aspects,
such as equipment and systems, is provided in sister IUSS guides.
2. Background
Global warming and South African legislation and policy make it imperative that built environment projects address
sustainability. However, there is still limited South African guidance on how sustainable development can be integrated
in built environment projects. There is also the perception that addressing sustainability in facilities is expensive and
complicated.
This document provides guidance 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.
3. 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 health facilities. This will lead to more rigorous debate on development options and support
more innovative and sustainable solutions.
• Setting sustainable development targets: The framework can be used by a development team to set explicit
and challenging sustainable development targets for health facility projects. This is done by setting quantified
targets against criteria in the document and putting in place systems to ensure that these are achieved.
• Monitoring and evaluation: This framework can also be used for monitoring and evaluating the performance
of development proposals and the operation of facilities. It enables different health facility development
proposals to be evaluated in relation to targets, enabling optimum solutions to be developed. Performance
targets can also be set, and tracked, from early conceptual design stages of development through to the
operation of the facility. This is supported through sustainability integration plans, which are described later in
this section.
• Coordinated development: Some criteria in the document may appear not to be within the remit of, or even
possible, in a single development. These criteria however can be achieved through partnerships and local
collaboration. This framework can be used to bring together key role players, such as a local municipality and
neighbouring landowners, in order to develop integrated plans which achieve key sustainability objectives.

4. Structure of the guideline
Sustainability is a broad and complex area. Similarly, facilities required for health in South Africa, vary widely in type
and in situation. In order to address this complexity in a readily accessible manner, the guide has been structured in
three main parts, as outlined below.
• Implementing sustainable development: This section provides a description of sustainability and translates
this into specific objectives for the built environment.
• Built environment sustainability objectives: This consists of sections where criteria and guidance is
provided for each of the sustainability objectives listed in the section above.
• Sustainability integration plans: This section outlines plans and processes that can be used to integrate
sustainability into design and operational processes.
The first two sections of the guide provide an introduction to sustainability and guidance on how this should be
integrated in the built environment. The actual integration process occurs through the development and
implementation of sustainability integration plans. Sustainability integration plans form the ‘sustainability contract’ for
driving sustainability performance throughout the life cycle of the building.
Sustainability integration plans are developed by completing the templates at the end of this guide. This is carried out
by following guidance in this document and undertaking further research and analysis of the particular health facility
type and its context. Through this process, responsive challenging targets, which are in line with best practice, should
be developed and captured in the plan. Once agreed, these targets should then guide detailed design, specification,
management and maintenance decisions in the project. Effective monitoring and evaluation and the involvement of
clients and users should be used to ensure targets are achieved.

PART B - INTEGRATING SUSTAINABILITY
1. Introduction
South Africa faces a range of social, economic and environmental challenges. HIV/Aids has resulted in significant
reductions in life expectancy since 1998. Unemployment is estimated to be between 20 and 30% and climate change is
leading to increasing water stress, reduced food security and loss of species and ecosystems (Department of
Environmental Affairs and Tourism, 2009a).
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 the construction
industry, in particular, operate in a highly fragmented way. In addition, the concept of sustainable development is still
not understood and has not been adequately translated into practical steps that can be implemented.
This section defines sustainability and translates this into built environment objectives. It also describes the role of the
built environment in creating environmental and other problems and shows how integrating sustainability
considerations into construction and the built environment can make a substantial contribution to improving the social,
economic and environmental performance of the built environment.
2. The environmental context

Increasing carbon emissions from human activities and a reduction in the ability of the natural environment to absorb
carbon dioxide are leading to an accumulation of greenhouse gases in the atmosphere. These gases trap more heat in
the upper atmosphere, leading to global warming and temperatures are predicted to increase by 2 to 6 °C by the end of
the century (Intergovernmental Panel on Climate Change, 2007). Estimates carried out for the City of Johannesburg
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 8.4 tonnes / capita - higher than Western
European averages of 7.9 tonnes / capita (Sustainable Energy Africa, 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 (Department of
Environmental Affairs and Tourism, 2009b):
• 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% of Africa’s population (about 200 million people)
currently experience high water stress. This is projected to increase to between 75 to 250 million by 2020 and
350 to 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 to 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 to 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.

3. The contribution of the built environment
Construction and the built environment make a substantial contribution to global warming and play a significant role in
most economies. Environmental, social and economic impacts attributed to the built environment at a global scale
include:
• Consumes 40% of energy use,
• Consumes 17% of fresh water use,
• Consumes 25% of wood harvested,
• Consumes 40% of material used,
• Employs 10% of the world’s work force
• Construction is the largest employer of micro-firms (less than 10 people)
• Built environments are typically located on the most productive land (estimated to be 250 million hectares
worldwide), reducing capacity for food production and ecosystem services
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 18 mt CO2 per year, or about 4% of
South Africa’s CO2 emissions, come from the manufacture of building materials (Construction Industry Development
Board, 2009)
Table 2 South African carbon emissions per sector
Sector C02 emissions
Commercial 10%
Residential 13%
Transport 16%
Industry 40%
Mining 11%
Other 10%
Total 100%
4. Carbon emission mitigation strategies

South Africa is a signatory to both the United Nations Framework Convention on Climate Change (UNFCCC) and the
Kyoto Protocol. In order to address UNFCCC commitments, the Long-term Mitigation Scenario (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 (Department of Environmental Affairs and Tourism, 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 strengthened
current energy efficiency and demand-side management initiatives such as environmental fiscal reform and carbon
taxation, which penalises 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 (Department of Environmental Affairs and Tourism, 2009b). 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 localisation of these activities
This guide reflects the requirement for a more radical transformation by detailing defining characteristics and
configurations related to health facilities which, combined with appropriate technology and behaviour, will support
improved sustainability performance. Improving sustainability performance should be informed by a clear
understanding of sustainability.
5. Defining sustainability
The World Wildlife Fund’s definition of sustainability is useful for the built environment as it is quantified and
geographically-based. This defines sustainability as the achievement of an Ecological Footprint (EF) of less than 1.8
global hectares per person and a Human Development Index (HDI) value of above 0.8 (World Wildlife Fund, 2006).
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 absorbs the corresponding waste. These estimates are based on
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, utilisation 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 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 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:
1. A long healthy life, measured by life expectancy at birth
2. Knowledge, measured by the adult literacy rate and combined primary, secondary, and tertiary gross
enrolment ratio
3. A decent standard of living, as measure by the GDP per capital in purchasing power parity (PPP) in terms
of US dollars
Progress towards sustainability at a national level can be understood by ascertaining performance in these two areas in
relation to sustainability targets.

6. South Africa’s Ecological Footprint and Human Development Index
performance
The figures below show that South Africa has an ecological footprint of 2.1, above the maximum 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

1
Ecological Footprint (gha) 2.1 1.8
2
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. Support for this improvement is provided in South African
legislation and policy.
7. The legislative and policy context

South Africa has a range of legislation and policy that aims to protect the environment and support sustainable
development. This emanates from the South African Constitution.
7.1. The 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 religion 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. 3
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:
7.2. Environment
Everyone has the right :
• to an environment that is not harmful to their health or wellbeing; and
• to have the environment protected, for the benefit of present and future generations, through reasonable
legislative and other measures that
• prevent pollution and ecological degradation;
• promote conservation; and
1 http://www.footprintnetwork.org/en/index.php/GFN/page/world_footprint/
2 Human Development Report 2006, United Nations Development Programme
3 Section 9 of the South African Constitution

• secure ecologically sustainable development and use of natural resources while promoting justifiable economic
and social development 4
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.
7.3. Sustainability policy and legislation

Cascading from the Constitution are a range of legislation, policies and strategies to support sustainable development.
This includes The National Development Plan, new building regulations which address energy efficiency, standards for
construction training developed by the Construction Industry Development Board and a standard for local content
developed by the South African Bureau of Standards. Detailed environmental legislation has been developed to protect
the environment such as National Environmental Management Act (NEMA).
Health facilities should comply with this policy and legislation. Compliance and alignment with policy and legislation
designed to support sustainable development will enhance the sustainability performance of the proposed health
infrastructure and help achieve the objectives set out in this guide.
8. Built environment sustainability objectives

The environmental, social and economic context and sustainable development legislation and policy indicate that
sustainability must be addressed in the built environment. It also makes it clear that many of the conventional practices
in the planning, design, construction and management of buildings must be substituted with 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 objectives that together, support sustainable development. These objectives are outlined below.
8.1. 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 minimises emissions and waste directed to landfill
• Materials: The negative impacts of construction materials are minimised
• Biodiversity: The building supports biodiversity
8.2. 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
8.3. Social objectives

The following objectives form the starting point for the next sections of this document where more detailed criteria and
guidance are provided.
4
Section 24 of the South African Constitution

1. Access: The building supports access to facilities
2. Health: The building supports a healthy and productive environment
3. Education: The building supports education
4. Inclusion: The building is inclusive of diversity in population
5. Social cohesion: The building supports social cohesion
8.4. Integrating sustainability objectives into health facilities

Integrating these sustainability objectives into health facilities development and operational processes requires
structured and effective procedures. These are outlined below for the development of facilities (developmental
procedures) and the management of facilities (operational procedures).
Developmental procedures
Addressing sustainability in new health facilities can be achieved through these 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, the funder and the owner
of the building. These targets should be based on a detailed understanding of the required facility and the
context within which it will be developed and will operate. Targets should take into account government
policy and strategies as well as local and international best practice. Targets, along with a monitoring and
evaluation plan, should be captured in a sustainability integration plan. This plan should be used to drive
sustainability performance through the life of the facility.
2. Design principles: Strategies and design principles required to achieve 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, performance improved to ensure that targets
are achieved or surpassed.
5. Detailed design and implementation: It is important to ensure that the principles set out in 2 above, are
carried through in to detail design, otherwise this may affect operational performance. This includes, for
instance, detail design for energy efficiency such as the appropriate location of switches and labels and the
development of instructions and training.
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 to ensure effective management and maintenance of the building.
Operational procedures
Addressing sustainability in existing or newly developed health facilities can be achieved through these steps:
1. Data: Operational performance data on your building should be captured on an ongoing basis. For
example, energy data can be obtained from sub-meters or utility statements.
2. Targets: This data should be analysed and where necessary normalised so that it can be compared to
targets (for example kWh / bed / day). This will indicate whether your facility is below, or above, target
performance. If performance does not meet targets, further investigation should be carried out.

