Designing Hospitals for East Africa: Which International Standards Apply in Kenya, Tanzania and Uganda?

The question, and the answer that actually governs

A promoter planning a hospital in Kisumu, Mwanza or Mbarara usually asks which international standard the hospital must follow, and expects a one-word answer: FGI, or JCI, or WHO.

The accurate answer begins by correcting an assumption repeated across most international commentary on the region: that East African countries lack hospital design regulation, and that international guidelines therefore fill an empty space. That is false, and it is checkable in an afternoon. All three ministries publish national facility standards, named above.

The real situation is more specific and more consequential. All three countries regulate hospitals through a licensing-tier system. The statutory documents answer one question with precision: at this facility level, what must the hospital provide, contain and be staffed with in order to be licensed? They do not answer the architect’s question: how should these departments be dimensioned, related, serviced and sequenced so the hospital works?

Those are two different instruments. A promoter who satisfies the tier and stops has a hospital that can open and cannot function well. One who adopts FGI wholesale and ignores the tier risks an expensive building that falls short of a statutory requirement the national standard specified all along. The second mistake is more common among international consultants; the first is more common among promoters. Both are avoidable, and both are decided before a line is drawn.

Hospital design in East Africa is governed by more than one instrument, and this article maps all of them: the five layers of authority, the route through each country, where FGI, HTM, JCI, WHO and SafeCare enter, what the radiation regulator separately controls, and which operating conditions reorder planning priorities. For what each international standard contains, see the companion article on FGI, HTM, JCI and NABH.

Five layers of authority, and why they are not interchangeable

Most confusion about hospital standards in this region comes from collapsing distinct instruments into a single question. There are five layers, each with a different legal character and a different enforcing body.

Layer 1 — The statute. The Act that makes it unlawful to operate a health facility without authorisation: Kenya’s Health Act, 2017, with facility registration under Cap 253; Tanzania’s Private Hospitals (Regulation) Act; Uganda’s Ministry of Health licensing framework. The statute does not describe buildings. It creates the obligation.

Layer 2 — The facility tier standard. The national document translating that obligation into what a facility of a given classification must contain. Kenya uses the six levels of the Kenya Essential Package for Health; Tanzania runs dispensary, health centre, hospital and referral hospital; Uganda runs health centre levels through general, regional referral and national referral hospitals. This layer is the mandatory floor.

Layer 3 — The licensing and inspection body. The authority that checks Layer 2 and issues the licence — in Kenya the Kenya Medical Practitioners and Dentists Council, which requires architectural plans as part of the submission, making the design itself a regulatory instrument rather than a construction document.

Layer 4 — The parallel approvals. Development and zoning consent, environmental clearance, fire and public health requirements, professional registration of whoever signs the drawings, and — where a radiation source is involved — the national radiation regulator. Each runs on its own timeline and answers to a different institution. A project that satisfies Layers 1 to 3 and neglects Layer 4 does not get built.

Layer 5 — The adopted specification. FGI, HTM, WHO facility guidance, ASHRAE, JCI, SafeCare. None is statutory in any of the three countries. Each becomes binding on a project because a funding agreement, an operator brief, an insurer or an accreditation ambition makes it so.

The practical rule follows directly. Layers 1 to 4 are established, not chosen. Layer 5 is chosen, and must be chosen consciously. A promoter who cannot say which framework governs Layer 5 on their project has not yet defined the project, and an architect who begins design before that answer exists is drawing on an assumption.

Kenya: the route

Health facilities are regulated under the Health Act, 2017, and classified across the six levels of the Kenya Essential Package for Health, each carrying defined service, capacity and staffing expectations. The Ministry of Health publishes Health Infrastructure Norms and Standards, indexed on its guidelines portal and hosted on the national health facility registry.

Registration and annual licensing of private, community and faith-based facilities sits with the Kenya Medical Practitioners and Dentists Council under Cap 253 of the Laws of Kenya. The submission includes architectural plans for hospitals and nursing homes, professional qualifications for clinical staff, clinical waste-management provision, and an inspection report following a pre-licensing site visit. The design is therefore part of the licence application, not merely a construction document — a distinction that changes when drawings must be complete.

