Adaptable and Flexible Healthcare Infrastructure. The RAF(+I) Framework for Post-Conflict Healthcare Facilities in Tigray, Ethiopia

Healthcare facilities in Tigray, Ethiopia, operate amid chronic resource scarcity, conflict-related disruption, and uneven recovery. Utilities, referral networks, maintenance systems, supply chains, and governance arrangements remain unstable. Under these conditions, physical condition provides an incomplete measure of clinical value: facilities may remain standing, reopen, and admit patients while their usable clinical capacity remains fragile. This gap between apparent functionality and dependable clinical capability provides the starting point for the thesis. It examines how resilience, adaptability, flexibility, and incrementalism can be conceptualized, assessed, and translated into architectural strategy for post-conflict healthcare infrastructure under evidence-light conditions, evaluating not only present facility performance but also the trajectories through which built assets retain, lose, or recover capacity over time.To make that gap analytically assessable, the thesis develops and applies the RAF(+I) framework. Resilience denotes the capacity to retain or recover usable clinical capacity under disturbance; adaptability, the capacity for substantial functional, spatial, or service-model change over time; flexibility, lower-friction reconfiguration within an existing operational boundary; and incrementalism, governed staged development and upgrading that preserve future capability. Together, these constructs frame the healthcare facility as a layered socio-technical asset: path-shaping layers—site order, structure, circulation, and primary service infrastructure—interact with faster-changing spatial, fit-out, service, and operational layers, as well as the governance conditions and wider repair ecology that surround them. Read in this way, the analytical focus shifts from nominal building condition to operability, serviceability, and change-readiness.Assessing these qualities under incomplete documentation requires a method designed for evidence- light conditions. The study therefore adopts a pragmatic mixed-method design calibrated to incomplete documentation and unstable field conditions, triangulating documentary review, remote sensing, direct observation, reconstructed analytical drawings, and bounded stakeholder accounts through explicit evidence-governance and attribution-control rules. Observable symptoms are tested against rival explanations before being attributed to architectural failure, which enables ordinal RAF(+I) assessment without false precision. On this basis, the empirical sequence moves from national and regional operability conditions, through the post-conflict macro constraint field, to facility case studies spanning the public healthcare hierarchy, from a rural health post to a comprehensive specialized hospital.The resulting evidence shows that physical survival and reopening do not, by themselves, explain facility performance. Usable clinical capacity is repeatedly shaped by the interaction of built form with lifelines, staffing, supplies, referral access, documentation, repair latency, maintenance capacity, and governance continuity. Across the cases, functional breakdown recurs through six mechanisms: early misfit embedded in path-shaping layers; restricted serviceability depth and maintenance access; workaround- dependent continuity; cumulative growth without governing integration; pressure transfer across referral tiers; and a weak repair ecology. Apparent continuity, on this evidence, may reflect coping rather than durable change-readiness.