In the 1970s, when the king of Saudi Arabia needed a heart operation, he did what Middle East royals had been doing for decades: He traveled to the United States. After his successful procedure at the Cleveland Clinic, more wealthy patients from the region followed, culminating in thousands receiving care at the hospital. But starting in 2012, these patients will no longer have to pull out a passport to get Western medical treatment. The Cleveland Clinic joins other major U.S. institutions, such as Johns Hopkins and the Mayo Clinic, in bringing its brand of medicine to the Middle East. When it opens in 2012, Cleveland Clinic Abu Dhabi will be a multi-specialty hospital on a par, its owners hope, with the world’s top medical institutions.

“The government of Abu Dhabi is taking bold steps to improve access to world-class treatment and reduce the need for patients to travel abroad for care,” says Mark Erhart, executive director of healthcare at Mubadala Development Co., which is the hospital owner (its sole shareholder is the government of the Emirate of Abu Dhabi).

It’s not just medical know-how that’s proving to be a valuable U.S. export. The U.A.E. is also importing architectural expertise. “In selecting an architect for this project, we looked for a firm that would be able to translate our vision to create an unparalleled extension of the Cleveland Clinic model of care here,” Erhart says. They chose the Omaha, Neb.–based firm HDR.

The globalization of American healthcare
Alan Dilani is founder and general director of the International Academy for Design & Health, based in Sweden, which tracks healthcare trends and research around the globe. He says the Middle East as a whole is witnessing a healthcare construction boom, and Abu Dhabi is not alone in its desire to build new hospitals and employ Western design services.

“Before, many wealthy people in the Middle East visited Europe or the U.S. for any kind of disease,” Dilani says. But now there is a desire to have those medical services closer to home, especially as international travel becomes more difficult, he says.

Investment in healthcare is on the rise around the world. “The minister of health in Saudi Arabia is looking to build 52 hospitals,” Dilani says. Turkey “is planning 24 new hospitals,” while countries in Eastern Europe, like Russia and Yugoslavia, are in need of large, 500- to 1,000-bed hospitals, according to Dilani. Vietnam, Thailand, and Malaysia are spending more on healthcare construction, while China has undertaken a mammoth infrastructure overhaul, including new hospitals. India is also building hospitals at an impressive clip, sometimes offering firms the chance to create multiple facilities at once.

“It’s the globalization of healthcare,” says Jean Mah, national market sector leader for Perkins+Will’s healthcare practice. “We’re finding that there are interesting developments in these countries due to [overall] economic growth, but a lot is fueled by a growing middle class that is demanding access to more healthcare.”

This rise in consumer demand is placing a higher premium on knowledgeable healthcare design, which translates into opportunities for U.S. firms with healthcare expertise. Some trends in Western design are being directly transplanted into foreign facilities: larger, single-bed rooms; advanced technology; softer interiors incorporating warm materials like wood; and evidence-based design techniques focused on patient outcome, such as daylighting.

But designing abroad is not as simple as grafting a Western approach onto foreign markets. “You cannot walk into a place like China and presume that your reputation precedes you, that your way is the only way, and that you are worth a lot of money,” says Ray Pentecost, vice president and director of healthcare architecture at Norfolk, Va.–based Clark Nexsen and president of the AIA Academy of Architecture for Health. “So much of [healthcare design] is culture-driven.”

As the market for healthcare design opens, new opportunities breed exposure to a whole new set of rules, from complex design competitions and meticulous cultural considerations to thorny billing systems and challenging materials sourcing. It’s a promising market abroad, but one that requires a special mix of business savvy and cultural sensitivity.

Hospital meets hotel
Looking at the interior renderings for the new Cleveland Clinic Abu Dhabi (CCAD), you could easily mistake the 2.7-million-square-foot project for an exclusive hotel. “One of the predominant goals is to create a five-star-hotel experience in a hospital, so much of the design is driven around creating that,” says Harold Nesland, international managing principal for HDR. Patients will enter a lobby outfitted in marble, stone, and wood. There will be expansive public spaces, including an upscale retail gallery overlooking the city. Private suites designed for royal families will appear to be carved out of marble.

The hotel-meets-hospital, a popular approach in the Middle East, extends to not only the aesthetics of the building but also the way guests are accommodated. “In the Middle East, you often have large families accompanying the patient,” Nesland says. The 364-bed hospital (expandable to 490 beds) has single-patient rooms slightly larger than a typical U.S. room, but the royal suites command a staggering 7,000 square feet each. Waiting areas feel more like hotel lobbies, while circulation patterns keep back-of-house activities—patient transport, logistical support—hidden from the public. The architects took great care to develop an intuitive and sophisticated wayfinding system that also addresses cultural requirements, like keeping royal families isolated and men and women segregated, as needed.

In other respects, though, the CCAD will mirror its U.S. counterpart. It will be a physician-led medical facility—staffed only by North American board-certified (or equivalent) physicians—that employs the latest technologies in surgery, imaging, telemedicine, and electronic medical records. Exporting the Cleveland Clinic brand of healthcare to the Middle East required considerable planning in the design phase. “Our processes have been fully integrated into the design,” explains William Peacock, director of operational support services at the Cleveland Clinic. “Over 300 physicians and clinical personnel [helped set up] each of the clinical and specialized care areas, and [went] through with the architects to assess how patients will move through the hospital.”

The CCAD is strategically sited on Sowwah Island, the new central business district of Abu Dhabi. The hospital’s exterior design of glass, steel, and stone is meant to be a powerful presence on the horizon, a building that speaks to its purpose of providing advanced medical care.

