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Identifying Best Practices of Hospital Architecture in The Tropics through

Comparative Analysis of Past and Present Planning and Design Parameters
and Considerations: The case of P...

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Identifying Best Practices of Hospital Architecture in The Tropics through
Comparative Analysis of Past and Present Planning and Design
Parameters and Considerations: The case of Philippine General Hospital.
Gene Lambert Giron 1, and Emmarie Rose Josue2
1Chulalongkorn University, Thailand, College of Architecture (Faculty, National University, Philippines), 6678012325@student.chula.ac.th
2College of Architecture, National University, Philippines, ervcruz@national-u.edu.ph

Abstract
The Philippine General Hospital (PGH), known as the national university hospital of the country, was designed in 1907 and built
in 1910 during the American colonial period in the Philippines as a component of Daniel Burnham's Plan of Manila following the City Beautiful
Movement concept. The current state of the original buildings of PGH, constructed prior to the development of the National Building Code
of the Philippines and other relevant interim laws and statutory policies, reveals that certain elements of PGH do not comply to current
architectural and site planning standards. This issue is further exacerbated by the rapid urbanization of Metro Manila and nearby provinces,
which exceeds the carrying capacity of PGH to provide healthcare services to the wider public. Consequently, the condition of PGH's facilities
is gradually deteriorating, which has adverse effects on its overall safety, performance, and cultural heritage value. Despite the
incompliances, PGH exhibits passive architectural design and site planning features that contribute to the development of policies and
principles for designing current and future healthcare facilities. The aim of this paper is to determine the most effective architectural design
and site planning principles for hospitals through a qualitative comparative analysis of past practices and current policies, focusing on the
building as the main unit of analysis. The study analyzed the as-built plans and conducted an actual foot survey of the PGH, and various laws,
policies, and standards related to architectural design and site planning of hospitals, including those from the Department of Health (DOH),
World Health Organization (WHO), and other pertinent entities. By examining these variables, the study will avoid obsolete and inadequate
practices and promote efficient, effective, and appropriate strategies for healthcare facility design, which will have positive implications not
only for the Philippines but also for other countries in the pursuit of a holistic and high-functioning healthcare facilities.

Keywords: Hospital, Healthcare Facilities, Best Practices, Architecture, Site Planning

Introduction
Disease outbreaks in the tropics are prevalent and are further exacerbated due to highly variable weather conditions, ecological
disturbances, and El Nino-Southern Oscillation (ENSO)-driven processes (Anyamba, et al., 2020), which makes countries such as the
Philippines vulnerable to various disease outbreaks. Hence, hospitals play a crucial role in providing care and other optimal benefits to
patients by ensuring an indoor climate that considers good indoor air quality and thermal comfort for the recuperation and comfort of
patients, and the productivity of healthcare professionals is envisaged by ensuring adequate ventilation and air quality. However, energy
poverty and inefficient technologies in developing countries, caused by various factors such as natural disasters and harsh environmental
conditions, pose a challenge to achieving a suitable indoor climate in hospitals, rendering healthcare operations more challenging than usual
(Toral, Alba, & Molina, 2021). Hence, passive design features and technologies are deemed essential for the sustainability of healthcare
facilities, not only to reduce energy consumption, carbon emissions, and overhead expenses but also to address the resiliency of healthcare
facilities (Adekunle & Basorun, The Evolving Roles of Landscaping in Campus Space Management: Ekiti State University, Ado-Ekiti, Nigeria in
Focus, 2016). To ensure the said sustainability, healthcare facilities should create an environment that emulates reasonable noise control,
air quality, thermal comfort, lighting, color, texture, privacy, and vista to create a well-designed environment that can improve healing
outcomes, reduce length of stay (LOS) for patients, and create a productive environment for healthcare professionals (Aripin). To achieve
this, factors such as window sizes, window levels, headroom and ceiling heights, landscaping, and hospital open spaces are deemed crucial
and must be carefully studied and considered (Uzuegbunam & Francis O., 2023). In the case of the Philippines, this strategy is not new. The
Philippine General Hospital (PGH), designed by William Parsons, the architect behind Daniel Burnham's City Beautiful Movement inspired
Burnham Plan for Manila, an urban planning and design concept for Manila in the late 19th century, showcased the principles of pathology,
function, hierarchy, and geometry in both macro and micro levels of development (Lico et al., 2017). William Parsons, along with his design
of various civic buildings in the Philippines, particularly in Manila, as part of the Burnham Plan of Manila, employed Yankee Architecture, a
hybrid architectural style used to dramatize the coexistence of Imperialist Neoclassical and Spanish Mission Revival styles, to make
colonization at that time a civilizing continuity rather than a disruption of native civilization and create a non-invasive sense of place for
Filipinos, respecting indigenous knowledge, flexibility of design, and accommodating cultural differences (Lico et al., 2017). This style resulted
in architectural design showcasing grandeur of scale, simplicity of geometric forms, application of Greco-Roman details, dramatic use of
columns, blank walls, curvilinear parapets, round arch entrances, white plastered walls, pyramidal terracotta tiled roofing, and dominant
Mirador towers (Lico et al., 2017), which resulted in the creation of large window openings, high ceilings and headroom clearances, atrium
areas housing gardens, and other landscaping features to adapt and optimize the tropical climate and environmental conditions of the
Philippines. Over time, various pandemics, medical outbreaks, and breakthroughs passed through the halls of PGH. Aside from the recent
Corona Virus Disease of 2019 (COVID-19) pandemic where the PGH transitioned into becoming the Special Corona Virus Disease Unit
(SCOVIDU), which served as the referral institution for COVID-19 cases in the Philippines (Toral, Alba, & Molina, 2021), the PGH also
accommodated thousands of patients who suffered from the Spanish Flu outbreak in 1918, which at that time successfully handled the said
pandemic despite being rendered incapacitated and overwhelmed due to the high number of active cases at that time (Cruz-Araneta, 2020).
Presently, being one of the key healthcare facilities in Manila and the Philippines, PGH is now labeled as a National University Hospital under
the University of the Philippines Manila (UPM), known for its role in patient care, research, and medical training (Cerrado & Tamondong-
Lachica, 2024). As a result of the rapid and cumulative urbanization of Metro Manila and the expanding operations of the hospital, the
existing condition of PGH and most of its facilities, if not considered obsolete and deteriorated, are incompliant with existing laws and
statutory policies to ensure a safe and habitable built environment. This is due to the continuous and rigorous operation of the hospital over
the years and fragmented design and construction interventions, which resulted in the worsening of some healthcare and working
conditions, adversely impacting the stakeholders of PGH, especially the marginalized sectors that the hospital is sworn to serve. Studies
show that challenges in the hospital are arising, particularly in layout optimization, which affects clinical pathways, performance
management, target management, talent management, and patient flow in hospitals, which is deemed important and highlighted by certain
studies according to 75% of hospital respondents. Hence, an aim to achieve standardized interventions for better patient safety and