Two further tracks run in parallel and are routinely underestimated. Kenya’s health governance is devolved, so county development and zoning approval is a separate consent with its own requirements and timeline, and those differ by county — a promoter in Kisumu and a promoter in Nakuru are not navigating an identical process. Environmental impact assessment through the national environmental authority applies to facilities of any scale.

Kenya’s structural distinction is this multiplicity. National standards, a county approval track, a professional council registration, an environmental clearance and, for radiation facilities, a separate regulator — each on its own clock. The planning consequence is that programme risk in Kenya is concentrated in approvals, not in construction, and the sequencing of those approvals belongs in the project programme from day one.

Tanzania: the route

Private facilities are governed by the Private Hospitals (Regulation) Act and its Standard Guidelines for Health Facilities Regulations, with the Ministry of Health publishing basic standards by facility level — dispensary, health centre, hospital, referral hospital — that address licensure, management, clinical services and, explicitly, infrastructure: premises, construction and safety. Tanzania also publishes national guidelines on water, sanitation and hygiene services in health care facilities that reach into the technical design and construction of those facilities directly.

Tanzania’s structural distinction is the weight its system places on the declared tier. Facility level drives statutory requirements directly, so a promoter who has not settled the tier has not yet defined the project — and a tier change late in design is not a variation, it is a different building.

A second feature matters commercially and is frequently missed by outside advisers. Faith-based hospitals in Tanzania can be designated to carry district hospital functions, which places a mission facility inside the public referral structure with the service obligations, catchment expectations and reporting that follow. For an architect, a designated facility is not planned like a private hospital of the same bed count. Its referral role, its bed mix and its outpatient load are set by its position in the public system.

Uganda: the route

Facilities are licensed through the Ministry of Health and the Uganda Medical and Dental Practitioners Council, within a tier system running from health centre levels through general, regional referral and national referral hospitals. The Ministry’s Health Sector Service Standards carry basic building requirements per facility level and point to the Ministry’s own health infrastructure designs, with standards referenced against Uganda National Bureau of Standards codes. Separate guidelines govern the designation, establishment and upgrading of health units — which matters to any promoter planning to move a facility up a tier later.

Uganda’s structural distinction is who commissions the work. The private-not-for-profit sector is unusually large, and the faith-based medical bureaus — Catholic, Protestant and Muslim — are institutional participants in Ministry of Health policy and standards processes rather than passive facility owners. In Uganda the mission networks are not merely clients. Their procurement logic, capital rhythm and governance differ from a private promoter’s, and a project brief written for one does not transfer to the other.

Who signs the drawings

Architecture is a licensed profession across the region. The statutory building-plan submission and construction supervision are carried by a locally registered architect — the Board of Registration of Architects and Quantity Surveyors in Kenya, the Architects and Quantity Surveyors Registration Board in Tanzania, and the Architects Registration Board in Uganda.

Specialist healthcare planning sits outside that reservation. Clinical briefing, departmental and adjacency planning, equipment planning, radiation-facility planning and standards strategy are consultancy work, not reserved acts, which is why hospital projects pair a specialist healthcare planner with a local architect of record. What matters at planning stage is only that the pairing is settled at appointment rather than left to permit stage, because the planner’s work begins well before there are drawings to submit.

Where international standards actually enter

Above the statutory floor sits the specification layer. This is where FGI, HTM, WHO guidance, ASHRAE, JCI and SafeCare live, and where a project’s ambition is expressed.

The operative discipline is that this layer must be established, not assumed. Donor-funded and development-financed projects frequently name a design framework in the funding agreement or terms of reference, and institutional lenders impose environmental and social requirements that enter the planning brief in their own right. The answer exists in writing on any given project, and should be read before an architect is briefed rather than discovered at design review.

How live this question is can be seen in the region’s regional cancer programmes, where centres inside a single national rollout are routinely financed by different development partners. Different funders in one national programme means the specification overlay can differ from centre to centre inside a single country, for the same clinical service, under the same ministry. Geography did not determine the specification. The funding agreement did.

Two consequences follow. Adopting FGI where no funder required it buys FGI-level cost without FGI-level obligation, and the value-engineering that follows usually strips the clinical benefit while keeping the expense. Treating the tier standard as a complete design brief produces a licensed building that works badly. The disciplined sequence: satisfy the tier, establish the mandated framework, then adopt further guidance selectively where it demonstrably improves clinical function or operating cost.

