Why Are We Still Building Unsafe Hospitals?


Why is it that hospitals are still being built without the necessary safeguards to ensure that they can function after a disaster, even though the necessary knowledge exists and is readily available, even though many countries have expressed the requisite political will to protect these critical facilities (but have not, necessarily, translated this will into action) and cost is not really the limiting factor?

The single most often-cited factor is the absence of a mechanism that demands accountability when an unsafe structure is built. Accountability for the construction and performance of a building is not a new concept. As far back as the 1700s B.C., Hammurabi’s Code of Law issued the following somewhat drastic legal decision: If a builder build [sic] a house for some one, and does not construct it properly, and the house which he built fall in and kill its owner, then that builder shall be put to death.

This may be the first historical reference to the enforcement of building standards, and while no one today would advocate applying such harsh measures, it does make clear that someone must take responsibility, and more so, when it comes to building critical infrastructure such as hospitals. This responsibility must be shared by the administrators, acting on behalf of the owner, as well as by the designers and builders.

The check consultant mechanism

Today, the importance of involving check consultants to accompany the entire building process—from design to construction and through delivery and an evaluation of performance—is acknowledged, if not universally practiced. A check consultant is an experienced individual, usually an engineer, or an independent organization that is knowledgeable about quality standards for structures and is acceptable to all parties involved. Some countries have an official mechanism to accredit check consultants, evaluating and validating their competency, independence and confidentiality. In France before 1978, insurance companies made it a practice to insure certain public buildings such as hospitals, schools and other large structures, only if an independent check mechanism, in this case a Bureau de Contrôle, was involved to certify that the building met certain design, construction and performance standards. Since 1 January 1978, the involvement of Bureaux de Contrôle in checking the design and construction quality control for buildings slated for public occupancy has been mandated by the law, the Spinetta Act. In the case of other buildings, such as private homes or multi-family dwellings, the use of Bureaux de Contrôle is not mandated by law but is sometimes voluntarily used and publicized by developers for marketing purposes. Property insurance companies charge lower premiums for buildings which have had design and construction checks by Bureaux de Contrôle. The Bureaux de Contrôle originally came into being not because they were imposed by law but rather because of private sector pressure from insurance companies, who recognized they needed specialists to identify potential risks and guarantee their reduction.

Many parties are involved in the construction of a building and thus have a vested interest in having a check consultant oversee the multiple stages of the design and construction. These include the owner of the construction, the architect, the engineers, the construction company and the insurance company. Often, it is the insurance companies who drive the process.

A large number of countries have building codes; however, the level of enforcement of these codes varies greatly from country to country. There are still many other countries in which public buildings are not required to carry insurance, and therefore building standards may not be applied properly or conscientiously. In some countries, the Department of Public Works or other national or municipal agencies act as the building inspectorate; however, the training of public sector building inspectors is usually insufficient to allow them to act as effective checkers.

The new UN publication Know Risk, which highlights global efforts and practices in disaster reduction, says that people have been living with risk ever since they first joined efforts, shared resources and assumed responsibilities in social groups; social development and human well-being have advanced only because people have taken risks. Today, reducing risk as it applies to critical infrastructure such as health facilities is often weighed in cost-benefit terms. But reducing the risk to hospitals is more than a medical issue. Hospitals have a symbolic social and political value that we cannot put a price tag on. A check consultant will advise on what constitutes an acceptable level of risk and how to keep the level of risk as low as is practicable and appropriate under the circumstances. In the case of the Bureaux de Contrôle, the cost of this mechanism is between 0.5% and 3% of the cost of construction, depending on the size and complexity of the project. Most usually the range is 0.5% to 1%. Undoubtedly, if we compare the cost of a check consultant with the decrease in insurance claims and reduced annual premiums over the life of the building, countries and building owners save money. If we add to this the social benefit of protecting our hospitals and health facilities, it makes even more sense.

This editorial draws on a presentation entitled Methods for the Enforcement of Standards in Design and Construction, made by Mr. Didier Deris of Guadeloupe at the PAHO/WHO Conference the Winds of Change, an international meeting held in Barbados in 2003 on building codes and their enforcement in health facilities and other institutions. Our thanks to Mr. Tony Gibbs for his review and comments.


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