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healthcare quality is envisioned (Lavado, Sanglay-Dunleavy, Matsuda, & Jimenez, 2010). Hence, as an argument, the researchers claim that
the original design principles and strategies employed in PGH that are overshadowed over time by PGH and its cumulative morphology,
particularly passive design strategies and concepts focused on tropical settings, will help generate design standards and policies for PGH and
other hospitals in the Philippines by turning the antagonized environmental conditions in the tropics into an advantage in designing and
redesigning healthcare facilities in the Philippines without fully relying upon high and expensive technologies to help improve everyone's
access to quality yet inclusive healthcare facilities and services. To do this, the researchers will employ a qualitative approach involving the
use of case study and thematic analysis methods of past and present conditions of PGH, focusing on passive design strategies by identifying
the potentials and constraints to extract and create policies that will serve as the findings of this paper. This will be made possible by
employing data gathering and analysis through foot surveys, gathering documents and artifacts, photographs and sketches, comparison and
benchmarking, and literary review and analysis of existing development controls in the Philippines to ensure that the objectives of this
research are met.

Methodology
For this paper, the researchers will conduct qualitative research through comparative thematic analysis (See Figure no. 1) of past
and present conditions of PGH, which will entail data gathering, analysis, and techniques to generate information beneficial to the study
and meet its objectives by employing:

Literary Review and Analysis

To fully understand and context the study area, the researchers analyzed and studied the historical roots and origins of PGH to
have a holistic overview of the existing situation before the foot survey and justify the findings rationally.

Figure30. Theoretical Framework of the study being conducted using Thematic Analysis

Gathering of Documents and Artifacts

Before the foot survey, the researchers secured plans and relevant documents courtesy of Archion Architects, the consultant in
charge of doing the PGH Master Plan, that can be used for validation and inspection.

Foot Survey
The researchers conducted a walking site visit of the study area in the second quarter of 2019. They immersed themselves in the
facilities and spaces to fully understand and grasp the situation in PGH. The data gathered during the foot survey will help validate the
findings from various literary reviews, reports, and information regarding PGH and its existing condition.

Photographs and Sketches

During the foot survey, the researchers took photos to gather evidence and findings of PGH and its existing condition for the
benefit of this study. Aside from photos, the researchers also produced digital sketches and drawings to reinforce the findings of the foot
survey.

SWOT-TOWS Analysis
To determine the positive and negative internal factors—that is, the strengths and weaknesses that are within the control of the
stakeholders or organization for the creation of solutions that directly address the negative issues or enhance the existing positive issues—
and external factors—that is, the opportunities and threats where the stakeholders or organization has a limit of control and only mitigation
or intervention can be made to adapt or adopt with the identified conditions of PGHs—the researchers will use a SWOT Analysis (See Figure
no. 2) on each finding impacting the best passive design practices for hospitals in the tropics (See Figure no. 1). The main goal of this study
is to produce policies, which can be achieved by extracting the potentials and constraints through a TOWS Analysis.

