Health
Hospitals are the only buffer your city has against sickness, accidents, and the natural decline that comes with age. Every hospital bed bills the city a monthly non-payroll operating cost on top of staff salaries. That bill covers supplies, utilities, food, and laundry.
The staff comes from a fixed blueprint mix of doctors, nurses, hospital engineers (lab and radiology), and non-clinical support like admin and cleaning. Understaff a hospital and it stays open, but it tips past the safe-staffing line and clinical outcomes start sliding.
The pressure side
Citizens get sick on a curve that depends on their age, and the curve is much steeper for the homeless. That matches the real-world picture of exposure, nutrition, and chronic conditions. Sick citizens that the hospital cannot admit wait on a list, and each day on that list adds a small base mortality risk that compounds with how vulnerable the patient already is. Healthcare satisfaction is a smoothed score that feeds your approval rating, so a brief bad week does not collapse it, but a long bad stretch will.
Births
Births are also a hospital affair. Couples that roll a child need a free bed in a working hospital to deliver. The fertility rate on this page is the long-run target the system aims for. The actual number of children per couple is drawn from a hand-tuned distribution that averages out to that target across many couples, so a quiet month does not mean the rate is broken.
Working life and retirement
Adults are in the labor market from the age they finish school until the retirement age set on this page. Past the retirement age, citizens leave their jobs and start drawing the monthly pension you set in Fiscal Policy. That makes the retirement age both a humanitarian setting and a hard line in your budget.
Salaries
This page also lists the monthly salaries the city pays for doctors, nurses, and hospital engineers. These bills land whether the hospital is full or empty. The cheapest sick bed is the one that never gets filled, so prevention pays. Shelters, schools, and low-density housing all keep people out of the hospital before you have to staff one for them.
Your levers
- Build hospitals to add beds.
- Hire doctors, nurses, and engineers up to the staffing template.
- Prevent admissions in the first place. Shelters cut homeless sickness sharply. Schools and clean air help too.
Parameters
Average length of stay days
5
Average length of stay in days for inpatients in hospitals.
Source: Healthcare Cost and Utilization Project (HCUP)
Homeless sickness multiplier
6
Multiplier applied to the sickness probability of homeless citizens, reflecting their increased vulnerability to illness due to factors such as lack of shelter, nutrition, and mental health.
Source: CDC
Cost per bed month
$6,000
Monthly non-payroll operating cost per hospital bed (supplies, utilities, equipment, food, laundry). Payroll costs are tracked separately via actual hired staff salaries.
Source: OECD Health at a Glance 2025
Nurse to doctor ratio
2.5
OECD average nurses per doctor. Anchors the clinical staff split in hospital blueprints. Ranges from 1.2 in struggling systems to 4.0+ in USA/Finland/Japan.
Source: OECD Health at a Glance 2025
Healthcare satisfaction baseline
0.64
OECD average share of population satisfied with healthcare. Used as a benchmark for the city’s healthcare satisfaction score.
Source: OECD Health at a Glance 2025
Safe staffing perception
0.44
Share of physicians and nurses who perceive current staffing levels as ‘safe’. Below this threshold, 30-day mortality for AMI and stroke increases.
Source: OECD Health at a Glance 2025
Hospital occupancy burnout threshold
0.85
Hospital occupancy rate above which staff burnout and safety risks increase. Sustained overcrowding raises mortality for serious conditions.
Source: OECD Health at a Glance 2025
Hospital workforce composition
Share of total hospital workforce by staff category (European average). Doctors covers clinical diagnosis/surgery. Non-clinical covers admin, IT, cleaning — mapped to DOCTOR profession in-sim. Support covers lab techs, radiology, maintenance — mapped to ENGINEER profession.
| Key | Value (percent) |
|---|---|
| DOCTORS | 0.14 |
| NURSES | 0.36 |
| SUPPORT | 0.1 |
| NON_CLINICAL | 0.3 |
Source: OECD Health at a Glance 2025
Acuity staffing multipliers
Maximum beds a single nurse can cover per shift, by patient acuity level. Lower acuity = more beds per nurse. Used in future acuity mechanic (Phase 11).
| Key | Value (ratio) |
|---|---|
| LOW | 6 |
| STANDARD | 4 |
| HIGH | 2 |
| CRITICAL | 1 |
Source: OECD Health at a Glance 2025
Readmission rates by early discharge
Probability of patient readmission by how many days before the standard length-of-stay they were discharged. Readmitted patients cost double. Used in future discharge policy mechanic (Phase 9).
| Key | Value (percent) |
|---|---|
| DAYS_EARLY_0 | 0.05 |
| DAYS_EARLY_1 | 0.15 |
| DAYS_EARLY_2 | 0.3 |
Source: OECD Health at a Glance 2025
Waitlist base daily mortality
0.02
Base daily death probability for citizens waiting on the hospital waitlist. Increases with wait time and age vulnerability.
⚠️ Source pending
Healthcare satisfaction smoothing
0.1
Exponential moving average alpha for healthcare satisfaction. At 0.1, takes ~10 days to reflect 63% of a change, preventing rapid swings from single-day events.
⚠️ Source pending
Life expectancy years
80.3
The average number of years a person in a given population is expected to live, based on current mortality patterns.
Source: OECD
Life expectancy homeless penalty years
17
The reduction in life expectancy for homeless individuals compared to the general population, reflecting the adverse health impacts associated with homelessness.
Source: United States Interagency Council on Homelessness
Citizen retirement age
65
The age at which citizens are considered retired and start receiving a monthly pension from the city, which can be set in the fiscal policies.
Source: OECD
Fertility rate
1.4
The average number of children that would be born to a woman if she were to live to the end of her childbearing years. Matches the OECD average; when cities have enough hospital capacity, this is the rate at which new citizens are born to existing citizens in the city.
Source: OECD Fertility rates
Doctor monthly
$18,000
The monthly salary paid to each doctor. This amount is deducted from the city’s healthcare budget.
Source: Bureau of Labor Statistics
Nurse monthly
$7,000
The monthly salary paid to each nurse. This amount is deducted from the city’s healthcare budget.
Source: Bureau of Labor Statistics
Hospital engineer monthly
$8,000
The monthly salary paid to each hospital engineer/technician (lab equipment, radiology, maintenance). Deducted from the city’s healthcare budget.
Source: Bureau of Labor Statistics