3. Walkthrough assessment: A walkthrough 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 built environment professionals or by health facilities personnel with the relevant training or
experience.
4. Audit: Performance in relation to targets and walkthrough assessments may indicate that a full audit is
warranted. Where this is required, detailed assessments and analysis should be carried out and a detailed
report with recommendations developed. This sustainability audit should provide a prioritised plan of
interventions that can be undertaken to improve performance.
5. Ongoing operational performance: In addition to the above steps an ongoing programming of
performance improvement is required. 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 a competent individual (such as a facilities manager) who is responsible for
operations. The competent person must be provided with appropriate training, resources and incentives
to achieve excellent operational performance. They should also be required to develop monthly
sustainability performance reports and issue these to key role-players, including a nominated senior
manager. Quarterly reviews of performance should be undertaken with key role-players in order to
improve performance on an ongoing basis.
8.5. Sustainability integration plans

Design and operational processes, as described above, are supported through sustainability integration plans which
used define targets for sustainability criterion and monitor their achievement. An example for the sustainability
criterion, energy consumption, is outlined below.
Development procedures
As part of the project briefing and concept design stages, the design team should draw on this guide and related best
practice to define targets against sustainability criteria listed in this guide. Where necessary, these criteria can be added
to, but should not be substantially reduced.
Targets would be defined and agreed for the different stages (Concept Design, Detailed Design, Handover and
Operation). Methodologies and documentation used to confirm the achievement of targets listed should also be defined
and agreed in the ‘Confirmation’ row.
Design Stage Reports developed by design professions for the client should include the Sustainability Integration Plans
with required confirmation documentation attached. Sustainability Integration Plans and related documentation can
then be reviewed by the client (with an appropriately qualified technical person acting as client adviser, if required)
and either accepted and rejected.
If accepted, the client would then sign and date the relevant sections of the plan and the development process would
then proceed. If rejected, the design team would then be obliged to undertake required actions, such as a redesign, to
ensure targets are met. On completion of this action, the Sustainability Integration Plan should be resubmitted to
ensure there is approval before the development processes proceeds. A section of Sustainability Integration Plan
development processes is illustrated in the table below.
Criteria Requirements Concept Design Detailed Design Handover Operation
Energy Target 10 kWh / bed / day 10 kWh / bed / day 10 kWh / bed / day 10 kWh / bed / day
consumption Confirmation Engineer’s Engineer’s Two months of Four months of
calculations / calculations / utility metered utility metered
modelling modelling readings readings
Acceptance Signature: Signature: Signature: Signature:
Date: Date: Date: Date:

Operational procedures
At handover, and during operation of the health facility, facilities management should draw on this guide and related
best practice in order to define targets against sustainability criteria listed in this guide. Where necessary, these criteria
can be added to, but should not be substantially reduced.
Targets should be defined and agreed for the different quarters (Q1, Q2, Q3, Q4) of a year. The methodology or
documentation for confirming the achievement of targets should also be defined and agreed for these quarters in the
‘Confirmation’ row. On a quarterly basis, facilities management should submit completed Sustainability Integration
Plans with required confirmation documentation. This should be reviewed by key role-players, including a nominated
senior manager. These reviews determine whether performance has achieved targets.
Where achieved, the plan can be accepted and signed by the senior manager. Where targets are not achieved, actions to
remedy these should be determined and allocated. Once agreed, the role-players allocated actions should then co-sign
the plan to ensure actions are carried out. This is illustrated in the table below.
Criteria Requirements Q1 Q2 Q3 Q4
Energy Target 10 kWh / bed / day 9.8 kWh / bed / day 9.6 kWh / bed / day 9.4 kWh / bed / day
consumption Confirmation Four months of Four months of Four months of Four months of
utility metered utility metered utility metered utility metered
readings readings readings readings
Acceptance Signatures: Signatures: Signatures: Signatures:

PART C - ENERGY
1. Objective
The building is energy efficient and uses renewable energy.
2. Introduction
Energy is used in health facilities to operate equipment, heat water, and to ensure that required lighting, ventilation and
thermal comfort standards are met. In most existing South African buildings, it is estimated that savings of up to 30% of
energy consumption can be achieved at little, or no, cost. In new facilities, where passive strategies, energy-efficient
equipment and renewable energy systems have been used, energy consumption can be 50% lower than in existing
older facilities.
Ensuring that health facilities are more energy efficient and use renewable energy has a wide range of benefits,
including:
1. Reduced carbon emissions and therefore global warming impacts
2. Reduced impact of mains power outages
3. Reduced negative health impacts associated with pollution from coal-fired power stations
4. Reduced operational costs
5. Improved internal environments as a result of better day lighting and natural ventilation
3. Criteria
Highly energy efficient facilities are developed by optimising and integrating solutions that respond closely to the local
site, the local climate and required internal functions. It is therefore difficult to prescribe a set of criteria for all
situations. However the following measures can be used to ensure energy considerations have been addressed.
4. 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 for energy. This can be achieved through these steps.
1. Challenging targets should be set for energy consumption, energy demand and renewable energy.
Challenging targets can be established through reference to standards and best practice.
2. Effective procedures must be established to calculate / model and test performance throughout the design
process. These procedures must ensure that where targets are not being met, design and management
options should be reconsidered to ensure that optimum solutions that will deliver target performance are
pursued.
3. Monitoring and evaluation systems should ensure that effective checks are in place at strategic points in
the design process to ensure targets are achieved. Confirmation of performance and that targets are being
achieved should be incorporated in formal stage design reports submitted to the client, who should then
formally accept, or not accept these. A format for this process is proposed with the Sustainability
Integration Plans described in the introduction.
4. Processes should be in place to ensure that ‘designed’ performance is achieved in operation through
having the right capacity and systems in place within the building. This includes appropriate staffing,

training, manuals, commissioning and monitoring processes to ensure that design targets are achieved in
operation.
4.1. Orientation
Orienting facilities so that the long facades face north – south helps to reduce unwanted heat gains from low angle
sunlight in the early to mid-morning and mid- to late in the 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. Minimising
energy consumption through orientation can be achieved through the following steps:
1. Long facades of facilities should be orientated to face within 15 degrees of a north – south orientation.
2. Glazing on west and east facades should be minimised. Where this exists this should be appropriately
shaded. Using trees or planting to create this shading is a low cost, easy option in many situations.
4.2. 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. Minimising energy
consumption through building shape can be achieved through these steps:
1. An analysis of the site and climate should be carried out. This should be used as key input of proposed
design, and the building should respond to local climate and topography.
2. Proposed building shape and form should be analysed to ensure that this supports optimal performance in
terms of reduced energy consumption and comfortable internal and external spaces.
4.3. Building depth

Limiting building depth enables internal space to be day-lit and naturally ventilated. This ensures that internal spaces
do not need artificial lighting or mechanical ventilation for much of the day, reducing energy consumption. Minimising
energy consumption through building depth can be achieved through these steps:
1. Building depths should not exceed 16 m.
2. Internal layouts should support effective day-lighting and natural ventilation. Care should be taken that
internal walls, furniture and equipment do not inadvertently reduce daylighting and ventilation
performance.
4.4. Insulation
Insulation, especially when combined with thermal mass, can be used to maintain comfortable indoor conditions
without significant use of mechanical equipment. Insulation ensures 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. Minimising energy consumption through insulation can be achieved through these
steps:
1. The building envelope U-values should achieve or surpass minimum values outlined in SANS 204 (South
African Bureau of Standards, 2007).
2. Analysis of the building envelope should be undertaken to identify areas with particularly high heat flows.
For instance, this may occur on an exposed west façade. Where this occurs, additional insulation and/or
shading measures may be appropriate to reduce flows in these areas.