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 Figure31. Sample SWOT Analysis to be employed as a methodology for the study.

Results
To contextualize the contents of this study, the researchers categorized the result of the findings for an organized and systematic
data and information presentation, namely;

The Philippine General Hospital, its History, Condition, and Value

Figure32. PGH during its early ages (left) to its current look (right)
(Source: https://static5.akpool.de/images/cards/212/2126946.jpg; https://up.edu.ph/up-pgh-to-continue-treating-non-covid-19-patients-
even-as-a-covid-19-referral-center/)

The Philippine General Hospital (PGH) is a top healthcare facility in the Philippines, serving over 600,000 patients annually. Built
in 1910, it offers a complete spectrum of medical, surgical, and diagnostic services, employing several top physicians nationwide. The hospital
is located on the University of the Philippines Manila campus, covering an area of about ten (10) hectares.

Figure33. PGH and the aftermath of the World War 2

(Source: https://coconuts.co/manila/features/10-landmarks-survived-battle-manila/ 053019;
https://www.trumanlibrary.gov/photograph-records/2013-4247)

Over time, PGH has withstood various calamities and disasters, especially World War II, which spanned the first quarter of the
20th century (See Figure no. 4). The PGH then, once used as a garrison by the Japanese during World War II, has since expanded from a 330-
bed hospital into a national University Hospital with 1,100 beds, 400 private beds, and 4,000 employees. Despite its growth and expansion,
the hospital's outdated structures, urbanization impacts, and exceeding operational capacity have deteriorated, affecting its ability to meet
healthcare needs, particularly regarding space and infection control. With the subsequent use and abuse, PGH has cumulatively worn down
most of its buildings, resulting in operational inefficiencies and non-compliance with various standards, laws, and statutory policies. Hence,

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for the next 25 years, PGH developed a Master Plan to direct its growth and development courtesy of Archion Architects and their Medical
Master Plan for PGH (Archion, 2019).

Figure34. The Proposed Medical Master Plan of PGH (Source: Archion Architects)

Located along Taft Avenue, one of Metro Manila's main thoroughfares, the hospital is strategically placed in the heart of Manila,
near major commercial complexes like Robinson's Manila. The Pedro Gil and United Nations Avenue Light Rail Transit 1 (LRT 1) stations are
conveniently near the campus.

Figure35. Site Orientation of PGH showing existing roads, sunpath, and prevailing winds "Amihan" (Cold Front), and "Habagat"
(Southwest torrential monsoon) (Source: Archion Architects)

The hospital is within a vulnerability zone vulnerable to damage from storm surges, tsunamis, and rising sea levels, making it
vulnerable to flooding (Archion, 2019). The Philippine General Hospital was founded in 1907 during the American colonial era. The Philippine
National Historical Commission has determined the following PGH buildings to be culturally significant, representing the structures' practical
uses and outstanding historical buildings that epitomize important architectural eras in Philippine history. These historic structures are still
standing and well maintained as important creations of renowned architects. The City Beautiful Movement by Daniel Burnham inspired the
architecture of the Philippine General Hospital. The movement aimed to promote healthy and livable surroundings by addressing the
pathological aspect of Manila's city planning. The hospital's planning included hierarchy in constructing buildings, open spaces, and road
networks to create an anachronistic and imperialist order and identity.

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 Figure36. Morphology of PGH from 1907 to 2012 (Source: Archion Architects)

The architectural design of buildings was influenced by architects educated at the Bon Ecole des Beaux-Arts in Paris, who
demonstrated the harmony and balance of Neoclassical and Baroque styles. The ideas of the City Beautiful Movement have improved the
physical environment. However, the American benevolent assimilation also created resistance, where architecture was subtly used as a
weapon for colonization and domination. The Americans used this blending of architectural styles to respect indigenous knowledge, provide
a non-invasive sense of place to the Filipino people, be flexible in design, and accommodate cultural variances. Grandiose in scale, geometric
form simplicity, Greco-Roman details application, dramatic use of columns, and a penchant for blank walls define neoclassical architecture,
not to be confused with Greco-Roman revival. Conversely, dominant mirador towers, white plastered walls, round arch entrances, and
curvilinear parapets define the Spanish Mission Revival. These days, this kind of building narrates a great deal about history and is considered
necessary (Lico et al., 2017). The National Historical Commission of the Philippines and the National Cultural Heritage Act of 2009 consider
that an Important Cultural Property should be safeguarded against exportation, modification, or demolition and receive government funding
in advance for preservation, conservation, and restoration (NHCP, 2011).

