WHO Director-General addresses World Hospital Congress
Dr Margaret Chan
Director-General of the World Health Organization
Excellencies, honourable ministers, distinguished delegates, ladies and gentlemen,
I thank Norway for hosting this 38th World Hospital Congress. I thank the organizers: the Norwegian Hospital and Health Service Association and the International Hospital Federation.
As we have just heard, Norway has much guidance to offer in terms of both ground-breaking past experiences and future aspirations. We need this guidance.
This congress is being held in a world of stark contrasts, of miracles and misery.
This is a world of instant electronic communications. This is a world where more than a quarter of health facilities in parts of Africa have no electricity whatsoever.
This is a world of unprecedented wealth and personal fortunes. This is a world with around 2.7 billion people living in countries with no safety net to cover medical bills.
In 2010, the USA alone spent US$ 124 billion on cancer care. Worldwide, some 30 countries, including 15 in sub-Saharan Africa, do not possess a single radiation therapy machine.
During this congress, you will take a look at the surgical operating room of the future. You will do so at a time when large parts of the developing world do not have the facilities, staff, or equipment to drain an abscess, perform a caesarean section, treat an open fracture, or correct a clubfoot.
Despite these contrasts, there are some similarities in our world. Nearly everywhere, costs are soaring, budgets are shrinking, and public expectations for health care are rising.
Our frontline antimicrobials are failing, everywhere, with few replacements in sight. Chronic noncommunicable diseases are rising, everywhere. Populations are ageing, and elderly patients are presenting with multiple co-morbidities.
A shift towards integrated care of higher quality at lower cost would bring benefits everywhere. Safe care is critical to all.
I welcome the emphasis this congress is giving to inequalities in health and to the ethical dilemmas clinicians face when making fair choices in an era of high technology. I welcome the emphasis on integrated approaches to service delivery that counter the fragmented health care market in many wealthy countries.
I have been asked to address the question of whether innovation and technology can be game-changers for the future. I can say “yes”, of course.
Some of the biggest leaps forward in medicine and health followed the discovery of new medicines or the development of new technologies and interventions.
But I say “yes” with several careful qualifications. In terms of actually being able to afford the latest technical innovations, health care in many countries is approaching the limit, the tipping point where constantly rising costs become unsustainable.
Much of what I have to say responds to this reality.
Ladies and gentlemen,
The perceptions of hospitals and their place within the broader health system vary greatly.
Many see hospitals as wasteful, spending more money than they should. Far and away, hospitals consume the lion’s share of national health care budgets. In some countries, hospitals consume more than 70% of total health spending.
Advances in medical technologies and devices are cited by many as a key reason for soaring health care costs. Some experts estimate that nearly half of the increase in health spending since 1960 can be attributed to the growth of sophisticated medical technologies destined for use in hospitals.
Medicine is one of the few areas of technical innovation where new products are nearly always much more costly, more sophisticated, more difficult to use, and more likely to malfunction.
This is certainly not the case with other areas of technology, like flat-screen TV’s or computers and hand-held devices, where products keep getting easier to use and cheaper to buy.
According to a recent study from the World Economic Forum, the price of new medical technologies is more often based on what the market will pay than on a rational economic model that looks at actual production costs. As other studies have shown, many clinicians are oblivious to the costs of the tests and procedures they order.
The high costs of new technologies are particularly unfortunate when an effective screening tool, like colonoscopy, becomes more and more expensive as the technology evolves.
In some countries, the most expensive procedure has become the default. Such a trend blunts the preventive power of tools that ought to be in routine practice, and routinely affordable.
Too often, hospitals acquire the latest technologies without the benefit of sound clinical trials demonstrating their advantages over existing technologies. New technologies do not always bring improvements in health outcomes.
In 2011, the Lancet Oncology Commission concluded that the costs of treating cancer are becoming unaffordable for even the wealthiest countries in the world. As noted, clinical oncology operates in a culture of excess: excessive diagnostic tests, excessive interventions, and excessive promises that create unrealistic hope and unrealistic expectations for patients and their families.
These expectations, in turn, lead patients to undergo end-of-life interventions that are toxic, painful, disconcerting, and extremely expensive yet of no proven benefit for patients.
Hospitals can also be dangerous. Worldwide, WHO estimates that nearly one million lives are lost each year because of errors during surgery. These errors occur in the richest as well as the poorest countries.