3. Surface colours also affect heat flows. Therefore, light-coloured materials should be used in building
envelopes to reduce heat gain from the sun. This is particular important for roofs.
4.5. 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 element. It is therefore important to design glazing to enable light and heat flow to be controlled.
Minimising energy consumption through solar shading and glazing can be achieved through these steps:
1. The glazing-to-wall ratio should be compliant with SANS 204 (South African Bureau of Standards, 2007).
2. Solar shading design should comply with SANS 204 (South African Bureau of Standards, 2007).
3. Glazing specified should have appropriate U-values, visual transmittance and solar heat gain coefficients
for the local climate and internal functions.
4.6. 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. Minimising energy consumption through openings
can be achieved through these steps:
1. Determine the type of passive environmental control and natural ventilation that will be implemented
within the building.
2. Ascertain optimum locations for openings in relation to the types of passive environmental control and
natural ventilation selected. For example, where cross ventilation is used for cooling, moving air should be
directed around people, therefore locations of opening should take into account the normal working
positions of people (i.e. seated or standing). Similarly, where night-time cooling is used, moving air should
be directed over thermal mass to cool this at night and therefore openings should be located to support
this.
3. Opening area locations and size should be compliant with SANS 10400.
4. Security, insects and control design (including ensuring controls can be used by people with disabilities)
should be considered in the detailed design of openings.
4.7. Air tightness

Uncontrolled infiltration and airflow through the building envelope can affect comfort and increase heating and cooling
loads in the building. Minimising energy consumption through air tightness can be achieved through these steps:
1. Careful detailing and specification should be carried out to minimise infiltration in the building. In
particular, detailing of window and door jambs, joints within facades and junctions between walls and
roofs should be appropriately developed to reduce unintended air flow.
2. A plan for rigorous construction supervision should be been put in place to ensure that building envelopes
are constructed in accordance with designs, and are of a suitable level of quality, to reduce infiltration.
4.8. Mechanical systems

Where possible, mechanical cooling, heating and ventilation should be avoided. If this is not possible, a mixed-mode
operation should be selected. A mixed-mode operation uses mechanical system when ambient and internal conditions
require this, but otherwise rely on passive systems to maintain thermal comfort and meet ventilation rate
requirements. Minimising energy consumption related to mechanical systems can be achieved through these steps:

1. Designing the building, or most of the spaces in the building, to be passively cooled, heated and ventilated
and thereby avoiding the requirement for mechanical systems.
2. Where spaces exist within a facility that are not tolerant of passive ventilation, adopting a mixed-mode
ventilation strategy.
3. Undertaking a detailed analysis of the local climate and building functions in order to identify the most
efficient mechanical systems.
4. Where mechanical systems have been used, including features that help reduce energy consumption such
as:
a. An economy cycle
b. Occupancy sensors
c. Controls that enable easy adjustment of systems in order to benefit from seasonal and occupancy
changes
4.9. Equipment
As equipment used in buildings 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. Minimising energy consumption by equipment can be achieved through these steps:
1. Selecting energy-efficient equipment. Power requirements, smart controls and equipment energy
efficiency ratings, such as Energystar, should be key considerations in the selection of equipment.
2. Ensuring that the equipment, or the local electrical circuits, have controls which ensure that equipment is
off when not required.
4.10. Internal lighting

Ensuring adequate lighting levels is key consideration in many spaces within health building and this should be
achieved in an energy-efficient way. Lighting is rapidly changing and increasingly efficient lamps and sophisticated
controls are being developed. Minimising energy consumption by internal lighting can be achieved through these
steps:
Carrying out a rigorous evaluation of lighting in order to establish optimum solutions in terms of energy efficiency,
human health and environmental considerations.
1. Applying criteria such as lumens per watt and lighting power density to establish the most energy-efficient
lamps and lighting layouts.
2. Designing appropriately-sized lighting switching zones (i.e. under 100 m2) to avoid lighting being on when
not required.
3. Specifying motion sensors in areas such as store rooms and meeting rooms to ensure lighting is off when
not required.
4. Optimising daylight within the building.
5. Using daylight sensors to switch off, or dim, lighting in areas where these is adequate daylight. Areas with
good daylight are usually found within a zone of about 6 m from external windows.
6. Lighting requirements are also listed in the IUSS guide Building Engineering Services.
4.11. 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 and be switched off when not required.
Minimising energy consumption in external lighting can be achieved through these steps.

1. Specifying external lighting only for areas that specifically require lighting, for instance for safety and
security reasons.
2. Locating external lighting as close to areas where it is required, in order to avoid losses and light pollution.
3. Including photo sensors, motion sensors and/or timers to ensure that lighting is only on when required.
4.12. Building Management System

A Building Management System (BMS) should be used in large buildings with complex equipment and systems. A BMS
enables different systems to be integrated and controlled to support energy efficiency. Minimising energy consumption
through a BMS can be achieved through these steps:
1. Specifying a BMS which coordinates different building systems to support energy efficiency.
2. Ensuring that the BMS is easy to use and understand and can be effectively operated by health facility staff.
3. Ensuring that there is appropriate training and support for the BMS proposed.
4. Specifying a BMS with features such as:
a. Easy access to equipment schedules so that these can easily be changed to suit occupancy patterns.
b. Reminders to ensure that BMS operators 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.
4.13. 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 for different uses in the facility. Sub-meters also show when and how energy is used
through profiles which show consumption and demand over time. Minimising energy consumption through sub-
metering can be achieved through these steps:
1. Designing an energy sub-metering system that will monitor all of the main energy uses in the facility. In
particular, the design of this system should be based on who can influence and control energy consumption
in a particular area. Thus, instead of all the lighting of an entire site being on a meter, it may be more
appropriate to sub-meter lighting for a specific building, where nominated personnel can be responsible
for ensuring that lighting is off, when not required.
2. Providing energy management data in formats and reports that can be easily understood and analysed to
support improved energy management.
3. Ensuring that energy management reports are issued to all key role players including facilities managers
and senior managers. Linking reporting to quarterly reviews which aim to improve energy efficiency over
time.
4. Any outsourced function, such as a restaurant or sports facility, should be sub-metered and invoiced for
consumption.
4.14. Renewable energy

Increasingly, onsite generated renewable energy is becoming a competitive alterative to mains power. It also has the
advantage that it increases energy autonomy, allowing facilities to operate even when there are mains power cuts.
Minimising energy consumption through renewable energy can be achieved through these steps:
1. Set renewable energy targets. In small rural clinic without electrification, targets may be 100%, this would
mean that all of the energy in the facility is sourced from renewable energy. In large facilities linked to
mains power, targets are likely to be lower. This is because the costs of renewable energy systems are still
relatively high and supply can be variable. However, the costs of renewable energy have dropped rapidly

and it is becoming increasingly viable to include this in planning of facilities in South Africa. A viable
approach is to establish a lower target for renewable energy (for instance 5 to15% of the energy consumed
in the facility) initially and plan to increase this over time as costs of renewable energy decrease.
2. Specifying solar water heaters to heat water in the facility. Heating from the sun is considered a renewable
energy and should be included when calculating renewable energy targets and performance.
3. In areas with reliable sunlight photovoltaic systems to generate renewable energy should be investigated.
In particular, this may be appropriate for external lighting where cabling costs may be avoided.
4. In areas with high quality reliable wind wind turbines should be investigated.
5. Other renewable energy systems such as biodigestors should also be investigated.
6. It may be possible to substitute standby generators with renewable energy systems that not only provide a
back-up capability, but also provide an ongoing supply of free renewable energy.
4.15. Energy targets

Data on energy consumption and demand in South African health facilities is not readily available. However, the
following table provides a number of targets that can be used to evaluate performance. It should be noted that more
challenging targets should be set and achieved over time, as better management and more efficient technology increase
performance.
Facility type Targets (Kwh / bed / day)
TB 10
Psychiatric 15
District 10
Regional 20
Tertiary 70

PART D - WATER
1. Objective
The building minimises the consumption of mains potable water.
2. Introduction
Water is used in health facilities for cleaning equipment, utensils and facilities as well as for laundry, irrigation, food
preparation, cooling and drinking. In most existing South African health facilities it is possible to reduce mains potable
water consumption at little, or no, cost. In new facilities, where water-efficient technologies, grey water and rainwater
systems have been used, water consumption can be over 50% lower than in older, less efficient facilities.
1. Ensuring that health facilities are more water efficient has a wide range of benefits including:
2. Reduced water consumption and associated negative environmental impacts
3. Reduced impact of water shortages or outages
4. Reduced operational costs
3. Criteria
The consumption of potable water in health facilities can be addressed in a range of ways, with the applicability of each
measure dependent on local circumstances and the functional requirements of the health facility. However, the
followings standard criteria can be used to ensure water efficiency is addressed.
3.1. Hand basin taps

Controlling and reducing water flows in hand basin taps decreases water consumption. Minimising water consumption
in hand basin taps can be achieved through these steps:
1. Specifying hand basin taps which have flow rates that do not exceed 6 ℓ / minute.
2. Including passive infrared (PIRs) or push-button controls to limit the duration of flows.
3.2. Toilets
Reducing WC flush rates in waterborne sanitation can be used to reduce water consumption. This can be supported by
the following measures:
1. Specifying WCs with flush rates that do not exceed 6 ℓ / flush.
2. Requiring all WCs to have dual flush controls which enable reduced flush rates when full flushes are not
required.
3. Ensuring that users, through instructions, are aware of the purpose of dual flush controls.
3.3. Showerheads
Showers should be specified in preference to baths as they are more water efficient. Controlling and reducing water
flows in showers can be used to reduce water consumption. The following measures can be considered in shower
design to increase water efficiency:
1. Shower head flow rates should be specified not to exceed 10 ℓ / minute.