Landscaping
Vegetation and other landscaping elements are important for hospitals in the tropics as they support psychological and
physiological health, significantly optimizing user and end-user experience, improving mental health, and lessening depression symptoms
(Chang & Chien, 2017), (Faris & Shukor, 2012). It also shields buildings from the sun, diverts wind, blocks precipitation, augments passive
cooling, and provides better natural ventilation (Boers, Hagoort, Scheepers, & Helbich, 2018), (Kondo, Fluehr, McKeon, & Branas, Urban
Green Space and Its Impact on Human Health, 2018). However, providing vegetation and other landscaping elements is only superficial.
According to studies, the arrangement and placement of plants affect airflow and microclimate air temperature in buildings. (Perini, Ottelé,
Fraaij, Haas, & Raiteri, 2011), (Zhang, Bae, & Kim, 2019). Design, density, and selection of vegetation also impact airflow and pollutant
deposition and dispersion, improving air quality; (Xing & Brimblecombe, 2019), (Janhäll, 2015), whereas tall and dense vegetation affects
the deposition of air pollutants near the source, shorter vegetation can enhance air circulation and air quality (Janhäll, 2015), (Dimoudi &
Nikolopoulou, 2002). Vegetation selection is also important as it can affect indoor and outdoor quality, safety, and ecology. Incorrect
selection of vegetation may lead to increasing suspended particles in the air, triggering allergies and various diseases, attracting other
unwanted microorganisms, intrusive and destructive effects on the building, and prevalence of exotic landscaping elements, which can upset
the ecological balance of the site.

Figure 37. The PGH and its facilities showcasing issues on Landscaping and similar elements
(From left to right are; Examples of unmanaged water features in PGH; another unmanaged water feature in PGH and inappropriate
vegetation in PGH; and unmanaged vegetative growth in open areas) (Photo taken: May 11, 2019)

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 The researchers found that PGH incorporated landscaping elements and features into the development when she visited the
study area and noticed it was adorned with vegetation. Still, the problems with poorly maintained landscapes and poor plant selection are
the root causes of landscaping problems. Because the development needs to properly manage the organically growing open areas
designated for landscaping, vegetative growth becomes uncontrollably wild and unbalanced. Several issues sprang from this situation,
including encroachment into spaces, building envelopes, and other areas thought unneeded for landscaping. There are also unmanaged and
stagnant water features on the site, which are prone to the growth of mosquitoes and other unwanted microorganisms, which is detrimental
to health. If left unmanaged, PGH will suffer more damage and deterioration to the building, less space optimization and performance,
and cross-contamination of the spaces. Another area for improvement with landscaping is choosing the right plants. A possible fire hazard
was discovered during the site visit by the presence of certain plants, such as eucalyptus, which is well-known for its capacity to drive away
mosquitoes, which are primarily endemic to tropical regions. Furthermore, some plants that can worsen patient conditions by causing
allergic reactions and other health risks are included in the complex. Some plants are also recognized to be developing exotic species. Exotic
species have not evolved to be much adapted to the native species or abiotic components of that system. They may move independently or
be brought to new places by people, but only when their movement is ecological as opposed to merely geographic are they regarded as
exotic. Calls for removing or managing exotic species arise from their potential negative impacts on ecosystems and biodiversity (Paul, 2001;
Luke et al., 2007). However, the said removal should be replaced with correct and proper landscaping. Aside from harnessing a favorable
environment for workers and patients, landscaping can help reduce the impact of storm surges. As seen in Figure no. 9, PGH is highly
vulnerable to storm surge, which, by history, is one of the fatal natural disasters that transpired in the Philippines in 2013, which took a toll
of 6,300 fatalities. Hence, addressing this issue with the help of landscaping can help minimize the adverse effects of natural disasters,
ensuring safety and security.

Figure 38. Projected storm surge conditions in PGH (Source: https://noah.up.edu.ph/)

Table 6. SWOT-TOWS diagram analysis for landscaping conditions of PGH

Strengths Weaknesses
1. Availability of open spaces for 1. Presence of Exotic Plants
Landscaping SWOT-TOWS analysis landscaping activities 2. Presence of allergenic and health-hazard
vegetation
3. Unmanaged landscape
1. Good soil to accommodate 1. Install native plants to improve 1. Replace exotic with native plants to
landscaping elements environmental ecological health improve environmental and ecological
2. Tropical climate conditions to 2. Install native plants with little to no health
Opportunities

accommodate vegetation health and safety risks 2. Replace potentially hazardous and
allergenic plants to improve patient
recovery and experience
3. Create a landscape management plan
and use low-maintenance landscaping
features to reduce cost without
compromising environmental quality
1. Possible prevalence of Storm 1. Install plants that can reduce the 1. Design landscape areas to be resilient
Surge impact of storm surges. and capable to withstand natural
Threats

2. Polluted environment and 2. Install plants that can help improve disasters
poor air quality the indoor and outdoor air quality of 2. Install native plants that help improve
PGH indoor and outdoor air quality.

