Spaces for Community Health Care Architectural Approaches for Health Promotion in the Contemporary City

A design-driven research explored through the lens of authorship

The proposed paper explores how the concept of authorship is addressed in the homonymous research project.

The design-driven research highlights the pivotal role of architectural design in shaping community health spaces – primarily through the redefinition of Healthcare Centres, primary healthcare structures at the neighbourhood level – as civic buildings, crucial for community health, social and urban regeneration.

The redefinition of spaces dedicated to the health of the community, fostering health promotion at the neighbourhood level, has become increasingly necessary considering the systemic vulnerabilities exposed by the pandemic, which heightened institutional awareness and prompted reforms in territorial care.

To ensure stability amid ongoing redefinitions while remaining adaptable to emerging challenges, architectural design and design-driven research can harness the concept of authorship in response to the continuous evolution of societal, political, environmental, and economic dynamics that shape the health realm.

This article explores this concept on two levels.

From a design-driven research perspective, authorship is valuable in its ability to construct a distinct narrative, enabling engagement with extra-disciplinary domains such as health and social care through the lens of architectural design.

In this specific case, by constructing a compendium of spatial possibilities, the design-driven research interprets a complex extra-disciplinary theme, bridging gaps and reconnecting the seemingly missing links between different disciplines.

On a second level, in the realm of architectural design for healthcare, authorship means transcending a purely functional or parameter-driven approach, allowing for the creation of new spatial realities. The architectural designer, as a contributor to an autonomous yet responsive discipline, adds meaning, unveiling unexpressed identities and defining a framework of uses and interpretations. This open system enables a continuous interaction between space and society, perpetually redefining the value and significance of places over time.

As the second part of the paper will illustrate, the disciplinary contribution of architectural design, and thus its authorship, has proven essential in shaping a paradigm shift in health that calls for urban spaces distinct from existing archetypes: new urban centralities for community health promotion.

Design-driven research(er) as auctor: reconnecting fragments

The primary objective of the presented research is to define the role and potential of architectural design in shaping the paradigm shift in community-oriented health spaces that has not yet been adequately accommodated, particularly at the Italian national level.

Engaging with the extra-disciplinary realm of the socio-health sector implied starting with the definition of the subject matter, outlining the evolution of primary healthcare and its shifting paradigms. The design lens has served as a tool to analyse, understand, and bridge extra-disciplinary demands, translating them into a compendium of architectural approaches that respond to the continuous evolution of healthcare models.

As early as 1986, the Ottawa Charter, the document of the First International Conference on Health Promotion, emphasized the importance of community actions in planning strategies to achieve better health. It is important to highlight that the concept of health was defined in 1948 by the Constitution of the World Health Organization as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (WHO 2020).

According to the Ottawa Charter, “an empowered community is one in which individuals and organizations apply their skills and resources in collective efforts to address health priorities and meet their respective health needs” (WHO 1986), thereby gaining greater control over the determinants of health. These determinants are understood as “social (and, to some extent, economic) factors that influence health”, whether they are “distal factors, meaning distant ones, such as income and education, or proximal factors, meaning those directly connected to health, such as lifestyle choices” (Maturo 2024).

This health concept, emphasized in the post-pandemic, showcases a paradigm shift from a vertical, disease-focused healthcare model to a horizontal, inclusive, community-oriented approach centred on prevention and active participation.

Forty years later, this shift is still far from being fully implemented. Although the pandemic period appears to have heightened institutional awareness of the importance of proximity in healthcare facilities and among professionals – as demonstrated, in the Italian case, by the funds allocated through the PNRR for the establishment of primary healthcare facilities, known as Case della Comunità, across the national territory – citizen participation in their own health remains a highly complex challenge for service organization, as well as for the definition of the spaces that should host them.

In the Italian context, the transition from simple outpatient clinics or, in regions where they already existed, from Case della Salute to Case della Comunità has not resulted in a true spatial rethinking but rather in a mere change in nomenclature.

Taking the Italian case as the initial observation, this research argues that questioning the role of widespread spaces for community health promotion is also, and necessarily, a significant opportunity for the architectural discipline: the definition of a “new typology of community building with a hybrid nature” (Setola 2022). On one hand, it would continue to host spaces dedicated to healthcare services; on the other, it should integrate spaces where the community can gather, interact, and actively shape its own health journey.