2. Push-button type controls may be used to limit the duration of flows.
3.4. Irrigation
Minimising irrigation water requirements can be used to reduce water consumption. The following measures can be
drawn on to increase water efficiency:
1. Planting locally indigenous species (species found in the local area) to avoid, or minimise, irrigation
requirements.
2. Where irrigation is required, specifying highly-efficient water delivery systems, such as a drip irrigation,
linked to soil moisture probes.
3. Using grey water and/or rain water to avoid use of mains potable water for irrigation.
3.5. Greywater systems

Greywater systems reduce mains potable water consumption by reusing lower quality water within the facility.
Greywater includes waste water from showers and hand basins and can include waste water from laundries and HVAC
systems.
Greywater systems are potentially hazardous to human health particularly in health facility environments. In particular,
greywater 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, greywater systems should only be designed,
implemented and operated by appropriately competent people. Potential greywater applications in health facility
environments include:
• Waste water from hand basins and showers can be directed to a greywater system and then used to flush
toilets or for landscape irrigation.
• Waste water from vehicle washes can be reused to wash vehicles up to three or four times before being
disposed of.
• 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 greywater specialists.
The following considerations in relation to greywater systems should be made:
1. Significant quantities of greywater can be sourced from showers and hand basins. However, it may not be
worth capturing water from all individual, or small groups of fittings particularly if these are widely
dispersed.
2. Greywater pipes and usage points should be appropriately labelled to prevent unsafe consumption.
3. The greywater system specified should be easy and cost effective to maintain.
4. Potential health hazards associated with the system should be eliminated as far as possible.
3.6. Rainwater harvesting systems

Rain harvesting water systems capture and store rainwater from roofs or hard landscape surfaces. This water is then
available for irrigation, to flush toilets or for other uses. In large facilities very substantial amounts of water can be
captured and used. 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 runoff 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 the ground surface.
• Hard surface rainwater: This system captures stormwater runoff 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 subsurface.

• Landscape surface runoff capture: Surface runoff 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 may therefore be more stringent.
The following considerations in relation to rainwater systems should be made:
1. All sources of rainwater should be considered, including water from large hard surfaces such as external
paving as well as roofs.
2. Where surfaces are clean and free from debris, it may be possible to use rainwater, without filtration or
treatment, for irrigation or to flush toilets.
3. Rainwater can also be directed to pervious surfaces such as permeable paving, grass and swales or to
retention ponds to ensure that stormwater flows are managed and flooding is avoiding. These systems
also allow for reducing irrigation requirements (see below).
3.7. Stormwater systems

Stormwater systems capture runoff from sites and direct this to municipal or other stormwater systems. Stormwater
runoff can be reduced through retention ponds, swales, soft landscaping and permeable surfaces. This supports
sustainability by reducing the requirement for irrigation and large-scale municipal stormwater infrastructure. The
following are examples of sustainable stormwater management measures:
• Retention ponds: Stormwater can be directed to retention ponds which store and manage stormwater flows
from site. Retention ponds can be attractive landscape features and used for rainwater harvesting. However,
care should be taken to ensure that sufficient capacity is always available to accommodate peak stormwater
flows and that access is controlled to prevent ponds from becoming a drowning hazard.
• Swales and soft landscaping: Runoff can be directed to and through swales and soft landscaping on site to
maximise the percolation of water into the soil. This can be used as part of landscaping strategy and reduces
irrigation requirements.
• Permeable surfaces: Avoiding hard surfaces and increasing permeable surfaces can be used to increase the
extent to which runoff is absorbed on site. Where there are hard surfaces, such as roads, absorbent edges
instead of kerbs, can be used to reduce stormwater runoff.
The following considerations in relation to rainwater systems should be made:
1. Local municipal requirements for retention ponds should be investigated. If retention ponds are not
required, investigations should be carried out to check whether predicted peak flows from site justify the
development of retention ponds. Retention ponds can be used as part of a landscaping and or rainwater
harvesting strategy.
2. Stormwater flows can also be directed through swales and soft landscaping to reduce flows and increase
onsite absorption of runoff.
3. The extent of hard surfaces should be minimised on site. Where this cannot be avoided, permeable hard
surfaces should be specified to allow water to percolate through surfaces and replenish groundwater.

3.8. Water consumption targets
Data on water consumption in South African health facilities is not readily available. However, the following table
provides targets that performance can be evaluated against. It should be noted that more challenging targets should be
set, and achieved over time, as better management and more efficient technologies increase performance.
Facility type Targets (ℓ / bed / day)
TB 120
Psychiatric 280
District 200
Regional 100
Tertiary 560

PART E - WASTE
1. Objective
The building minimises waste directed to landfill.
2. Introduction
Waste in South African health facilities is largely directed to landfill sites. Not only does this use up valuable land, but
this can also lead to air, soil and water pollution if 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 reduce energy
and resource consumption and creates jobs and income.
1. Ensuring that health facilities minimise waste and reuse and recycle waste products have the following
benefits:
2. Reduced loss of land to landfill
3. Reduced energy and resource consumption
4. Job and small enterprise creation
3. Criteria
Waste 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 facility. However, there are a range of considerations
which can be used to address waste in facilities. These are outlined below.
3.1. Provision for recycling

Recycling can be encouraged by developing provision that makes this easy to undertake. Provision includes easy-to-use
receptacles for different types of waste at the point at which waste is generated. It also includes providing space in the
right locations so that waste can be easily collected and stored. Effective recycling can be supported through these
steps.
1. Appropriate waste receptacles should be located at the source of waste to ensure waste is not ‘spoilt’ and
reduced in value by being mixed with other waste. For instance, clean waste paper can be spoilt if mixed
with food waste.
2. Adequate recycling storage space should be provided in an appropriate location. This storage space should
be protected from weather to ensure that recycling material is not spoilt. It should also be large enough for
waste material to be sufficiently stockpiled to make collection and transportation financially viable.
Recycling storage spaces should be located near public highways so that these can be easily accessed by
recycling contractors.
3. Potential waste streams for recycling should not include medical or hazardous waste which should be
disposed of in accordance with regulation and best practice standards.
4. More detailed guidance on waste management in health facilities is provided in IUSS Infrastructure Design
for Waste Management guides.
3.2. 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. This can be supported through these steps:

5. Identify all potential recycling waste streams. This should include paper, cardboard, tin, glass, plastic,
timber, electrical appliances and so on. Potential waste streams for recycling should not include medical or
hazardous waste which should be disposed of in accordance with regulation and best practice standards.
6. Identify appropriate associations and local recyclers related to each of these waste streams and engage
with them with a view to ensuring that appropriate provision and systems are put in place to maximise
recycling. Develop agreements with recyclers which detail how and when recycling will take place. Ensure
that provision for recycling is aligned to agreements and requirements.
3.3. Engagement with suppliers

Engaging with suppliers can be used to reduce waste and transportation impacts. Waste and transportation impacts
can be reduced by minimising packaging, use of reusable containers and optimised logistic supply chains. This can be
supported in the following ways:
1. Identify all major suppliers of goods to the health facilities. Engage with these suppliers on transportation
and packaging with a view to minimising impacts in these areas.
2. Carry out investigations to ascertain whether packaging waste and transport impacts can be reduced
through increased use of reusable vessels and additional onsite storage capacity for goods. Capture and
confirm agreements to reduce and recycle waste with suppliers in writing and ensure both parties have
copies of this.
3.4. Construction waste

Construction is a major source of landfill waste. Waste from construction can be reduced through planning and
monitoring processes. The following steps can be used to reduce construction waste.
1. Construction waste minimisation and recycling should be included as a specific requirement within tender
and contract documents.
2. The contractor should be asked to develop a construction waste management plan in order to minimise
waste. This plan should include specific construction waste management targets. For example, this could
require that 50% of all waste generated on site must be recycled. The plan should identify parties
responsible for implementing the plan and ensure that appropriate monitoring and evaluation systems are
in place for targets to be achieved.

PART F - MATERIALS
1. Objective
The negative impacts of construction materials are minimised.
2. 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 vary widely depending on the material. The selection of materials and products to be used in facilities is
therefore important in reducing negative environmental impacts.
• Careful selection of construction materials used in health facilities can lead to 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
3. Material use in health facilities

Most materials used in construction are 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 screen materials in
order to select, and specify materials and components, which have the least negative impacts on human health and the
environment.
4. Criteria
Material and component selection in health facilities can be informed by developing material and product selection
criteria and using this as a basis for specification and design. It can also be shared with suppliers in order to elicit
confirmation of impacts for different types of product. The nature of these criteria will depend on local circumstances
and the respective requirements of the health facility. However, a series of steps can be used to check that key material
and component considerations have been addressed. These are outlined below.
4.1. Building reuse

Using existing facilities instead of building new, reduces the requirement for construction materials and therefore the
impacts associated with extraction, manufacture and transportation can be avoided. 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 improves its efficiency and avoids the requirement to replicate services elsewhere.
Therefore, in most circumstances it is preferable to reuse and refurbish existing facilities rather than build new
facilities.
This can be supported by identifying existing facilities that can be used, or continue to be used. If necessary, refurbish
and/or expand these rather than building a new facility.