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Open Spaces
Open spaces in hospitals are essential for controlling the microclimate conditions, giving residents a comfortable
environment, and significantly lowering the prevalence of COVID-19 and other infectious diseases (Yung Yung, Norhayati, & Norafida, 2018),
(Ekhtiari & Akbari, 2022), (Jiang, et al., 2021); (Jiang, et al., 2022). Response and recovery from natural disasters also depend heavily on
public open spaces. When properly planned and designed, it can improve disaster resilience by acting as agents of recovery, offering life
support, and acting as primary points for safety and emergency routes (Shi & Woolley, 2018). Open spaces also offer places for surface
runoff water retention and percolation as they lower the chance of flooding (Lourenço, Beleño de Oliveira, & Marques, 2020), (Silva & Costa,
2018). Open spaces, with proper planning, management, and maintenance, also promote efficient and sustainable landscaping practices
and strategies (Adekunle & Basorun, The Evolving Roles of Landscaping in Campus Space Management: Ekiti State University, Ado-Ekiti,
Nigeria in Focus, 2016); (Ganesh, Sinha, Verma, & Dewangan, 2021) and enhance airflow to facilitate effective and efficient natural
ventilation (Kleiven, 2003).

Figure 39. Mapping of open spaces in PGH (Red, Purple, and Gray: Impervious Surface Area, Green and Yellow: Unpaved Surface Area)
(Source: Archion Architects)

The researchers found that although there is an abundance of open spaces in PGH (See Figure no. 10), the allocation of these
open spaces is not balanced properly. As shown in Table no. 2, which is from Presidential Decree no. 1096, also known as the National
Building Code of the Philippines, There are two (2) types of open spaces, namely: Impervious Surface Area (ISA), which is the paved open
spaces for roads, sidewalks, and other paved developments inside a site, and Unpaved Surface Area (USA), which is the unpaved open spaces
for gardens, lawns, and similar developments within a site (Republic of the Philippines, 1977). The findings of Table no. 2 show that PGH has
an excess of 16,150.65 square meters of ISA and a deficit of 15,898.29 square meters of USA, which means that the abundance of open
spaces within PGH is excessively allotted to paved open spaces, and is extremely lacking on unpaved open spaces. Not to mention that, as
shown in Figure No. 12, the current condition of the unpaved courtyards for unpaved open spaces is unmanaged and underutilized. This
scenario may exacerbate the quality of the environment where PGH is situated, especially as shown on Figure no. 11, PGH is susceptible to
the adverse impacts of flooding. And without sufficient unpaved open spaces, the quality of environment to promote a healthy, safe, and
secured development is compromised.

Table 7. Computation of PGH's Total Lot Area composition (Source: Archion Architects)
PD no. 1096 Existing
Site Development Parameters Remarks
Limits % sq. m. % sq. m.
Total Lot Area Fixed 100% 95,179.00 100% 95,179.00 - -
PSO Maximum 50% 47,589.50 49.73% 47,337.14 252.36 Excess
ISA Maximum 20% 19,035.80 36.97% 35,186.45 (16,150.65) Surplus
USA Minimum 30% 28,553.70 13.30% 12,655.41 15,898.29 Deficit

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 Figure 40. Projected flooding conditions in PGH (Source: https://noah.up.edu.ph/)

Figure 41 The PGH and its facilities showcasing issues in designing and managing their open spaces (From left to right are; Typical photo of
a courtyard in PGH, Waste management measures of PGH affecting open spaces; Exposed and unprotected utility courtyards in PGH
directly adjacent to the Emergency Department) (Photo taken: May 11, 2019)

Table 8. SWOT-TOWS diagram analysis for open space conditions of PGH

Strengths Weaknesses
1. Unbalanced distribution of open
Open Spaces SWOT-TOWS analysis
1. Availability of open spaces spaces
2. Unmanaged open spaces
1. Identify in the master plan the ideal
Opportunities

1. Include on the redevelopment and paved versus unpaved open spaces

1. Ongoing redevelopment and master master plan directives of PGH the ratio
plan of PGH management and proper allocation of 2. Mandate the property management
open spaces. and its role to improve and manage
open spaces effectively
1. Protect and rehabilitate existing open
1. The expansion of PGH should be
Threats

1. Future expansion of PGH and its spaces by proper allocation and

more preferably vertical than
built-up areas establishing development limits and
horizontal.
restrictions

Natural Ventilation
Hospitals can maximize natural ventilation by orienting facades toward the wind direction, building on a north-south orientation,
and using atriums and courtyards for natural lighting and ventilation (Mahmoud, Badrawy, & Mousa, 2019). With high air changes per hour
from opening windows and doors, there is less chance of airborne infection than in rooms with mechanical ventilation. Architects consider
wind an essential factor in reducing the energy needed for fans and mechanical cooling, so they incorporate natural ventilation (Kleiven,
2003). Natural ventilation in buildings is accomplished using wind towers, chimneys, stack ventilation, single-sided ventilation, and double
façades. In tropical areas, natural ventilation can increase indoor environmental quality and energy efficiency, enhancing thermal comfort
in hospital design, whereas improving the indoor environment requires mechanical ventilation systems (Kleiven, 2003). However, adding air
conditioning to naturally ventilated wards can raise operating and energy costs (Rahman, Haw, & Fazlizan, 2021). Additionally, ventilator
fans, cross ventilation, and passive cooling techniques are preferable over artificial ventilation sources to improve thermal comfort in tropical
climate buildings, which can cause sick building syndrome. Air conditioning systems significantly impact indoor air quality, particularly in