Hospitals can be hotbeds of infection. The SARS outbreak of 2003 was a disease primarily spread by sophisticated hospitals in wealthy settings. We need to keep this in mind as we nervously watch the emergence of the H7N9 avian influenza virus and the novel coronavirus.
Hospitalized patients may also be exposed to super-pathogens that have developed resistance to all mainstay antibiotics and many, if not all, second-line medicines as well. In some developing countries, the spread within hospitals of contagious diseases, like tuberculosis, is a major problem.
As everyone in this room knows, hospitals are a political issue. Politicians often promise to build hospitals as a way of winning votes, and not based on an assessment of priority needs of the population or consideration of recurrent costs.
Once a hospital is built, it is extremely difficult to shut it down, again for political reasons, even if it is underutilized and a significant drain on public funds. In many national health plans, hospitals are the financial “heavy-weights”, yet they are “light-weights” when it comes to policy and management.
Hospitals can be overburdened through flaws in other parts of the health system. For example, when primary health care services are of low quality, people will flood the emergency rooms of hospitals even for the most routine complaints.
In their design, hospitals can be dehumanizing, showing little respect for the dignity of human life. People may be treated like a collection of specialized body parts, and not as human beings with spiritual needs.
Last year, the WHO Regional Office for Africa conducted a perception study of the quality of health services. Nearly 11 000 users of health services were surveyed to gather their views. What do they want? What works? What is missing?
Let me highlight just one conclusion from this study. The expectations of African people for health facilities are not extravagant. They are very basic, almost sadly so. To have a health facility nearby. To find medicines in the facility instead of empty shelves. To be treated by friendly and responsive staff.
A frequent complaint is the lack of compassion, especially for severely ill children and their desperate parents. As one respondent noted, “In all hospitals, even in clinics, there is no love.”
This is sad commentary, especially given the critical role that hospitals play in every health system. The acute and specialized care they provide makes a life-and-death difference. Hospitals heal, cure, and comfort. They facilitate safe childbirth and dignified deaths.
The relationship between hospital clinicians and public health officials has often been viewed as tense if not antagonistic. This should not be the case.
Primary health care and hospital services are not in conflict. They are complementary and mutually beneficial. People cannot enjoy the highest attainable standard of health without the services of hospitals.
As more and more countries aim to achieve universal health coverage, access to hospital services is an important indicator of coverage achievement.
One example makes this point clear. As public health knows very well, the unacceptably high number of women who die during pregnancy and childbirth will not go down until more women have access to skilled attendants at birth and emergency obstetric care. Complications of childbirth cannot be predicted. All women need access to these services.
When primary health care works well, when public health addresses and reduces risks within the community, hospitals are freed to do a much better job and invest their resources more strategically. With the rise of conditions requiring long-term care, many countries are strengthening community and home-based care, further freeing hospitals to do their job well.
Given the world-class challenges facing public health, including noncommunicable diseases, hospital services are certain to become increasingly vital.
As the UN Political Declaration on NCDs clearly stated, prevention must be the cornerstone of the global response to these costly, deadly, and demanding diseases. Yet even if prevention were perfect, we would still have clinical cases of heart disease, cancer, and diabetes, with their multiple complications and acute events.
Many of these events will need to be managed in hospitals. And they will need to be managed with greater efficiency and less waste.
As the international community approaches the deadline for reaching the Millennium Development Goals, I am personally encouraged by a new brand of thinking in public health.
It is this: poor people deserve the very best possible health care because they have been given so little else in life. When this thinking prevails, it can breed the very best innovations.
Ladies and gentlemen,
A breathtakingly beautiful new hospital, inaugurated in 2011, now stands atop a hill in one of the most underserved and deprived areas of Rwanda. This is in the Butaro district, a rural area with more than 340 000 residents but not a single clinic, not a single doctor, before the hospital was built.
This is a 150-bed hospital designed with dignity and furnished with state-of-the-art equipment, examination rooms, and labs.
Architects and engineering firms from abroad provided pro bono designs and guidance. That hospital got the best in the world. Everything was built with local labour, local materials, local tools, and local solutions. Construction created jobs for 3,500 men and women.
Walls were built from volcanic rock that had previously been viewed as just a nuisance in the farming fields. Local masons mastered the technique of “jigsaw” joinery and then took these skills, and these rocks, on to other construction jobs.
