Urban planning approaches to the organization of a medical district

Vilenskii Michael Yur'evich ORCID: 0000-0002-0231-0550 PhD in Architecture Associate professor, Department of Urban Planning, Saint-Petersburg State University of Architecture and Civil Engineering 190005, Russia, Saint Petersburg, 2nd Krasnoarmeyskaya str., 4, office 308A vilenm@list.ru Other publications by this author

Kaledina Anastasiia Andreevna Master's Degree; Department of Urban Planning; St. Petersburg State University of Architecture and Civil Engineering 190005, Russia, Saint Petersburg, 2nd Krasnoarmeyskaya str., 4, office 308 -A anastasiakaledina@yandex.ru

Introduction

Urban planning has always been evolutionarily linked to public health care. The growth of urbanization, on the one hand, leads to the spread of diseases, on the other hand, gives impetus to their intensive confrontation and contributes to the development of healthcare in general ^[1]. In this context, the development of medicine as a complex of scientific directions and related biochemical, technological and other fields of research, providing them to management and financial institutions and industries, together create prerequisites for the formation of new approaches to the placement and organization of centers for the development of the medical sector and related health care systems for the population. These changes significantly affect the functional and planning organization of cities and urbanized territories ^[2]. Against this background, innovative territorial formations of medical industry organizations and urban structures are developing.

In Soviet urban planning practice and theory, since the 20s of the twentieth century, various concepts and approaches to group forms of medical territorial organization have been formed. A medical area, clinical or hospital town is identified in the Code of Rules for the Planning of Settlements (1930) on the basis of the concentration of medical facilities in a single area of urban territory.  Within the framework of the organization of the Soviet model of healthcare – the Semashko system ^[3], approaches to network multilevel medical care for the population were formed. Against this background, separate group forms of organization of health care elements, which are based on medical complexes as a set of buildings aimed at providing the population with only medical activities, are developing to date and partially implemented in the 70s of the XX century. Group forms of medical organization are specialized or highly specialized in the provision of medical care, including within the framework of departmental subordination of medical care. Group forms are developing as an urban planning complex based on the placement of hospitals, clinics together with educational facilities and research institutes of a medical profile based on the modernization of healthcare institutions ^[4] without direct reference to the territorial level of medical care. At the same time, these healthcare facilities are the centers of scientific research activities.

Modern Russian practice boils down to the development of existing or new complexes of subordinate facilities within the framework of a single medical organization or group forms in conditions of placement in a single urban development complex of several organizations. To a large extent, group forms are formed on the basis of established objects that no longer have the spatial potential for subsequent development, integration with the urban environment and are not adequately provided with appropriate infrastructure. In cases of new placement, such facilities represent a completed urban development complex that does not take into account both the long-term development of the territory and the possibility of creating collaborations with other healthcare institutions, fundamental and applied research facilities. As a result, the possibilities of transforming medical complexes into a new functional and territorial form are extremely limited and are not taken into account when developing long-term urban development strategies.

In St. Petersburg, an example of the development of a healthcare system within one organization is the Almazov NMIC, which is developing as an expanded structure of a single medical organization within the territorial boundaries of an existing site. The group form of the united territory of several medical organizations is the Mariinsky Hospital and the A. L. Polenov RNHI. The established boundaries of the urban development complex, the urban environment and the historical and urban environment limit further territorial growth and the possibility of territorial transformation of the group form.

 As a result, there is a need to define a new approach to the spatial organization of medical facilities and complexes, which would provide for the emergence and development of high-tech medical facilities ^[5], collaboration of medical facilities, creation and development of integrated infrastructure ^[6] for the formation and development of medical territorial entities integrated into the urban planning structure.

Group forms of interaction of medical facilities in world practice have been established in Europe since the XVIII century. when medical schools were established at hospitals ^[7], as a result, university clinics were approved as centers for the development of medicine. In the second half of the 19th century, pharmacological laboratories were developing and the achievements of chemistry were applied in medical practice ^[8]. The opening of laboratories in leading European clinics and hospitals is beginning. A group form of cooperation between educational and scientific facilities is emerging. Models of cooperation and integration between the university and the clinic are being approved ^[7]. Since the end of the twentieth century, types of organizational models of group forms have been developed in relation to the elements of the group ^{[9, 10]}. Since the 2000s, universities and clinical hospitals have been forming academic health science Centers (AHSCs) for the development of medicine and innovation, academic and clinical integration has been developing ^{[11, 12]}. As a result of the interaction of the objects that make up the group, interdisciplinary research begins to develop ^{[13, 14]}. The process of transition from individual group forms to larger interconnected elements of the group form leads to the formation of a medical cluster connected by a common functional task. In 1981, a proposal was developed in the USA to place a group of hospitals in clusters ^[15]. Llobrera et al. (2000) used the concept of a "medical industrial area" as a concentration of medical academic, educational, research and pharmaceutical production facilities forming a territorial information center ^[16]. The trend of development of a territorial form of medical high-tech activity integrated into the structure of the city, based on the concentration of medical facilities, begins.