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hospitals where HVAC systems are crucial for maintaining clean air. Poorly maintained systems can increase risks of sick building syndrome
and building-related illnesses due to microbial contamination. Air conditioners can build up pollutants like CO2 in residential buildings
without fresh air intake. Monitoring indoor air quality parameters like CO2 concentration is essential for assessing IAQ and ensuring occupant
comfort (Božić, Ilić, & ilić, 2019); (Wong & Huang, 2004); (Mansouri, Wei, Alessandrini, & Mandin, 2022); (Wong, Mui, Shi, & Hui, 2008). Air
conditioning systems are crucial in reducing microbiological contamination in hospitals, and consistent control strategies help decrease the
risk of bacterial and fungal infections. Regular air-control measures are essential for reducing the dissemination of airborne biological
particles (Rahayu, Saam, Sukendi, & Afandi, 2019); (Božić, Ilić, & ilić, 2019). Aside from windows, ventilators, air conditioning, building
orientation, and facade designs affect ventilation and indoor air quality. Thermal comfort can be attained with minimal energy consumption
using adequate ventilation systems and facade components such as window sizes, shading, and building materials (Chenari, Carrilho, & da
Silva, 2016); (Tschirhart, Jiraporncharoen, & Angkurawaranon, 2020). Natural ventilation within classrooms has been shown to improve the
temperature, relative humidity, and carbon dioxide concentration. Comfort levels can be maintained while CO2 concentration is
reduced using basic natural ventilation methods (Almeida, Pinto, Pinho, & Lemos, 2016); (Jia, et al., 2021)

Figure 42. The PGH and its facilities showcasing augmented natural ventilation strategies and operational conditions (From left to right
are; Typical photo of nursing wards, emergency department; Tuberculosis Directly-observed treatment short-course (TB-DOTS) and
infectious diseases facility, and Pharmacy) (Photo taken: May 11, 2019)

Researchers discovered that the original William Parsons design of PGH retained large window openings, single-loaded corridors,
arcaded walkways, and public areas. With a passive design approach, this feature enhances PGH's need to allow natural ventilation and
lighting. This approach helps PGH cut its overhead costs related to technology and maintenance and encourages and develops a low-impact,
ecologically friendly, and compliant development. Furthermore, this approach contributes to the previously mentioned advantages of
natural ventilation for tropical healthcare facilities. Nevertheless, this characteristic is not seen in its entirety or in detail during
development. The features mentioned above lead to the inappropriate use of some open areas where air can flow freely and effectively. A
case in point is shown in Figure 13, where patients are housed in makeshift wards on public single-loaded corridors. This may lead to cross-
contamination and the spread of infectious diseases throughout the hospital's premises. Some open spaces are also used as improvised
storage areas because of their size, which can lower the efficacy and quality of hospital supplies. As Figure No. 13 shows, some areas that
need natural ventilation to achieve a good air change rate also lack it, which can result in cross-contamination and the spread of different
diseases. High humidity is also anticipated because of the Philippines' hot and humid weather and PGH's proximity to Manila Bay. Large
window openings allow humidity to have negative effects such as fungal, mold, mildew, and vegetative growth on unexpected areas such
as various building surfaces, including ceilings, walls, floors, fenestrations, and more which can render the hospital premises unsafe,
unsanitary, and potentially lead to even more deteriorations which is the very opposite of what a healthcare facility needs. The local pollution
levels are another urgent problem with ventilation. The area is experiencing about 130 micrograms per standard cubic meter, while the
acceptable limits are framed at only 60 micrograms per standard cubic meter, as Table No. 4 illustrates. Even though air quality is improving,
as Table 4 indicates, it is still insufficient to guarantee and ensure a healthy environment suitable for medical facilities.

Table 9. Total suspended particulate matter reports in the vicinity of PGH

Source: https://air.emb.gov.ph/wp-content/uploads/2016/04/DenrAirQualityStatReport10-11.pdf; https://emb.gov.ph/wp-

content/uploads/2015/09/1-Air-Quality-1.8-National-Air-Quality-Status- Report-2008-2015.pdf

