Bayalpata Hospital, a model of sustainable rural health

The new Bayalpata Hospital was made possible through a collaboration between the government of Nepal and NGO Possible Health. Designed by New York City-based Sharon Davis Design, the hospital transforms an aged and overrun clinic into a model of sustainable rural health, bringing healthcare to the most remote area of Nepal, where the doctor-patient ratio is, on average, 150 times worse than recommended by the World Health Organization. Construction of the hospital began in late 2014 and proceeded in phases, over a 5 year period, to maintain the operation of the hospital during construction.

Located in Achham, one of Nepal’s poorest and most remote regions, the new 7.5-acre campus, with a built area of 45,500 square feet, is set on a hilltop and surrounded by the terraced slopes of the Seti River valley. Due to poverty and limited infrastructure, most patients travel to the hospital on foot, even pregnant women, and journeys can take up to five or six days. To serve this community, the hospital includes five medical buildings that house outpatient, inpatient, surgery, antenatal, and emergency facilities for 70 beds, plus clinical functions, such as pharmacy, radiology, and laboratory spaces. An additional administration block with offices and a 60-seat canteen, plus 10 single-family houses and an eight-bedroom dormitory, serve the hospital’s staff and their families. Bayalpata is not only an institution but also a home.

With this new campus, Bayalpata is expected to deliver low-cost, high-quality care to more than 100,000 patients a year from Achham and its six surrounding districts, more than eight times its original capacity. The hospital has two operating theaters, one for each of the only two practicing surgeons in western Nepal, Dr. Pawan Agrawal and Dr. Bikash Gauchan (who also serves as Bayalpata’s Healthcare Director). Bayalpata Hospital also features the sole dental office in the region, led by dentist and oral surgeon Dr. Rekha Gauchan and serving a population of one million.

With a 10-hour drive from the nearest regional airport and a three-day drive from the nearest manufacturing centers around Kathmandu, Sharon Davis Design introduced rammed earth as a locally available material and low-tech construction method that minimized the cost-prohibitive transportation of building materials into this mountainous region. Soil from within a 2km radius around the site was mixed with a 6% cement content to stabilize the earth for better durability and seismic resistance. Reusable, plastic lock-in-place formwork facilitated faster construction and the employment of unskilled local labor, while local stone was used for foundations, pathways and retaining walls. Built-in furniture, exterior doors, and louvers were fabricated from local Sal wood. Bayalpata serves as a model of how rammed earth and other local materials, which have been traditionally used for simple vernacular structures, can be utilized to create modern architecture.

Dr. Bikash and Dr. Rekha—who reside with their children on the hospital campus—described how patients feel comfortable in the buildings due to their warm, earthen quality--a stark contrast to the cold, institutional architecture of many healthcare facilities in Nepal. "When we are in these buildings we feel at home, because our homes in our district are made of mud walls," Dr. Bikash explained. Dr. Rekha agreed, adding, "the sense of inner peace is always there." This deeper connection to the community can help contribute to a greater number of overall positive health outcomes for the hospital.

A grid-connected, 100kW photovoltaic array, installed across all south-facing roofs, generates more energy on site than the campus requires. Passive heating and cooling are also essential to the design—only the operating theatre within the surgery building is mechanically conditioned. Insulated roofs, an uncommon feature in the region, along with massive rammed earth walls, retain daytime heat gain in the winter, and keep interiors cool in the summer. Breezeways, clerestory ventilation, and ceiling fans increase airflow to further mitigate summer heat. The campus includes new water supply and storage, wastewater treatment facilities, and a network of landscaped terraces and bio-swales that manage monsoon-driven erosion.

The architecture maintains a vernacular scale through setbacks and gabled roofs. Tall windows frame dramatic views and clerestory glazing provides natural daylighting throughout all clinical areas, to reduce the need for artificial lighting. Landscaped courtyards offer a sheltered environment for designated patient seating and informal family waiting areas, and all rooms provide patients with access to outdoor gardens or balconies. Where the medical spaces were painted white for sanitary reasons, the rammed earth was left exposed for the interiors of the housing and dormitory.

The Nepali Times has called Bayalpata Hospital an exemplar of “how to upgrade Nepal’s rural health” and a “functioning model of accessible and affordable care in remote Nepal.” In a recent editorial in the same paper, Dr. Bikash references the current global coronavirus pandemic and suggests that “For Nepal, the real pandemic is poverty,” the symptoms of which Bayalpata’s medical staff treat every day. He links disease and social inequality, explaining, “The Lancet Global Health Commission says 8 million people every year die around the world from treatable conditions in low and middle income countries. Yet, that does not qualify as a global pandemic. More than 1,200 women die in childbirth every year in Nepal, that is three fatalities every single day. Tuberculosis kills 6,000 people in Nepal every year. There were 2,736 fatalities in road traffic accidents in Nepal last year. All of these deaths were in one way linked to deprivation and inequities.” Bayalpata Hospital now serves precisely those patients who “either do not have access to healthcare or cannot afford it.”