Since the 2010s, cooperation between medical facilities based on clustering has been developing in Russia for the sustainable development of healthcare organizations ^[17]. The medical cluster is used for the development of the pharmaceutical industry and the organization of its connection with medical practice ^[18]. A medical cluster is organized to establish a functional connection between the cluster members, ranging from producers to consumers ^[19]. The medical cluster is considered within the framework of integration interaction for the development of scientific direction in healthcare ^[20]. L. F. Zakieva (2022) analyzes the placement of medical group forms in the city structure within the cluster system as a public service system ^[21]. These studies are mainly aimed at studying the managerial and functional properties of the group form for the direct development of healthcare organizations that are part of the group. As a result of the analyzed sources, there is no practice of studying the consideration and establishment of spatial, functional parameters and characteristics of the connections of medical facilities with the urban structure ^{[22, 23]}.

In world practice, the approach to the formation of a medical infrastructure for the provision of high-tech medical care based on the concentration of medical facilities is considered in conjunction with the development of innovative areas. It was examined by J. Clark and others (2009); A. Forsyth (2014); B. Katz, J. Wagner (2014, 2019); the NSW Innovation and Productivity Council (2018); SGS Economics and Planning (2020); T. Yigitcanlara etc. (2020). B. Katz and J. Wagner outlined three models of the innovation district, as one of the anchors of the territory has identified large health facilities ^[24]. NSW-IP identified the model of an innovative territorial health and education zone as an international-level territorial center based on the concentration of large research hospitals and universities interconnected by certain commercial regulation ^[25].

Since the end of the twentieth century, urbanization at the territorial level has contributed to the consideration of a set of medical facilities as drivers of urban development, as a result of which it is necessary to define conditions and create them for the development of innovative territorial formations based on the medical industry in the structure of urbanized territories, accepted by the authors as a medical district. A medical district is a territorial form of placement and development of medical and related complex infrastructure integrated into the urban environment. Within the framework of the functioning of the medical district, there is a synergistic effect of the development of medicine as a complex of scientific directions that contribute to the high-tech provision of medical care to the population within the framework of regional and interregional services.

The medical district acts as a center that provides a full cycle of the healthcare system and through the territory confirms the thesis "healthcare as community development" ^[26]. The study of the connection of the medical district with the planning structure of the city in the context of growing urbanization is a priority task, therefore, in order to study the aspects of the formation of the medical district as a territorial form, the international experience of the development of such facilities is considered.

Research methodology

The object of the study is the medical district. The subject of the study is the spatial and territorial principles of the organization of the medical district. The purpose of the study is to determine the classification requirements that define the medical area. The study is based on the analysis of the allocation of territorial entities in accordance with the typological characteristics of health facilities. It includes the assessment and analysis of group medical forms, the allocation of classification requirements for the studied territorial forms and their subsequent systematization.

Criteria for the allocation of a medical area were determined based on the presence of a university clinic or an educational hospital serving as a center of innovation ^[27], around which infrastructure facilities and other health facilities forming the object under study are concentrated. As a result, 60 research sites were selected in countries with advanced methods of high-tech medicine. Out of 60 territories, the following research objects were identified as separate innovative territories in the field of healthcare, as well as independent territorial formations in the urban structure. Thus, 19 territories were identified for a more detailed study. The territories of the research objects and the urban space adjacent to them were considered within the framework of historical-evolutionary, morphological, structural and functional analysis.

To determine the planning options of the area, the territory of the object under study was divided by the street and road network into planning elements: a medical unit, an infrastructure unit and landscaped areas. The districts were analyzed according to the transport criterion to determine the permeability of the territory of the district by public or local transport, the availability of a transport hub for establishing transport links between the district and the city, the functional links between the objects of the district and the localization of the main elements of the district were determined.