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Table 10. SWOT-TOWS diagram analysis for natural ventilation conditions of PGH
Strengths Weaknesses
1. Availability of large fenestrations 1. Some spaces lack fenestrations where
Natural Ventilation SWOT-TOWS analysis 2. Availability of single-loaded corridors it is supposedly needed
3. Availability of Open Spaces 2. Public spaces where air circulates are
used inappropriately
1. High levels of humidity creating a 1. Maximize capture of air but retaining, 1. Identify spaces that require natural
cooler air rehabilitating, and providing ventilation and determine adequate
2. Existing facilities using the original additional large fenestrations window sizes to optimize airflow in
design are designed for a tropical 2. Reflect on the original design of PGH spaces where it is needed.
setting by William Parsons, as it is found that 2. Supplement the lacking spaces to
Opportunities

certain features promote good avoid makeshift interventions on

natural ventilation spaces within PGH
3. Maximize and optimize existing 3. Consult the original design of PGH and
features promoting natural assess if the old hospital is amenable
ventilation in PGH to current interventions or if new
buildings are needed for PGH not to
compromise the quality of existing
facilities.
1. High levels of humidity damage the 1. Design fenestrations, public spaces, 1. Existing and future facilities
structure and open spaces to regulate excess depending on the space, should be
2. High levels of suspended particulate humidity. designed to accommodate an
matter in air 2. Use vegetation that improves indoor acceptable volume of natural air and
3. Uncontrolled spread of diseases and and outdoor air qualities, and levels of humidity
Threats

pathogens reduces or filters particulate matter 2. PGH should mitigate the excessive
suspended in the air humidity and suspended particulate
3. Regulate utilization of public spaces matter in the air to ensure a good
and avoid utilizing public spaces for quality of airflow in PGH
activities that could create cross- 3. Identify spaces in PGH where natural
contamination and spread of airflow should be regulated
pathogens

Natural Lighting
Ineffective and uncontrollable natural and artificial lighting in hospitals can result in error-producing conditions for workers and
adverse or lagging patient recovery and performance (McCunn, Safranek, & Davis, 2020); (Maleetipwan-Mattsson, Laike, & Johansson,
2015). Hence, it is essential for workplace productivity and patient satisfaction. Natural light is also necessary for suitable addressing of
functional issues for the architectural design of healthcare facilities as it improves in defining spatial volumes, spaces, colors, textures, and
shapes. It also impacts human psychology by influencing an excellent mental state and creating a dynamic visual environment for employees
(Ozorhon & Uraz, 2014); (Morales-Bravo & Navarrete-Hernandez, 2022). Natural light is also linked to increased thermal comfort, ensuring
a comfortable atmosphere for patients and employees, energy savings, and a lower risk of airborne infections linked to mechanical
ventilation systems (Rahman, Haw, & Fazlizan, 2021). Natural light exposure also improves patient recovery rates as it lessens headaches
and eye strain. It also shows improvements in patients with seasonal affective disorder. Together with a proper vista of the outdoors, studies
show that patients experienced shorter hospital stays after surgery and lesser use and dependence on analgesics (van den Berg, 2005); (Choi
& Beltrán, 2006). The amount of natural light affects healing processes, enhancing people's safety, productivity, and health. Employers can
also benefit financially as it promotes patient recovery rates, lowers stress levels, and keeps people in good health, making the workplace
more pleasant (Edwards & Torcellini, 2002).

Figure 43. The PGH and its facilities showcasing natural lighting strategies and operational conditions (From left to right are; Underlit
nursing home facility for the elderly in PGH; underlit nursing wards in PGH; underlit stairwells and circulation spaces in PGH, typical
naturally lit arcades and single loaded corridors in PGH) (Photo taken: May 11, 2019)

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 The researchers found that some spaces lack an adequate amount of both natural and artificial lighting. This is due to the
subsequent changes made to PGH due to the World War 2 aftermath, the expansion of services and carrying capacity, and the need to
accommodate current healthcare trends and demands. This resulted in intensifying and densifying the use of PGH, resulting in additional
spaces that consumed the former open and public areas within its original buildings, which reduced and morphed fenestration design and
spatial allocation. This resulted in a reduction of openings, leading to former naturally lit spaces being underlit, affecting its performance in
delivering a holistic and functional healthcare facility to both patients and workers. Some spaces are still naturally lit; however, they are not
maximized or even prioritized. This scenario is highly detrimental to hospital operations as it can adversely impact the safety of patients and
workers alike. This also reduces the potential benefits of natural light for patients and workers, which was mentioned in the previous
paragraph. It is highly recommended that the stakeholders involved in PGH study the basic and optimized lighting requirements for hospitals
to fully achieve a healthcare facility that is adaptable not only to tropical settings but also to the requirements of healthcare facilities in
general. One of the researcher's assumptions is that if PGH can return to its original design, natural light and ventilation optimization will be
possible. Hence, to accommodate the continuous call for PGH and the expansion of its services, it is suggested that future developments
should avoid over-intensifying and densifying spaces of existing buildings so as not to compromise their intended function.