4.2. 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 refrigerants can contribute directly to global warming if they are released or leak into the atmosphere. The
following steps can be taken to reduce global warming impacts associated with building materials and products.
1. As far as possible, specify construction materials with low embodied energy such as timber. Specifying
locally-manufactured or sourced materials rather than imported materials and products can reduce
impacts related to transportation. Where high-embodied energy materials such as cement and aluminium
must be used, the quantities of these materials should be minimised.
2. Avoid the use of refrigerants. Where these must be used, for instance in HVAC systems, cold rooms or in
fire-suppression systems, select refrigerants which have no, or low, global warming potential (GWP) and
ozone depleting potential (ODP) impacts.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. It is therefore preferable to reuse materials that may have already been used in another
building or to select materials with recycled content. This can be supported through the following steps.
1. Where possible, materials from other buildings that are being demolished should be reused. Aspects that
can be reused include structural 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. Materials with recycled content should be selected in preference to materials without any recycled content.
Recycled content should be confirmed in writing by suppliers and manufacturers. Steel, for example, can
be specified to include recycled content.
4.3. 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. Reduced material use can be supported through the
following measures.
1. Avoiding material use can be supported in a range of ways. For instance, ceilings and plastering can be
avoided through better concrete finishes. Improved floor finishes can be used to avoid the requirement for
carpets and tiling. The use of passive systems can be used to reduce the requirement for ducting and
plants associated with mechanical ventilation, heating and cooling.
2. More intelligent use of materials can enable overall quantities of materials used to be reduced. For
instance, structural strategies such as pre-tensioning concrete slabs and the use of waffle slabs should be
used to reduce concrete requirements. The use of precast concrete elements also can lead to reduced waste
compared to conventional construction.
3. Dual use of materials and products can enable reduced material use. For instance, photovoltaic panels may
be used both as a roofing material and to generate energy.
4.4. Sustainable sources

Materials can be defined in terms of whether they are from sustainable or non-sustainable sources. Materials from
sustainable sources include timber, thatch, cork, and wool that are farmed on a sustainable basis and therefore can be
harvested in an ongoing manner. Other materials such as plastics and metals are mined and therefore once these
sources are depleted, will not be available. Sourcing materials from sustainable sources can be supported through the
following measures.

1. Where possible, materials from sustainable sources should be specified. For example, timber, and plant-
based products can be used in many applications in preference to materials that have to be mined and
processed.
2. Materials from sustainable sources means that these are grown and harvested in a sustainable manner.
This can be established through written confirmation from suppliers and independent certification. For
instance, a Forest Stewardship Council (FSC) certificate can be used to establish whether timber is from a
sustainable source.

PART G - BIODIVERSITY
1. Objective
The building supports biodiversity.
2. Introduction
Biodiversity plays a very important role for man through provision of 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 natural amenities such as gardens which support recuperation
• Providing a source of fresh healthy fruit and vegetables
2.1. 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 greenfield sites and building outside
municipal boundaries. Health facility sites can support biodiversity through considered site planning and landscaping
strategies.
3. 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 number of criteria can be used
to check that key biodiversity considerations have been addressed. These are outlined below.
3.1. Site location

Biodiversity is being lost at a rapid rate through urban sprawl. Preserving existing biodiversity can therefore be
achieved by avoiding greenfield site and building only within urban boundaries. Support for biodiversity through site
selection can be achieved through the following steps.
1. Health facilities should be built on brownfield (already built-on) sites in preference to green field sites.
2. Facilities should be located within urban boundaries in order to avoid using land that is, or could be, used
for agriculture or for biodiversity and ecosystem services.
3. Sites with low ecological value should be built on in preference to sites with high ecological value. Where
sites with high ecological value are used, designs should ensure that this is preserved, and enhanced.
3.2. Design for biodiversity

Biodiversity can be supported through site layouts and landscaping that retain existing biodiversity and enhance this.
Biodiversity can be supported through the following design considerations.
1. In sites of high ecological value, surveys should be carried out to ensure that development is based on a
understanding of existing biodiversity and ensures that this is enhanced.

2. Where there are nature links and wildlife corridors between sites, planning should ensure that these are
preserved and enhanced to support biodiversity.

PART H - TRANSPORT
1. Objective
The building supports energy efficient transportation.
2. 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
2.1. Transportation in health facilities

Transportation is important in health facilities as large numbers of people and goods need access to these facilities
every day. This includes health facilities staff that commute to work and health facilities users who need to visit the
facility for treatment. The right location and provision of transport-related facilities help to ensure that negative
transport impacts are minimised and potential health benefits associated with exercise are supported.
3. Criteria
Transportation impacts related to 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 facility. However a series of
steps can be used to ensure that transportation considerations in relation to sustainability have been addressed. These
are outlined below.
3.1. 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. Support for energy-efficient transport through access to public transport can
be achieved in the following ways.
1. Health facilities should be located near good public transport nodes, including bus, train and bus rapid
transport systems. Walking distances between public transport nodes and the health facility should not
exceed 1 km, and ideally, be less than 400 m.
2. Safe, direct and easy-to-use routes between public transport nodes and key locations within the health
facility should be developed. Route design and management should be in line with best practice standards,
particularly in relation to disabled access and environmental safety.
3.2. Provision for walking

Walking can be encouraged through safe, direct and easy-to-use routes. The following steps can be used create
provision for walking.
1. Safe, direct pedestrian routes to health facilities sites from neighbouring areas and public transport nodes
should be provided.

2. Safe, direct pedestrian routes around health facilities site should be provided.
3. Safe pedestrian provision includes safe road crossings such as bridges, underpasses and zebra crossings. It
also includes appropriate finishes, visual supervision by surrounding facilities, lighting and provision in
line with best practice for people with disabilities and environmental safety.
3.3. Provision for non-motorised transport

Provision for cycling, such as safe parking areas and designated, safe routes encourage cycling as an alternative to the
use of motorised vehicles. As well as environmental benefits, cycling has health and productivity benefits. Cycling can
be supported through the following provision.
1. Secure cycle storage should be provided undercover near main building entrances and staff common areas.
Sufficient showers and lockers should be provided for staff who cycle. International norms indicates that
cycle parking provision should be between 10 and 25 spaces per 100 beds in hospitals.
2. The use of cargo bikes or hand-pushed trolleys should be considered for moving goods around large sites
in preference to using motorised vehicles. This can be supported by providing routes that are appropriate
designed and managed. This includes ensuring that the width of routes, changes in levels, surfaces, lighting
levels and signage are in line with best practice.
3. Safe provision for cycling routes around the site should be provided including ensuring that crossing
points, lighting, signage and surface finishes are in line with best practice.

PART I - RESOURCE USE
1. Objective
The building makes efficient use of resources.
2. Introduction
There are limited resources in the form of land, finance and raw materials to construct and maintain building. It is
therefore important to use resources 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
2.1. Resource use in health facilities

Health facilities use financial resources for 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 for
resources to be available for other uses.
3. Criteria
Resources 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 facility; however, a series of steps can be used to
check that key resource considerations have been addressed. These are outlined below.
3.1. Strategic planning

Detailed long-term strategic plans for health facilities should be developed that take into account future development.
These should ensure that expansion or changes that are envisaged can be accommodated. However, care should also be
taken that unnecessarily large areas are not allocated for health facilities to avoid land being unused. Strategic planning
can be used to support efficient resource use through the following measures.
1. A long-term strategic site plan should be developed for the health facility that addresses changes that may
occur in the future, such as expansion or contraction. This helps ensure that change can be accommodated
and that facilities can be designed to become more effective and efficient over time, instead of being
developed in an ad hoc way that can lead to inefficiency and wastage.
2. The potential for sharing services and facilities with neighbouring landowners and sites should be
investigated. For instance, total parking requirements can be reduced where this is shared between two or
more facilities, particularly where operational schedules differ. Similarly, stormwater, sewage, recycling
and renewable energy systems can become more viable when costs are shared between a number of users.
3.2. Occupancy density

Robust sustainable facilities accommodate change through flexible and adaptable allocation and configuration of space.
Over-provision of space should be avoided, as excess space has to be serviced and maintained, even if not used. Health
facilities should therefore be designed to accommodate change and support spatial efficiency and effective use. This can
be supported through the following measures.

1. Overall space allowance in the health facility should be in line or below health facilities norms, for instance,
in terms of gross area per bed. Best practice guidance on space use can be found in respective IUSS
guidelines and international standards.
2. Proportions of space use in the health facility should be in line with good practice health facilities design.
For instance, space allocated for circulation, support and ancillary services as a proportion of the total area
should be in line with best practice norms.
3.3. Food production

Food production in the form of orchards or vegetable gardens are a productive use of 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. Resulting fresh produce can be used to supplement diets of users of
the health facility and in the local community, supporting improved health. Food production on site can be supported
through the following measures.
1. Vacant land within the health facility sites should be developed for local food production. Care should be
taken that inappropriate sites are avoided. In particular, sites with potential health hazards related to
waste, pollution and sewage should be avoided.
2. Appropriate provision in the form of irrigation, fencing, organisational and capacity requirements should
be established to ensure that food production is effective and sustained. The cost of irrigation systems and
water can be reduced by linking gardens to rainwater harvesting, stormwater management and greywater
systems (see Water).
3. Food gardens can be used to provide healthy fresh food to the health facility and local community and be
used as a health and educational resource (see Health and Education).

PART J - MANAGEMENT
1. Objective
The building is managed to support sustainability.
2. 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 healthcare 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 healthcare as result of maintenance and repairs
• Ensuring that maintenance is planned for, and effectively carried out
2.1. 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.
3. Criteria
Building management 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 number of measures
can be used to ensure that building management supports sustainability. These are described below.
3.1. Energy and water sub-metering

Energy and water submetering enables facilities managers to manage the consumption of energy and water in health
facilities and reduce costs associated with these services. Energy and water sub-metering can be supported through the
following measures.
1. Energy submetering should be installed to ensure energy consumption in areas with substantial loads is
monitored. Energy metering systems should support assessment of energy consumption trends, profiles
and enable comparison with benchmarks and targets. In large facilities this capability may be provided in a
Building Management System (BMS). In smaller facilities, metering can be provided through sub-meters
and online metering systems. In very small facilities, monitoring can be supported through manual reading
and recording energy and water consumption. In these cases it is important that meters are readily
accessible and can be read easily.
2. Water submetering should be installed which enables water consumption in all areas with substantial
consumption to be measured and monitored. Water sub-metering technology can also include water leak
detection and this should be specified for large water installations.
3. Water and energy consumption should be monitored and reported monthly. Reports should be circulated
to key role-players, including facilities managers and nominated senior managers . Quarterly reviews
should be held to ensure performance is improved over time.