Also for Abu Dhabi, the Dallas-headquartered firm HKS designed the Danat Al Emarat Women’s and Children’s Hospital, due to open next year. This $205 million, 150-bed hospital is sited on the mainland. “There is sand everywhere; they have sandstorms. How do you bring a building into that site?” asks Enrique Greenwell, an HKS vice president. The solution is a strong podium clad in a perforated and corrugated metal skin that creates a highly textured surface, allowing views out while reflecting sunlight in different directions. This base, which houses the diagnostic treatment area, is capped by a flowing glass structure meant to resemble a hijab, the head covering worn by women in the Middle East. At night, LEDs allow the veil to glow and give the perforated metal base a moiré effect intended to evoke an Arab lamp.

The facility’s interior circulation reflects that men and women frequently require separate transit paths, and its ventilation accommodates the tradition of burning an expensive wood called oud or a perfumed coal called bukhoor when a child is born. Some interior spaces face Mecca for daily prayers.

The project includes 22 royal and VIP suites, reached via their own entrance and elevators. “This is a completely different program from a U.S. suite,” says Dan Noble, executive vice president at HKS. “Individual VIP suites are about one-quarter of the floor. It’s like going to a fancy hotel in Vegas.”

Greenwell says designing the royal suites required some translation. “We met another big challenge in just defining the term ‘royal.’ We began doing an approach that was very trendy, contemporary, and elegant, and [the client] really embraced it. As time went by, though, they got comments from locals who thought it wasn’t ‘royal’ [or traditional] enough.”

Public vs. private
U.S. architects working on healthcare projects in China have a very different role from the hands-on approach they take in the Middle East. In China, they are only allowed to produce the design, which they then hand over to a local design institute. The designing firm can’t be sure how the final structure will turn out. “It’s very much a surprise. Everything from the detailing to the orientation of the building can change,” says Ed Scharff, an associate principal at TRO Jung|Brannen. His firm has designed several projects in China, including the Shenzhen Third People’s Hospital, which won a 2008 AIA National Healthcare Design Award and is currently under construction. TRO Jung|Brannen’s competition-winning proposal for the Shenzhen hospital illustrates two key differences when working in the Chinese market. Conceived in the wake of the SARS epidemic, the 500-bed specialty hospital and outpatient clinic includes something a U.S. facility for infectious disease never would: windows that open. “When you get into the healthcare practice in China, it’s inevitable that you’re going to have to deal with feng shui,” says Chan Byun, a TRO principal. In China, it is believed that a hospital should take advantage of prevailing winds by placing ill patients downwind, he explains. It is also believed that patient rooms should face south.

Another programmatic difference is something known as the “dirty core.” In China, Scharff explains, contaminated waste goes to a special core in the building and never crosses into the “clean” sections of the facility. In a patient tower, there will be “clean” public elevators and separate soil elevators, adding a layer of complexity to circulation plans.

China has plans to upgrade its national health system, including its healthcare facilities. The government issued a policy report last April calling for the construction or renovation of 2,000 county-level hospitals and tens of thousands of local health centers.

You can be sure there will be no 7,000-square-foot suites in these projects. “One of the things to consider with hospitals in China is the huge daily flow of people. You are in the thousands of people a day just for outpatient,” Scharff says. “Single patient rooms are pretty rare in a public hospital, and three to a room is not uncommon. We’ve designed hospitals with six-bed wards.”

While Shenzhen is a project of the Chinese government, private owners also are undertaking a large number of projects in Asia. Singapore, which is located within a six-hour flight path of many major cities, has seen private owners jumping into the healthcare sector to serve wealthy local populations and the possibility of medical tourism. “There is a market for a center of excellence that is based on American … standards of care and operational models, and that is a bit of a departure from the national standard offered through their healthcare system,” says Ron Smith, senior associate in healthcare at HOK.

For Singapore’s ParkwayHealth Novena Hospital, HOK designed a 780,000-square-foot facility that will focus on cardiology, orthopedics, and neurology. All rooms will be private, and the facility will offer patient-floor balconies, gardens, and rooftop landscaping. As in the Middle East, there is a premium on user experience. In the lobby, patients check in at a concierge desk. The facility, which is currently under construction, has an exterior clad in double-pane thermal glass with special tinting and shade features to mitigate the strong sun (Singapore is nearly on the equator). One section of the façade uses photovoltaics in the glass to generate energy. The building is expected to achieve Greenmark Platinum certification in Singapore, similar to LEED Platinum.

Refurbish, replace
A hybrid of private and public funding, private finance initiatives—or PFIs—are increasingly supporting the construction of healthcare projects around the globe. The world’s largest healthcare PFI project to date is now under construction in London. Designed by HOK, the $1.2 billion expansion of St. Bartholomew’s and The Royal London Hospitals will integrate new structures into existing historic fabric. In the U.K. market, “New construction is down, but a large number of hospitals need to be restructured, so they have a lot of refurbishment work,” Dilani says. And what will be the next big market in the coming decade? “Australia,” Dilani says. “Australia is the place to go right now,” because of its plethora of aging hospitals in need of replacement. Warren Kerr, national director for Perth, Australia–based Hames Sharley Health Group, says that while there is a thriving local base of healthcare designers, there is a need for outside expertise, especially on big-ticket specialty projects. “It is unlikely that individual firms have specific experience in these specialized fields. It would make sense to joint venture with an overseas firm who has recently completed a project of [a similar] nature.”