Table 11. SWOT-TOWS diagram analysis for natural lighting conditions of PGH
Strengths Weaknesses
1. Presence of large fenestrations to 1. Some spaces lack the required
harness natural light fenestration to accommodate natural
2. Presence of public and open spaces to light
Natural Lighting SWOT-TOWS analysis harness natural lighting 2. Some spaces lack artificial lighting to
enhance the function of various
spaces

1. PGH is originally designed to function 1. Study and analyze the original design 1. Evaluate and assess PGH and its
utilizing natural light primarily of PGH on how natural lighting was current spaces, which need natural
Opportunities

utilized and maximized lighting to address fenestration sizes

2. Maximize the availability of open and other possible interventions
spaces and large fenestrations to 2. Establish a parameter for ideal natural
accommodate natural light wherever and artificial lighting requirements and
it is needed standards for PGH
1. Continuous and the need for expansion 1. Avoid over-intensifying and densifying 1. Ensure proper and adequate lumen
of PGH impacts the allotted current operational and functioning (or other units applicable) quantities
fenestrations and open spaces to facilities so as not to compromise the and standards in crucial spaces to
accommodate natural light natural lighting of PGH avoid potential accidents for both
2. Accidents are most likely to happen if 2. Limit redevelopment activities on the patients and workers
issues with natural lighting are not original facilities of PGH to avoid 2. Determine minimum window size
Threats

addressed possible compromise of spaces and requirements of various spaces in PGH

their capability to render effective 3. Determine obstructive spaces on the
and efficient operations old buildings of PGH and identify
possible future relocations of these
spaces in order to not compromise the
basic lighting requirements of some
spaces.

Conclusion
This research paper found several ways to enhance healthcare facilities in the tropics, especially in PGH, using the results from
landscaping, open spaces, natural lighting, and natural ventilation. These methods can also apply to other healthcare facilities with similar
goals and directions. Native plants can improve patient experience and environmental health in tropical healthcare facilities, so optimizing
landscaping. Among these are putting in plants to lessen the effect of storm surges, replacing potentially dangerous plants with native ones,
designing a low-maintenance landscape management plan, and enhancing the air quality inside and outdoors. Furthermore, it advises
planting native plants to improve these features and creating robust landscape areas that can resist natural calamities.
Appropriate administration and distribution of open spaces should be part of PGH's master plan and redevelopment guidelines. The master
plan should specify the ideal ratio of paved to unpaved areas, and the expansion should be vertical rather than horizontal. Effective
management of open spaces and preservation and rehabilitation of existing ones should be the mandate of property management. It is
discovered that different techniques used to optimize natural ventilation are already established precedents that seek to maximize air
capture while maintaining and rehabilitating big fenestrations. The original design of PGH and the necessity of new constructions to preserve
the caliber of the current facilities should also be considered in the strategy. The findings suggest that the interested parties review William
Parsons' original design, which encourages natural ventilation since it uses current elements like fenestrations, public areas, and open areas
to control excessive humidity. However, its capacity to maximize airflow was compromised due to the modifications made to the current
facilities over time. PGH should control too-high humidity and suspended particles to guarantee proper airflow and ensure that current and
future facilities can handle suitable natural air volume and humidity levels. Therefore, as it enhances the hygienic conditions of PGH, lowers
particulate matter in the air, and improves indoor and outdoor air quality, control of humidity levels and vegetation should be followed to
address the problem above. To prevent overusing spaces and other facilities, expansion within the development might be a good direction
to consider. Overuse of hospital facilities can have several adverse effects affecting patients and staff alike. Public spaces should also be
used responsibly to avoid cross-contamination and pathogen spread. Healthcare institutions must also identify areas that need natural
ventilation and choose suitable window sizes since this will maximize airflow in those areas most in need of it. This is so because certain
hospital areas could need ventilation or controlled or limited airflow. Complementing the empty spaces can also help to avoid improvised
interventions. To prevent improvised and temporary facilities, PGH should reassess its spatial inventory, determine what is missing or lacking
in its facilities, and take appropriate action. Still, PGH is one of many places where these results are applicable. On natural lighting, It is

144
imperative to maximize open spaces and large windows on natural lighting, avoid over-intensification and densification of the current
facilities, and limit redevelopment activities on the original facilities. These factors help provide ideal natural and artificial lighting
requirements, guarantee appropriate lumen quantities and standards in critical areas, and determine minimum window size requirements
for various spaces. It is also essential to study PGH's existing condition and layout to find obstructive spaces on the old buildings and revert
to their original design, which harnesses natural lighting as a design feature. It is also essential to assess and evaluate PGH's current natural
lighting conditions quantitatively to maintain basic lighting needs. This is to lower the risk of accidents involving patients and staff and ensure
effective and efficient operations for healthcare facilities in the tropics and in general. The policies and principles may also be modified by
current and future healthcare institutions choosing to optimize the resources offered by tropical environments. To summarize most of the
mentioned policies and principles, many design strategies to maximize the benefits and resources of a tropical climate can be seen and
learned from the previous and original design of PGH. It is highly recommended that a study to extract further and identify other design
principles and standards employed before the institutionalization of the National Building Code of the Philippines to PGH be done to identify
other best practices of the architects in maximizing the resources within the tropics, and design in general. Aside from extracting past lessons
from the original buildings of PGH, it is also ideal if these passive design strategies from the original building design of PGH be enhanced and
augmented by current technologies to amplify sustainable practices in architectural design, which promotes good environmental quality
and responsibility to the site which it serves, and the site where it is situated.

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