The quality ladder is wider than JCI

Commentary on the region treats JCI as the default quality ambition. Across these three countries it is the exception — held by a small number of facilities in the largest cities, and representing a commitment in cost, staffing and systems that most 50–200 bed hospitals have no reason to make.

For many mission hospitals and mid-size private facilities, the more appropriate benchmark is SafeCare: standards developed by PharmAccess with Joint Commission International and the Council for Health Service Accreditation of Southern Africa, accredited by ISQua and written specifically for healthcare in resource-restricted settings. It differs from JCI in kind rather than in difficulty. It grades facilities on a stepwise improvement ladder rather than a single pass-or-fail bar, which suits a facility building capability over time. Some tertiary hospitals are right to target JCI from the outset; the point is that the choice should be deliberate rather than inherited from commentary. It has been adopted within national quality assurance programmes in Kenya and is active in Tanzania, which gives it institutional as well as clinical weight.

SafeCare is a quality-certification pathway, not a design code, and should never be treated as one. But it carries direct planning consequences: a hospital intending to climb its levels must be planned so the building does not cap its grade. Separation of clean and dirty flows, sterilisation logic, records security, sanitation and waste handling sit in the architecture, not the management system. Staged ambition works — licensing at opening, SafeCare in early operation, JCI held open — but only if the plan does not spatially foreclose the higher rungs.

The conditions that reorder planning priorities

Standards settle what the hospital must satisfy. Operating conditions settle what the plan must prioritise, and this is where resource-constrained planning stops being a phrase and becomes a set of numbers. Four conditions dominate across all three countries at differing intensities, and each claims land, capital and programme — which makes each a pre-design decision, not an engineering detail.

Power. Power reliability differs between the three countries, and within each between the capital and the secondary towns. The planning consequence is constant: the hospital is planned around a defined autonomy — hours of full clinical operation independent of the grid, which departments hold protection priority, and how much site area, structure and fuel logistics generation and storage require. Those numbers size real estate and capital budget.

Water. Water scarcity is a planning condition rather than an occasional event across much of the region: municipal supply is variable in the cities and often partial in secondary towns; boreholes, storage and treatment are standard on mission and development-financed projects, and Tanzania publishes national guidelines on water and sanitation services in health facilities. Storage autonomy in days and the water discipline of the highest-demand departments must be fixed before the site plan is frozen, because tanks, plant and boreholes claim land.

Workforce and maintenance capability. Specialist clinical staff are unevenly distributed in all three countries, and so — more consequentially for architecture — are biomedical and maintenance engineers. Staff housing on or adjacent to site is a retention instrument in secondary cities and belongs in the site plan. Every system specified must be maintainable by the workforce that will actually exist around the hospital: lifecycle mismatch is committed at planning stage and discovered in year five.

This is not a marginal concern, and the region’s governments treat it as first-order. Intergovernmental participation agreements and tripartite service-level agreements are now signed between national health ministries and county or district governments, establishing frameworks for preventive maintenance, quality assurance and rapid technical support specifically for high-value radiotherapy equipment. When a national government signs maintenance agreements at the same level of ceremony as the equipment itself, the message to any promoter is explicit: the installation is not the achievement. The uptime is.

Supply chain and capital rhythm. Much of the medical infrastructure these hospitals depend on — imaging, radiotherapy, sterile processing and critical-care equipment — is imported across all three countries, with the lead times and cost exposure that implies, and capital in this segment arrives in tranches. Together these make phasing a planning instrument rather than a programme detail: the site must be planned as a sequence of complete, functioning hospitals, not as one end state that is unaffordable until the final phase.

None of this argues for lower standards. It argues for correctly ordered priorities.

East Africa is not one climate

Precision matters here, because this is where outside commentary most often forfeits its credibility. Nairobi sits at altitude in a mild highland climate. Mombasa and Dar es Salaam are hot, humid coastal environments. Kampala is equatorial. The genuinely hot, dry conditions occur in the arid and semi-arid corridors — northern Kenya through Garissa, Wajir and Turkana, the central Tanzanian plateau, and parts of northern Uganda.