3.2. Facilities management manual
A facilities management manual provides technical detail on all aspects of the building and how maintenance and
management should be carried out. A facilities management manual can be developed through the following steps.
1. A detailed facilities management manual should be developed for health facilities. This should include a
detailed schedule for building maintenance and equipment checks on lighting, plumbing , HVAC systems
and medical and other equipment.
2. The facilities management manual should include, and refer to, a full set of as-built drawings and
equipment manuals. Both hard copies and electronic copies (.pdf and editable) of as-built drawings and
manuals should be provided.
3. A register of critical equipment and systems should be in place to ensure equipment is inspected, tested
and maintained as required.
4. Facilities managers in the building should have a full induction on the building’s systems and the facilities
management manual.
5. The facilities management manual should be regularly reviewed and updated to reflect changes as a result
of upgrades and renovations.
3.3. Senior management commitment

Senior management commitment is an important aspect of effective facilities management. This can be developed
through the following steps.
1. A senior manager should be nominated and made responsible for facilities management and sustainability
performance. Responsible operational staff should be required to provide monthly reports on key
performance indicators of the facilities, such as energy and water consumption. Facilities managers and
the nominated senior managers should meet quarterly to review performance and ensure targets are
achieved.
2. Effective facilities management policies in relation to sustainability should be developed. For instance,
these should guide how energy and water consumption is monitored, managed and reported on. Facilities
management policies and guidelines should be endorsed by senior management. There should also be a
requirement for facilities management to report on facilities performance regularly to senior
management.

PART K - LOCAL ECONOMY
1. Objective
The building supports the local economy.
2. Introduction
The construction and maintenance of 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 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
• A diversified local economic base
• Increased local capacity for new construction and maintenance of facilities
2.1. 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 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.
3. Criteria
Supporting the local economy 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. Measures that can
be used to support the local economy are outlined below.
3.1. Small enterprise support

Small local enterprises supports sustainability by creating local jobs and a diversified local economy. It can also enable
services, products and maintenance required in a health facility to be delivery more efficiently and rapidly.
1. Small local enterprises should be provided with opportunities to tender for relevant construction and
maintenance contracts.
2. Where local small enterprises have limited capacity and experience, support should be provided. This may
include encouraging small enterprises to enter partnerships with more established, larger enterprises.
3.2. 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. A review of local materials and components should be carried out to establish the nature, capacity and
suitability of local products. Where production capacity is adequate and the quality and performance of
materials and products is suitable, preference for local products should be made.
2. A standard for local content verification has been developed by the South African Bureau of Standards.
This can be referenced in specifications to support verification of local content (South African Bureau of
Standards, 2013).
3.3. Construction employment

The construction industry employs significant numbers of people. This can be enhanced through designs, specifications
and construction techniques which support labour-intensive processes. If considered carefully this does not need to
lead to additional costs or longer construction time . Local construction employment improves the local economic
impact of projects and ensures that there is local capacity to undertake repairs and maintenance of facilities at their
completion. Construction employment can be supported through the following steps.
1. Construction employment should be key consideration in the design, specification and construction of a
facility. Targets for construction employment (i.e. x person years per R 1 million construction budgets)
should be set and included in tendering requirements. Monitoring processes should be in place to ensure
targets are achieved.
2. Local maintenance and management capacity should be developed during construction in order for this to
be available for the facility on completion. Local people and small enterprises who have experience and
skills as a result of working or training on the facility should, as far as possible, be engaged to undertake
ongoing maintenance work. Additional training should be provided, if this is required.

PART L - PRODUCTS AND SERVICES
1. Objective
The building supports use of more sustainable products and services.
2. 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
2.1. Products and services in health facilities

The impact of products and service used in health facilities over their life time is extensive. Therefore careful
consideration of the type and nature of products and serviced used in health facilities is an important in supporting
sustainability and reducing negative impacts.
3. Criteria
Supporting the more sustainable products and services 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. The measures outlined below provide a number of steps that can be taken to support more sustainable
services and products in health facilities.
3.1. 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 where possible. Sustainable local products and
services can be supported through local produce procurement in the following ways.
1. Local produce should be specified in preference to produce imported from other areas.
2. Contractual agreements with, for instance, outsourced catering contractor, should require use of local
produce, where this is viable.
3.2. Vegetarian options

Meat-based meals have significantly higher ecological food print impacts relative to vegetarian meals. Providing
vegetarian options can therefore support reduced food impacts within health facilities. Sustainable local products and
services can be supported through the following steps.
1. Vegetarian options should be provided in catering establishments within the health facility.

2. The provision of vegetarian options should be made a requirement of outsourced catering contracts.
3.3. 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. Non-bottled drinking water should be made readily and freely available
throughout the health facility. This may include provision of drinking fountains at entrances and on main circulation
routes.
3.4. Reusable 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 these measures:
1. Reusable vessels should be specified in preference to disposable containers, for services such as catering.
2. Provision such as storage and washing facilities should be in place to ensure that reusable vessels can be
used easily and safely.

PART M - ACCESS
1. Objective
The building supports access to facilities.
2. Introduction
Current work patterns and lifestyles mean that many people have to access facilities such as banking, retail, childcare
and communications on regularly or daily. 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
2.1. 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.
3. Criteria
Supporting access to facilities 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. A range of
measures that can be used to support access to facilities are indicated below.
3.1. Banking
Access to banking can be provided through formal banking facilities, internet banking or through bank ATMs. Access
can be supported in the following way: Banking facilities should be readily accessible to users and occupants of health
facilities through local provision. Where facilities are not locally available, access to banking facilities should be
investigated and established in discussion with relevant role-players.
3.2. 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. Grocery retail should be readily accessible to users and occupants of
health facilities through local provision. Where facilities are not locally available, access to grocery retail should be
3.3. Communication
Access to telephone and internet can be provided through personal devices, internet cafes or at stand-alone kiosks and
booths. This can be provided within the health facility or within easy walking distance of this. Access to communication
can be supported through the following measures.

1. Access to Internet and telephone facilities should be made available within the health facility or in the local
area. Where facilities are not available, access should be investigated and established in discussion with
relevant role-players.
2. Charging points should be provided for personal cellphones and tablets.
3.4. Cafés and canteens

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. An accessible, affordable café, restaurant or canteen with healthy food should be provided
within the health facility or in the local area. Where facilities are not available, access should be investigated and
established in discussion with relevant role-players.
3.5. Childcare
Childcare and afterschool school care for children can be provided on site or within the local area. This supports
sustainability by reducing time and travel impacts of travel related to childcare. Childcare and/or afterschool care
should be provided within the health facility or in the local area. Where facilities are not available, access should be

PART N - HEALTH
1. Objective
The building supports a healthy and productive environment.
2. Introduction
Health facilities, by their definition, aim to support health and wellbeing 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 conditions. In health facilities, it is particularly important to avoid conditions and situations that may
be harmful to human health.
Ensuring that facilities support the health in users and construction workers 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
3. Criteria
Ensuring construction and health facilities promote health can be addressed in a variety of ways. The applicability of
each measure will depend on local circumstances and the respective functional requirements of the health facility.
However, outlined below are a series of criteria that can be used to check that health promotion has been addressed in
facilities.
3.1. External views

Views and a connection to the external environment improve internal environmental conditions and help improve
recovery rates and reduce employee absenteeism. Health through external views can be supported through the
following provision.
1. Health facility staff working areas should have views to the external environment. Internal working spaces
without views should be avoided.
2. Patient areas should have views of the external environment. The location of patients, i.e. seated, in bed or
walking, should be considered in framing views. In addition, the composition of the external view should
also be considered and large obstructions close to windows should be avoided.
3.2. Daylight
Day lighting can help reduce energy consumption associated with artificial lighting. It also improves internal
environmental conditions for patients and health facility employees. Health through improved daylighting can be
supported through the following provision.
1. Health facility staff working areas should be well day lit.
2. Patient areas should be well day lit.
3. Daylighting can be measured within buildings using a lux meter. Lux level requirements are determined by
the activities taking place within the space and should follow best practice standards for daylighting.
Lighting requirements are also listed in the IUSS Building Engineering Services guide.

4. Daylight performance can be predicted through modelling. This is an effective way of checking that
proposed designs achieve required lighting levels. Modelling should follow best practice protocols and
design performance should be evaluated against relevant lighting standards. Areas with a daylight factor of
over 2% are generally regarded as having good daylighting. Lighting requirements are also listed in the
IUSS Building Engineering Services guide.
3.3. 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. Health can be promoted through the following
measures.
1. Health facility staff working areas should be well supplied with adequate supplies of fresh air. Volumes of
fresh, non-recirculated air should be in line with good practice standards for the type of activities and
population densities accommodated and airborne infection control.
2. Patient areas should be well supplied with adequate supplies of fresh air. Volumes of fresh, non-
recirculated air should be in line with good practice standards for the type of activities and population
densities accommodated and airborne infection control.
3. Ventilation guidance is also provided in the IUSS Building Engineering Services guide.
3.4. 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. Health can be supported through
the following measures.
1. Construction materials should be screened to avoid products being used in health facilities that have
negative impacts on human health.
2. In particular, building materials that emit offgas substances such as formaldehyde and volatile organic
compounds that are harmful to human health, should be avoided.
3.5. Contractor health and safety

There are significant 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. For
instance, 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. Health and safety in construction can be supported through the following
measures.
1. Contractor health and safety should be considered as a key issue in the design of the building. Appropriate
design risk assessments and mitigation measures should be undertaken to ensure construction risks are
minimised.
2. Construction planning, procedures and processes should consider health and safety as a key issues and
ensure that risks are minimised during construction.
3. During construction, appropriate procedures must be place to ensure that health and safety plans are
implemented and monitored.

