“Prevention is better than treatment” is more than a wise proverb. It is also at the center of the efforts of every health system that values the protection of the life and well-being of its population. It is also the challenge faced by disaster management systems, which aim at reducing risk to acceptable levels and thus contributing to sustainable development.

The Safe Hospitals Initiative, started in the Americas in 2004, has influenced the thinking of the 168 United Nations Member States, leading to the commitment as a goal for 2015 that all new hospitals should be built in such a way that continued operation in disasters is ensured and that existing hospitals should progressively improve their safety levels in this respect.

The development of instruments for safety evaluations, in order to understand and analyze the situation of hospitals, compare results, and prioritize interventions, proved to be the best strategy to move from theory to practice, giving priority to interventions in those critical services for which continuous operation can represent the difference between life and death.

Presently, the Hospital Safety Index (HSI) is the most widely used instrument of this kind in the world. In March 2012, 31 countries and territories in the Americas reported its use in setting priorities. It is also one of the central elements in the implementation of national and subnational policies and programs for safe hospitals. More than 1,400 hospitals have been evaluated with the HSI. The results showed that 51% are in category A, that is, they have high probability of continuing to function in disasters; 37% in category B, meaning that they can resist a disaster but that equipment and critical services are at risk; and 12% in category C, which indicates that they will very probably stop functioning in disasters and be unable to guarantee the lives of their patients and personnel.

WHO representatives from around the world met in Turkey to study the hospital safety evaluation instruments used in the different continents and agreed to take the HSI as a basis for a global instrument that can be adapted to different realities. Some regions of the world adopted the HSI as such, while others adapted it to their own context.

Countries in Europe that implemented actions for safe hospitals translated the HSI into their respective languages and have applied it without variations. In the countries of the Eastern Mediterranean, where there are high levels of social and political violence that require temporary and variable health services to be set up, the structural component is much less important than the availability and capacity of the health workers who operate these services.

In the countries of South East Asia, with highly diverse realities, the main focus is in having a series of tools based on the HSI, making it possible for the countries to apply the instruments and adapt the components to their levels of development and implementation of the Safe Hospitals Initiative. The countries of the Western Pacific, in turn, developed a series of goals (benchmarks) aimed at steadily increasing the response capacity of hospitals in the region. Although they did not try to assign numerical values in ranking hospital safety levels, they have established mechanisms for prioritization based on hospital complexity. In Africa, the application of the HSI has begun in Uganda, and the region is currently generating common policy papers to delimit the framework of action for disaster risk management in the health sector and the implementation of the program of safe hospitals, with the participation of experts from PAHO.

The evaluation of the safety of medium and small hospitals and health facilities of lower complexity is another important step that many countries of the Americas have initiated. The results to date show that it is necessary to check the instruments and the criteria for relative assessment in greater detail, so that they can provide useful results, especially for those communities that only have lower-complexity health facilities and, accordingly, should ensure their operation with no interruptions.