Climate-responsive healthcare design is therefore a site-level brief, not a regional one. A hospital in Nairobi, one in Mombasa and one in Lodwar face three different climate briefs, and a consultant arriving with one answer for all three has not understood the region. The architectural methods for hot and resource-constrained conditions are treated separately in this publication. At planning level the requirement is only this: the climate brief is written for the actual site, before the building form is fixed.

Where Indian and East African planning conditions converge

The convergences are real: constrained capital, assumed utility interruption, import exposure, maintenance-sensitive specification, and radiation licensing as a separate discipline. The divergences matter equally — statutory instrument, climate sub-region and professional registration are country-specific on every project.

Cancer infrastructure: the standards that travel, and the regulator that does not

Radiation medicine is the one domain where international standards apply across these countries with almost no local variation. The physics of a bunker does not change at a border, and the IAEA safety standards — the International Basic Safety Standards, GSR Part 3, together with the associated safety guides for radiotherapy facilities — are the international reference from which national radiation frameworks are built. What does not travel is the regulator, and the regulator is the binding party.

Kenya. The Kenya Nuclear Regulatory Authority operates under the Nuclear Regulatory Act No. 29 of 2019, which commenced in January 2020 and succeeded the former Radiation Protection Board. That Act carries a provision every promoter and architect planning oncology should read: it defines a regulated “activity” to include the siting, construction, commissioning, operation and decommissioning of facilities. Siting and construction are themselves regulated acts. A radiotherapy bunker in Kenya is a licensing matter before it is a building matter. Kenya’s radiation framework is comprehensive and still being built out, with further regulations in development — which tells a promoter something useful: engagement with the regulator is a live conversation, not the reading of a settled code.

Tanzania. The Tanzania Atomic Energy Commission authorises the possession and use of radiotherapy sources under the Atomic Energy Act No. 7 of 2003, through a dedicated application covering the facility and its proposed commissioning date.

Uganda. The Atomic Energy Council regulates under the Atomic Energy Act, Cap 154, requiring advance notification of any practice involving a radiation source. Its register covers medical facilities holding radiation sources across the country, and notification is required before a practice begins rather than after a facility is built.

The capacity picture, and where it is moving. This is the part most commentary gets wrong by treating the region as static. It is not static, and the direction of movement is the commercial headline.

Public radiotherapy in all three countries began as a capital-city service, concentrated in a small number of national referral hospitals. It is now being deliberately pushed outward into regional referral cities, financed through a mix of national budget, IAEA programmes and bilateral development partners, and commissioned at a pace set by funding rather than by clinical demand. Cancer incidence in each country runs far ahead of the treatment capacity available to meet it, which is the pressure driving the expansion.

Installed capacity is therefore a moving number in every one of these countries, and no article should be read as a register of it. The IAEA’s Directory of Radiotherapy Centres is the authoritative source for what exists on any given date, and it should be checked directly at the start of a project rather than taken from commentary.

The planning headline is the same across the region: radiotherapy capacity is being deliberately decentralised out of the capitals into regional referral cities. That is precisely the secondary-city, capital-disciplined, maintenance-exposed project type where hospital planning is hardest and where getting it wrong is least recoverable.

One rule follows for any hospital that may ever host cancer services: the radiation facility is planned at the beginning, even when built in phase three. Bunker siting, structural provision, shielded circulation and regulator engagement cannot be retrofitted into a completed site plan at tolerable cost, and in Kenya the siting decision is itself a regulated act. The technical planning of these facilities is covered in this publication’s LINAC and PET-CT articles.

What transfers from hot, resource-constrained hospital practice

Certain operating constraints recur across geographies, and planning judgment formed under them transfers, even where statutory instrument, climate sub-region and professional registration must be established country by country.

Studio Athenos has planned hospitals in Rajasthan since 2007 under a standing set of conditions: summer temperatures above 45°C, grids that cannot be assumed, water that must be stored and treated, doctor-founder promoters building 50–200 bed hospitals under strict capital discipline, and maintenance ecosystems that punish over-complex specification.