3.6. Community health education
The World Health Organization indicates that environmental risk factors play a role in 80% of regularly reported
diseases (Prüss-Üstün and Corvalán, 2013). Health facilities should therefore be used to promote increased awareness
and health education in users, staff and the local community about prevention, healthy and safe environments and
healthy diets. Provision for community health education is described in the next section (Education).

PART O - EDUCATION
1. Objective
The building supports education.
2. Introduction
Education and ongoing learning is increasingly been seen as an essential component of sustainable development and a
competitive economy. healthcarehealthcareEstimates indicate that a 1% increase in training days leads to a 3%
increase in productivity (International Labour Office, 2010). The importance of education is recognised in healthcare
through the requirement for healthcare professionals to undertake continuous professional development (CPD).
Education and ongoing learning can be supported through technology and spaces in facilities. Examples of this include
training rooms and access to ICT and reading material.
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 healthcare
• Ability to attract and retain staff
• Increasing awareness and knowledge of health issues in the local community and therefore improving disease
prevention
3. Criteria
Ensuring construction and health facilities promote education and ongoing learning 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 steps can be used to check that education and ongoing learning considerations
have been addressed. These are outlined below.
3.1. Contractor education

There is considerable scope to improve education and skills levels within the construction industry. This can be
supported through careful planning and skills programmes during the construction of health facilities. The following
steps can be taken to support contractor skills development.
1. Skills targets can be determined, and set, as part of a construction programme.
2. Contractors can be requested to develop a skills development plan.
3. Guidance on targets, skills development plans and monitoring and evaluation procedures is provided in the
Standard for Developing Skills through Infrastructure Projects (Construction Industry Development Board,
2013)
3.2. Notice boards

Notice boards are an easy and cost-effective way of communicating information. They can be used to support education
and awareness by drawing attention to new or important information. For instance, information on new healthcare
policy, procedures and processes can be communicated. An added benefit of notice boards is that they are not reliant on
a particular technology such as email and can be located where they will be seen by all personnel on a regular basis.
This helps to ensure information is communicated to all levels of staff within a health facility. The following measures
can be used to ensure notice boards support education and awareness.

1. Notice boards should be located in key settings in the health facility where they can be used to
communicate key information to facility staff and users.
2. Communication and education plans should be developed to ensure that notice boards are updated
throughout the year with relevant notices and information. These plans should ensure that information is
presented in an easy to understand and attractive way.
3.3. Space for learning

Formal training can be supported through access to training rooms. More informal ongoing learning can be provided
through access to resource centres where learning material, computers and the Internet can be accessed. It is estimated
that modern work forces should spend at least the equivalent of 5% of their working hours on training and ongoing
development in order to remain abreast of developments. Learning can be supported through the following measures.
1. Appropriately-sized and equipped facilities should be provided to enable formal training for staff.
2. Appropriately-sized and equipped facilities should be provided to support informal, ongoing learning by
staff, such as distance-education courses.
3. Appropriate facilities and equipment should be provided to support wider community health education
programmes.
3.4. 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. Education through employee
induction can be supported through the following measures.
1. Employee induction processes should be developed to ensure that all employees understand the building
and its systems and are able to use these appropriately. All new employees should be required to attend
an induction and existing employees should have refresher inductions.
2. Building induction documentation and processes should have an emphasis on resource efficiency and
ensuring that the building is managed and maintained to support sustainability.
3.5. Building user manual

Building user manuals aim to complement employee induction processes by providing easily accessible and
understandable information related to a facility in order to support user behaviour that supports sustainability.
Education through building user manuals can be supported through the following steps.
1. A building user manual should be developed for the facility. This should describe all key building systems
related to sustainability in the building and provide guidance on how these should be operated correctly.
Aspects that should be included are: internal and external lighting, heating, ventilation and air-
conditioning, waste and recycling systems, water and sanitation systems, natural ventilation and passive
environmental control systems and transportation systems, including provision for cycling and walking.
2. The building user manual should be accessible and easy to use. Diagrams and photographs should be used
to support understanding. Building user manuals, or sections of manuals can also be placed on notice
boards, online, or on an Intranet site to support ready access.
3.6. Community health education

Health facilities should be used to promote increased health awareness and education in users, staff and the local
community. In particular, there should be an emphasis on healthy living and disease prevention. The following
measures can be used to support community health education in health facilities.

1. Noticeboards in waiting rooms and on main circulation routes can be used to publish relevant health
education and awareness material.
2. Monitors in waiting areas can be used to run health education programmes.
3. Educational spaces within the facility can be programmed to provide community health education classes
and events.
4. Food gardens, water fountains, sports facilities and catering facilities can be used to educate users and the
local community on aspects such as diet and exercise.

PART P - INCLUSION
1. Objective
The building is inclusive of diversity in population.
2. 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
3. Criteria
Ensuring health facilities are inclusive 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 steps can be
used to check that key inclusion considerations have been addressed. These are outlined below.
3.1. Environmental access

Facility location, design and management should support environmental access and ensure that health facilities are
inclusive. This requires a comprehensive approach that ensures that access considerations are effectively integrated
into all aspects of the health facility including physical access, signage and facilities management training.
Environmental access in the facility can be supported through the following measures:
1. Routes from local public transport, homes and workplaces within walking distance of the health facility
catchment area should be easy to use and accessible. Pedestrian routes should be developed to comply
with best practice inclusive design standards. This may require engaging with a range of role-players
including the local municipality, departments of roads and public and private transport providers. Where
routes are currently inaccessible, plans should be developed to ensure that these become progressively
more accessible and safe to use. Ensuring that upgrading local access routes in local Integrated
Development Plans (IDPs) can help ensure that this is addressed by local municipalities.
2. The facility and the site should fully comply with building regulations and the IUSS environmental access
requirements. A comprehensive, linked-up approach should be taken and all aspects of the facility
including routes, physical access, furniture, fittings, signage, emergency egress, equipment and facilities
management should be taken into account.
3. Systems and management should be in place to ensure that environmental access standards are
maintained during operation. For instance, there should be procedures to ensure that routes are not
inadvertently made inaccessible to wheelchair users as a result of equipment being placed in lines of
travel. Similarly, staff should be trained so that they know when assistance may be required, and how to
provide this in order to enable inclusive access and use of facilities and equipment in the facility.

3.2. Accessible transport
Inclusive local transport is an important part of enabling access to health facilities where users and staff are not able to
walk to the facility because of distance, inaccessible routes or as result of a disability or ill-health. The following
measures can be used to support inclusion through accessible transport.
1. Local regular, affordable and efficient local public transport systems should be in place. These systems
must be accessible to people with disabilities and comply with best practice access standards. Where local
public and private transport systems do not exist.
2. Local public transport systems must linked to the health facility with accessible safe routes that are
designed and managed in line with best practice standards. This route should not be further than 400 m.
3. People should also be able to access public transport easily from places of work or residence within the
catchment area of the health facility.
4. Where local public accessible transport provision does not exist, interim measures should be put in place
to ensure that everyone is able to access the health facility. This may include arrangements with local
private providers or health transport which is able to provide accessible transport. At the same time, long-
term plans should be developed to ensure that local accessible transport is developed. This may require
engaging with a range of role-players including the local municipality, departments of roads and public and
private transport providers.
3.3. 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 on health facility staff, including long distance commuting which can disrupt family life and reduces
the proportion of family budgets available for non-transport related costs such as education and health. Increasing the
availability of local affordable accommodation can be achieved through partnership agreements with local developers
and social housing organisations. Access to affordable accommodation can be supported through the following
measures:
1. Local affordable local accommodation should be provided for health staff. Where this does not exist,
options for developing this should be investigated.
2. Options for local affordable accommodation can be investigated with local developers, the local
municipality, social housing foundations and departments of housing.

PART Q - SOCIAL COHESION
1. Objective
The building supports social cohesion.
2. 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 improving 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 better levels of service and fewer mistakes and less wastage.
Ensuring that health facilities support social cohesion has a range of benefits, including:
• More efficient and effective use of resources
• Improved communication and coordination
• Reduced wastage
3. Criteria
Ensuring health facilities support social cohesion 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 steps can be used to check that key social cohesion considerations have been addressed. These are outlined below.
3.1. Shared used of facilities

Shared use of facilities helps to ensure that valuable facilities are well used and beneficial impacts are experienced by a
larger number 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. Similarly, an agreement with a local college, school or library to access facilities for learning can be used to
avoid having to replicate these within the health facility. Shared use of facilities can be supported through the following
measures.
1. Shared development and/or use of facilities, such as parking, crèches, education facilities, fitness and
leisure, and gardens should be explored with relevant local organisations. Shared facilities enables capital
and operating costs for user organisations and users to be reduced. It can also lead to more efficient and
increased usage of the facility.
2. Where sharing will or may occur, provision should be made for this in the design. This includes ensuring
that appropriate access control, security and supervision measures are in place.
5. Where sharing of facilities occurs, appropriate management systems should be put in place to ensure that
operational responsibility for the facility is clearly defined and managed. In addition, a clear system for
managing access and apportioning costs must be in place.