The transition to Case della Comunità has often resulted in a mere rebranding of existing structures rather than a true spatial evolution capable of enhancing their urban role. In parallel with developments in Italy, the research draws on international experiences, focusing primarily on the British and Spanish contexts. These models are particularly relevant for comparison as they share the Beveridge framework of universal healthcare and incorporate primary care facilities like Case della Comunità.

The British model has been a pioneer in neighbourhood-based primary healthcare, leading to the development of structured architectural guidelines. The Health Building Note 11-01 provides not only functional, parametric, and dimensional recommendations but also concrete examples through significant case studies (Department of Health, 2013).

In Spain, primary healthcare is organized at the regional level, with facilities known by different names (Centro de Salud, Centro de Atenció Primaria, Centro de Saúde). These structures are widely distributed across the country and are often of architectural interest, featuring diverse spatial responses that integrate with their specific urban contexts.

The approach to the case study analysis has been conducted from an interscalar perspective, emphasizing the need to interpret these structures in relation to their urban context.

At the urban scale, the study highlights the relationship between health centres and the service network, the characteristics of the urban fabric, green spaces, sustainable mobility, and residential density. This analysis is carried out at different levels: the city scale, the neighbourhood scale (within a two-kilometre radius), and the immediate surroundings of the building (within a 250 mt. radius).

The architectural analysis examines not only the volumetry of the building but, more importantly, its spatial relationships at the ground level, its interior-exterior connections, and the distribution of both indoor and outdoor spaces. Particular attention is given to areas with a stronger community-oriented function and their relationship with more private, strictly health-related spaces.

Design(er) as auctor: adding meaning

The case study analysis has revealed that, where architectural design has challenged a purely parametric approach based on standards and dimensional requirements, and has instead undertaken a careful spatial construction rooted in its disciplinary prerogatives, it has been able to anticipate – even when not explicitly required by guidelines – a paradigm shift. This shift moves from introverted, specialized buildings conceived as mere service containers to urban landmarks capable of accommodating new modes of use and engaging with the community.

This overcoming of a purely technical approach demonstrates the ability of an authored architectural project to go beyond merely responding to contingent demands, shaping buildings with enduring significance and intrinsic architectural value.

As highlighted by Gianni Ottolini in Forma e significato in architettura, architecture must inevitably confront the shifting definitions of what is considered objective, functional, or comfortable at a given time, while also engaging with the tension between historical contingency and the enduring nature of beauty. In unfolding within a real context, even when originating from a temporary need, it succeeds in establishing a framework for individual and collective behaviours and new ways of inhabiting space. “However, this does not preclude the possibility that the material form thus defined may acquire a lasting significance that extends beyond the explicit or implicit design proposal regarding its intended use” (Ottolini 1966).

The set of spatial possibilities identified through a survey of the most significant case studies highlights three main ways in which the architecture of community health spaces can spatially translate new prerogatives while preserving its intrinsic value: integrating spaces dedicated to the community, articulating thresholds of privacy between these and the more traditional healthcare areas, and reestablishing a relationship with the city through the design of public space, whether outdoors or internally configured.

Firstly, promoting a culture of health in places close to those frequented by communities in their daily lives means considering who the community spaces are intended for and designing environments suitable for associations, public events, and groups such as schools, the elderly, and people with disabilities. It means opening to the possibility of new and diverse gestures.

The spaces of a Healthcare Centre welcome a diverse range of individuals and, consequently, a variety of actions and gestures: the patient waits and seeks answers; the citizen participates, gathers information, collaborates; the doctor, the healthcare worker, the social assistant provide care, offer solutions, educate, comfort, work, take breaks, communicate. Educators, artists, and poets could also animate public events connected to the well-being of the community.

This approach is well exemplified by the Kentish Town Health Centre in London, designed by the British architecture firm Allford Hall Monaghan Morris. The project was exhibited at the Venice Architecture Biennale in 2012 and was referenced in the 2013 National Health System (NHS) guidelines for the design of primary healthcare facilities.