Power and water autonomy are fixed as numbers before schematic design. Phasing is planned as a sequence of complete hospitals rather than a single end-state drawing. Maintainability is treated as a design criterion equal in weight to clinical function — the discipline the region’s governments now write into service-level agreements for their own regional cancer equipment. Specification is matched to the service ecosystem that will actually exist rather than to catalogue ambition. Regulated radiation facilities are planned from the first site sketch, under India’s AERB regime — one of the more demanding national radiation-licensing frameworks, and structurally comparable to the IAEA-anchored licensing KNRA, TAEC and Uganda’s Atomic Energy Council administer. The 150-bed NABH-accredited Balaji Cure & Care Hospital in Jaipur and the AERB-licensed cancer centre at Bikaner were planned under exactly these constraints.

Eight mistakes that recur, and the decision that prevents each

• Assuming there is no local design regulation. Prevented by: obtaining the national facility standards and the tier requirements at inception, before any international framework is discussed.

• Treating the licensing tier as a design brief. Prevented by: recognising the tier defines what must exist, and sourcing the departmental specification separately and deliberately.

• Adopting FGI wholesale without a funder that requires it. Prevented by: reading the funding agreement or terms of reference to establish which framework is actually mandated.

• Leaving the facility tier unsettled into design development. Prevented by: fixing the registration tier before schematic design. A tier change is a different building, not a variation.

• Appointing a designer before the brief exists. Prevented by: settling tier, funder specification, referral role and service ambition first. Design that begins before those answers is drawing on assumptions, and every assumption corrected later is paid for twice.

• Assuming the grid. Prevented by: fixing power autonomy in hours, and department protection priority, before schematic design.

• Leaving radiotherapy to a later phase without planning it in the first. Prevented by: placing bunker siting and the regulator’s approval sequence in the first master plan wherever cancer services are conceivable — in Kenya, siting is itself a regulated activity.

• Treating three countries as one. Prevented by: resolving the country-specific route early — Kenyan county approvals and KMPDC registration, the Tanzanian facility tier and designation status, Ugandan bureau commissioning — and writing the climate brief for the actual site.

Fifteen questions to answer before planning a hospital in East Africa

1. Which national facility standard applies, and at which licensing tier will the hospital be registered?

2. Who is funding the project, and does the funding agreement or terms of reference name a design framework?

3. Which approvals run in parallel — licensing council registration, county or district development consent, environmental clearance — and on what timelines?

4. Which locally registered architect will act as architect of record, and has that appointment been made before any permit application?

5. What quality certification or accreditation is intended at opening, at year three, and at year ten?

6. What is the facility’s defined role in the referral chain, and is it or could it become a designated facility within the public system?

7. What bed count is genuinely fundable in phase one, and what is the end-state master plan?

8. How many hours of full-facility power autonomy must the plan guarantee, and for which departments?

9. What is the water source, and how many days of storage will the site hold?

10. Which specialist staff can realistically be recruited and retained, and does the site plan include staff housing?

11. Who will maintain the engineering systems, under what agreement, and does the specification match their capability?

12. Is radiotherapy, nuclear medicine or advanced imaging ever intended, even in a later phase?

13. Has the national radiation regulator been engaged, and at what stage does its approval sequence begin?

14. Is adjacent land available for expansion, and can it be secured now?

15. What does the operating-cost model assume about power, water and maintenance, and does the plan deliver those assumptions?

For promoters and mission networks

Every decision named in this article — the licensing tier, the funder’s specification, power and water autonomy, expansion land, whether radiotherapy is ever intended — is inexpensive to settle before design and expensive to reverse afterwards. That gap is the whole argument for a disciplined pre-design stage.

Studio Athenos advises international hospital projects on pre-design planning, standards strategy, clinical and departmental programming, equipment-driven design and radiation-facility planning, working alongside the locally appointed architect where statutory submission is required. The practice offers a remote pre-design planning review: a structured examination of site, clinical brief, licensing tier, standards strategy and phasing logic, conducted before major commitments are made. Write to rahul@studioathenos.in.

Ar. Rahul Saxena, IGBC AP, is Principal Architect and Founder of Studio Athenos, Jaipur — a specialist healthcare architecture practice focused on NABH-compliant hospitals, radiation-oncology infrastructure and resource-constrained healthcare planning since 2007.