3.2. 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, but they also provide a space for relaxed social interaction. This
interaction, and the relationships and communication networks created, can make a significant contribution in
improving organisational effectiveness and responsiveness. In healthcare facilities this is a valuable resource which
helps to motivate individuals and build strong teamshealthcare. Social spaces can be supported through the following
measures:
• An appropriate number and type of social spaces should be provided in and around the health facility. This will
be determined by the size of the organisation and facility.
• Social interaction within, and between health teams and professions is supported by having larger social
spaces such as canteens and common rooms. This is more likely to support cross team interaction compared to
a series of small social spaces that only cater for particular staff teams, or staff members such as doctors, or
nurses.
3.3. Stakeholder involvement

Involving people in decisions on issues that 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 stakeholders 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, the involvement of managers, building technical staff and health services staff can be used to support goals such
as improved energy efficiency by ensuring that objectives and respective roles in achieving this is understood and
supported. Stakeholder involvement can be supported through the following measures:
• Appropriate stakeholders should be involved in the design of health facilities. Stakeholders include building
staff, facilities managers and representatives of user groups such as users with disabilities. Stakeholders should
be involved at points when their input can add value to the designs. This is particularly important at the
conceptual design stage. Stakeholder involvement should include ensuring that appropriate measures are
taken to support effective participation, such as graphical presentations and the development of readily
understandable three dimensional models.
• Appropriate stakeholders should also be involved in the management of facilities (facility managers and
representatives of user groups including people with disabilities). Involvement should be through quarterly
reviews. This is used to report on facility performance and for determining and agreeing actions for improving
performance. Performance information should be shared in a readily accessible manner and presentations and
short reports with graphs, tables and diagrams should be used instead of lengthy technical reports.

PART R - REFERENCES
1. CIDB. 2013. Standard for developing skills through infrastructure contracts. [Online].
Available: www.cidb.org.za.
2. Construction Industry Development Board (CIDB). 2009. South African Report on

Greenhouse Gas Emission Reduction, Potentials from Facilities, A Discussion Document.
CIDB.
3. DEAT. 2009a. State of the Environment Report. [Online]. Available:

http://soer.deat.gov.za/themes.aspx?m=387.
4. DEAT. 2009b. The National Climate Change Response Policy. DEAT, Pretoria.
5. Department of Environmental Affairs and Tourism (DEAT). 1998. National Environmental

Management Act. DEAT, Pretoria.
6. 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, WRC Report 1430/1/05. Water Research Commission, Pretoria,
South Africa.
7. Intergovernmental Panel on Climate Change (IPCC), 2007. Climate Change Synthesis Report
2007. IPCC. [Online]. Available: www.ipcc.ch.
8. International Labour Office. 2010. Skilled workforce for strong, sustainable and balanced
growth: A G20 training sStrategy. [Online].
Available:www.oecd.org/g20/topics/employment-and-social-policy/G20-Skills-Strategy.pdf.
9. Prüss-Üstün, A and Corvalán, C. 2013. Preventing disease through healthy environments.

Towards an estimate of the environmental burden of disease. World Health Organization.
[Online]. Available: www.who.int/
quantifying_ehimpacts/publications/preventingdisease.pdf?ua=1.
10. SABS. 2012. SATS 1286. SABS. Pretoria. [Online]. Available: www.sabs.co.za/Local-
Content/index.asp.
11. South African Bureau of Standards (SABS). 2007. SANS 204 Energy Efficiency in Facilities,
SABS. Pretoria.
12. Sustainable Energy Africa (SEA). 2006. State of energy in South African cities. SEA. Cape Town.
13. World Wildlife Fund (WWF), 2006. Living Planet Report 2006.WWF. [Online]. Available:
www.panda.org.

PART S - APPENDIX A: SUSTAINABILITY INTEGRATION PLANS
Template completion instructions
Text in italics indicates the information that should be inserted into the plan. The clear (unshaded) section should be
completed during the early stages of conceptual design for new developments and at the onset of operational
performance improvement programmes. The grey section should then be completed at the relevant stages, i.e. Concept
Design, Detailed Design (for development processes) or Quarter 1, Quarter 2 (for operational processes).
List criteria Target List target List target List target List target
from this guide Confirmation List documentation List documentation List documentation List documentation
and any others and or methodology and or methodology and or methodology and or methodology
that have been used to confirm used to confirm used to confirm used to confirm
identified achievement of achievement of achievement of achievement of
target target target target
Signed by client Signed by client Signed by client Signed by client
(advises by client (advises by client (advises by client (advises by client
technical adviser, if technical adviser, if technical adviser, if technical adviser, if
necessary) to necessary) to necessary) to necessary) to
indicate acceptance indicate acceptance indicate acceptance indicate acceptance
of achievement of of achievement of of achievement of of achievement of
target target target target
Sustainability integration plan: development template

Template for each sustainability criteria listing: criteria, target, confirmation method and documentation and
acceptance by the client (advised by a technical adviser, if necessary) for key design development stages. This template
should be duplicated and completed for each sustainability criterion.
Target
Confirmation
Target
Confirmation
Target
Confirmation
Target
Confirmation
Target
Confirmation
Target
Confirmation

Target
Confirmation
Sustainability integration plan: operation template

Template for each sustainability criteria listing: criteria, target, confirmation method and documentation and
acceptance by the client (advised by a technical adviser, if necessary) for each quarter (i.e. Q1, Q2, Q3, Q4). This
template should be duplicated and completed for each sustainability criterion.
Criteria Requirements Quarter 1 Quarter 2 Quarter 3 Quarter 4
Target
Confirmation
Target
Confirmation
Target
Confirmation
Target
Confirmation
Target
Confirmation
Target
Confirmation


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IUSS HEALTH

Task Team: C:04

Form: Health facility guides

Title: Environment and Sustainibility

INFRASTRUCTURE UNIT SUPPORT SYSTEMS (IUSS) PROJECT 1

INFRASTRUCTURE UNIT SUPPORT SYSTEMS (IUSS) PROJECT 2

INFRASTRUCTURE UNIT SUPPORT SYSTEMS (IUSS) PROJECT 3

INFRASTRUCTURE UNIT SUPPORT SYSTEMS (IUSS) PROJECT 4

HVAC: Heating, ventilation and air-conditioning.

Occupants: People who occupy the building on a normal working day.

INFRASTRUCTURE UNIT SUPPORT SYSTEMS (IUSS) PROJECT 5

INFRASTRUCTURE UNIT SUPPORT SYSTEMS (IUSS) PROJECT 6

BMS: Building Management System

CIDB: Construction Industry Development Board

DEAT: Department of Environmental Affairs and Tourism

EF: Ecological Footprint

FSC: Forest Stewardship Council

GDP: Gross Domestic Product

GWP: Global warming potential

HDI: Human Development Index

HVAC: Heating, ventilation and air-conditioning

IPCC: Intergovernmental Panel on Climate Change

LTMS: Long-term Mitigation Scenario

NEMA: National Environmental Management Act

ODP: Ozone depleting potential

PIR: Passive infrared

PPP: Purchasing power parity

SABS: South African Bureau of Standards

SEA: Sustainable Energy Africa

UNFCCC: United Nations Framework Convention on Climate Change

WC: Water closet

WWF: World Wildlife Fund

INFRASTRUCTURE UNIT SUPPORT SYSTEMS (IUSS) PROJECT 7

INFRASTRUCTURE UNIT SUPPORT SYSTEMS (IUSS) PROJECT 8

3. How to use this document

INFRASTRUCTURE UNIT SUPPORT SYSTEMS (IUSS) PROJECT 9

INFRASTRUCTURE UNIT SUPPORT SYSTEMS (IUSS) PROJECT 10

2. The environmental context

INFRASTRUCTURE UNIT SUPPORT SYSTEMS (IUSS) PROJECT 11

4. Carbon emission mitigation strategies

INFRASTRUCTURE UNIT SUPPORT SYSTEMS (IUSS) PROJECT 12

INFRASTRUCTURE UNIT SUPPORT SYSTEMS (IUSS) PROJECT 13

Measure South Africa Sustainability target

7. The legislative and policy context

7.1. The South African Constitution

3 Section 9 of the South African Constitution

INFRASTRUCTURE UNIT SUPPORT SYSTEMS (IUSS) PROJECT 14

7.3. Sustainability policy and legislation

8. Built environment sustainability objectives

8.1. Environmental objectives

8.2. Economic objectives

8.3. Social objectives

INFRASTRUCTURE UNIT SUPPORT SYSTEMS (IUSS) PROJECT 15

8.4. Integrating sustainability objectives into health facilities

INFRASTRUCTURE UNIT SUPPORT SYSTEMS (IUSS) PROJECT 16

8.5. Sustainability integration plans

INFRASTRUCTURE UNIT SUPPORT SYSTEMS (IUSS) PROJECT 17

INFRASTRUCTURE UNIT SUPPORT SYSTEMS (IUSS) PROJECT 18

4. Design and operation

INFRASTRUCTURE UNIT SUPPORT SYSTEMS (IUSS) PROJECT 19

4.2. Building shape

4.3. Building depth

INFRASTRUCTURE UNIT SUPPORT SYSTEMS (IUSS) PROJECT 20