In 2009, it won an RIBA competition initiated by a general practitioner Dr. Roy Macgregor, whose vision was to create a building that would host spaces where health and art could merge to promote community well-being. This multidisciplinary work, at the intersection of architecture and primary care medicine, contributed to the creation of a building that embodies a holistic approach to health and well-being.

This project stands as an example of how architectural design can integrate cross-disciplinary priorities, spatially interpreting the holistic nature of care, the central role of culture in community health, and ultimately shaping an institution that bridges health, community, and culture.

The building itself is a single-volume structure that incorporates urban spatiality, shaping an internal street around which a rich system of spaces and functions unfolds, cutting through the mass of the building to establish multiple relationships with natural light and the exterior at different heights and perspectives. The interior spaces accommodate a wide range of experiences for visitors, allowing them to walk, wait, pass through, engage, consult, take a break, and communicate: an array of spatial appropriations that define the space itself, reflecting the diverse services related to health, well-being, social interaction, and community culture.

In the second place, articulating thresholds of privacy between these new spaces and the more traditional healthcare core business (medical clinics, analysis rooms, and other essential primary healthcare services) is essential.

In Community and Privacy: Toward a New Architecture of Humanism, Serge Chermayeff and Christopher Alexander state that “to develop both privacy and the true advantages of living in a community, an entirely new anatomy of urbanism is needed, built on many hierarchies of clearly articulated domains […] ranging from the most intimately private to the most intensely communal” (1968).

The same could be said for a healthcare centres: it should be a civic building, open to spontaneous use by the public. As such, it provides spaces for community gatherings – squares, courtyards, atriums, halls, terraces – while also serving as a place for clinical consultation, which requires areas ensuring privacy. In between, it is essential to establish thresholds that gradually transition toward increasing levels of privacy.

The spaces of the Waldron Health Centre, described by its designers (Henley Halebrown Architects) as a civic building (like a library or a town hall), but with the humanity and intimacy required for clinical consultation, have been conceived in relation to one another, defining a meaningful spatial journey for users (primarily patients) through key places: the designed new square, the foyer, the cloister, the waiting room, and the consultation or examination room.

Replacing a previous, nondescript single-story healthcare centre, the new architecture – with its strong urban character – reshapes the neighbourhood fabric, a predominantly residential area, by structuring a public space.

The project redefines the perception of a healthcare facility. While maintaining the primary function of medical assistance – with the necessary level of privacy for clinical consultations – the building successfully assumes a key urban role, actively engaging with the city's public space.

Establishing an osmotic relationship with the urban space is considered essential to be able to transform healthcare centres into spaces open to their community.

This involves working on public open spaces, enclosed public spaces, and the transitional elements that mediate between the two. This process generates public interiors, “those interiors that we make to be public: those within which we consider ourselves to be free individuals, and where we see ourselves among others; those within which we are conscious of our place in society and in the world” (Pimlott 2016).

Located in the historic centre of Córdoba, the Centro de Salud Lucano (designed by Estudio de Arquitectura Javier Terrados) originates from the transformation of its ground floor into an urban passageway. This intervention interprets a key aspect of Córdoba’s urban morphology, where large and dense blocks are often traversed by inner courtyards.

The passageway punctures the continuous building frontage at street level, inviting pedestrians inside through a sequence of gateways, porticos, and patios – open-air rooms and urban interiors – allowing them either to enter the building, which opens onto the inner courtyard with a fully glazed ground-floor façade, or to continue their route, re-emerging onto a perpendicular street. This architectural gesture encourages movement and, as the architect describes, creates “the impression of a sanctuary, a contemplative oasis for passersby in one of the most touristic areas of Córdoba’s historic center”, where otherwise “public space sustains consumption and tourism as primary activities, [...] the glass of storefronts imposes a barrier to senses and bodies, [and] ground floors are only frequented by those who can afford to buy” (Terrados 2012).

By making the building permeable, this intervention opens the space of community healthcare to the city, inviting it in while simultaneously keeping its fast-paced rhythms at a measured distance.

Design-driven research can harness the concept of authorship to assemble extra disciplinary fragments, highlighting how architectural design can activate societal change constructing new and unexpected narrations, exposing things that could be otherwise.