Results

As part of the analysis, 60 research objects were identified in cities in Europe (25%), Australia (5%), America (60%), Asia (10%) with different populations from 100,000 to more than 1 million people. The study showed that in Europe, medical territorial formations are typical for large cities (62.5%), in the United States in cities with millions (30%), in Asia and Australia they are spread throughout the territory. Statistical data on the location of medical districts in cities by parts of the world (Fig.1) show that for world practice, medical districts are typical for cities with a population of one million (27%). It has been revealed that there may be several medical districts in a million-plus city and an urban agglomeration with a population of more than 1 million people. Cities and urban agglomerations with a population of more than 1 million people are the most urbanized, therefore these territories have the greatest conditions for the formation of medical innovative formations.

Fig. 1. Statistical diagrams of the location of medical districts  

The study identified 19 territories: 5 in Europe (26%), 1 in Australia (6%), 3 in Asia (16%), of which 1 in China and 2 in Israel, 10 in the USA (52%). As a result of the study, the properties of the medical district were determined, such as integration into the city's planning network, connection with residential areas. Against this background, the medical district can be considered as a planning element of the city. As a result of the historical and evolutionary analysis, four main stages of the formation of the district were identified, depending on two directions: territorial unification of objects (60%) and spatial sprawl (40%). It was revealed that medical districts either form over several centuries (45%) or develop rapidly over the course of a century (55%). This higher percentage confirms that medical districts are a modern trend.

As a result of the situational analysis, the districts were identified according to their location in the planning structure of the city. There are central (30%), peripheral (20%), middle (25%) and agglomerated (25%) districts. In relation to the planning structure of the city, integrated (80%) and autonomous territories (20%) were obtained relative to the urban structure. A group of basic medical facilities and additional medical facilities performing outpatient and dental functions has been identified. The main group of medical facilities forms the medical part of the territory and represents institutions that are the main places of employment, organizing the territory around themselves and capable of being city-forming. The analyzed territories are multidisciplinary medical (90%), which corresponds to the trend of complex treatment ^[14]. As a result of the study, a systematization of medical districts was compiled (Fig. 2). The main principle of systematization was the allocation of criteria and their characteristics based on the determination of factors for the formation of spatial links between a medical district and an urban structure.

Fig. 2. Systematization of medical districts

As a result of the study, one of the approaches to the formation of a medical district was identified – localization (Fig. 3). Localization is based on the transport and pedestrian accessibility of the main medical facilities that form the concentration of medical district facilities. The localization of medical areas is diverse: in Amsterdam up to 1 km; in Milwaukee 3 km; in Las Vegas and Houston up to 4 km (Fig. 3). Thus, the travel time between the main functionally connected objects of the area is within 15 minutes, transport accessibility within the study area is represented by a range from 1 to 4 km.

Fig. 3. Localization in cities

a - Amsterdam, b - Las Vegas, c - Houston, g - Milwaukee

Some medical districts have been granted legal status (for example, the Illinois Medical District Act, 2022).  This status is used to regulate the development of the district. Also, a medical area can be a separate element of urban zoning.

As a result of the study, a trend in the development of medical districts in urbanized territories was obtained, a systematization of medical districts was compiled based on criteria integrating the medical district into the planning structure of the city, an approach for the spatial organization of the medical district was determined and the presence of a certain status for the urban development of such facilities was revealed in territorial formations. The experience of the formation of medical districts based on localization has been analyzed in world practice. The benefit of medical districts is to improve the provision of high-tech medical care to the population. For the development of high-tech medical services, the approach of concentrating medical facilities in a single territory should be followed, contributing to the better development and dissemination of medical science and practice.

Conclusions

A medical district can become a long-term form of territorial development, in which changes in the medical field can be foreseen in advance. The medical industry is currently changing, accordingly, it is possible to assume the development of knowledge, facilities and technologies that will be laid down when planning a medical area. The Russian Federation has adopted documents aimed at the development of specialized high-tech medical care and medical innovations(The Strategy for the development of healthcare for the period up to 2025, the Strategy for Scientific and Technological Development of Russia (2024), the national project "Healthcare" (2018), the state program "Development of Healthcare" (2017), various federal projects in the field of healthcare, the Decree of the President of the Russian Federation "On the Strategy for the development of healthcare in the Russian Federation for the period up to 2025"). Thus, conditions are being created for the development of an innovative territorial education – a medical district.

The medical district, taking into account its characteristics and integration into the urban environment, is a special planning element that requires appropriate regulatory regulation. The placement of such facilities and the reservation of territories for them should be established both at the level of the Russian Federation (within the framework of the territorial planning scheme of the Russian Federation in the field of healthcare, as well as the establishment of a special TOP status for such territories), and at regional levels, and at the level of cities of their planned location. In this regard, a special mechanism for urban planning regulation and planning of medical areas is needed.