The hospital set new standards for infection control as an integral part of the architectural design. This was especially important given the high burden of tuberculosis in the area. An ingenious system of fans, windows, and ultraviolet lights mimics the infection control achieved with far more costly systems that are prone to break down.
Each hospital bed faces a large window with a view of the lush valleys below. This is a deliberate recognition of the spiritual side of healing. Families gather in verandas, and the wards are full of colour.
This is a modern hospital in an impoverished rural part of Africa that is now delivering world-class medical care.
A new ward offering comprehensive cancer care opened last July. This new Center of Excellence offers a suite of services, from cancer diagnosis, chemotherapy, and surgery, to psychological support and palliative care, that is almost never available in rural parts of Africa.
The people wanted this hospital, and worked for it, sometimes in shifts through the night. Construction was completed ahead of schedule and under budget.
It is the pride and joy of the community, as well as their lifeline. The poor deserve the very best, and they have it in Butaro, Rwanda.
Another ingenious recent innovation addresses the fundamental need for energy. This is solar power in a small portable suitcase produced by a non-profit team in the USA. It was specifically designed to support emergency obstetric care in health facilities with no or unreliable electricity supplies.
Collecting energy from the sun, it provides highly efficient medical lighting, power to run computers and medical devices, like fetal monitors, and power to recharge batteries and cellphones. It can be adapted to power refrigerators, also for blood banks.
Maintenance is low. The design is robust, even in the harshest environments, and simple. A single switch turns the system on. The lighting system lasts for 70 000 hours. That means around 10 to 20 years.
First deployed in Nigeria in 2009, the solar suitcase is now in use in 24 countries. In some villages in Africa, it provides the first electricity, and the first electric lighting, ever seen by the community.
WHO worked with this non-profit organization, called We Care Solar, in Liberia and has seen first-hand the difference for maternal health that light and power can make. This is sunshine saving lives.
Some innovations benefit hospitals in all countries, and not just the developing world. This is true for patient safety.
Patient safety is a comparatively new discipline that has rapidly risen to star status. This rise began in the late 1990s, with eye-opening reports documenting the scale of harm caused by medical errors.
These reports had media appeal, which gave them popular and political traction. And understandably so. Medical errors cause deep indignation. Health care should heal, not hurt, injure, or kill.
To address the large number of deaths caused by surgical errors, WHO adapted a simple checklist used by pilots in the airline industry, one of the safest industries in the world.
The WHO Surgical Safety Checklist was introduced in 2008 and has since been widely applied, significantly reducing surgical errors. Studies suggest that, if fully implemented, nearly half of the estimated one million deaths caused by surgical errors could be averted.
Building on this success, WHO has developed a Safe Childbirth Checklist to address the huge burden of preventable maternal and newborn deaths, especially in low-income settings.
What good does it do to offer free maternal care and have a high proportion of babies delivered in health facilities if the quality of care is substandard or even dangerous?
A pilot study of the checklist, conducted in India and published last year, demonstrated a 150% increase in adherence to accepted clinical practices for maternal and perinatal care in an institutional setting. No additional resource investments were made. Just a paper checklist, like pilots use.
A large randomized controlled trial is under way to quantify the impact on reducing morbidity and mortality
A congress session later today will focus on hospital partnerships. WHO has worked to link hospitals in Africa and Europe in an innovative hospital-to-hospital partnership that aims to improve systems for patient safety.
Top priorities identified include safe surgical care, reducing health care-associated infections, managing hospital waste, and improving the safety of medicines.
If all countries are now facing similar health challenges, it makes sense for wealthy countries to learn from innovations in emerging economies. Why not South to North technology transfer, especially in countries where the crisis of health care costs has spiraled out of control?
For example, a hospital-based eye care system developed in India for cataract surgery delivers better outcomes, with fewer complications, than similar systems in wealthy countries. It does so at one sixth of the costs, after adjustment for differences in purchasing power.
Studies of this success cite innovations in processes and methods that improved efficiency with no compromise of quality. In fact, the number of post-surgical complications is less than half of that seen in wealthier countries.
In India, this system of eye surgery has recently expanded into rural areas with primary care vision clinics.
Ladies and gentlemen,
Worldwide, the burden of disease has shifted dramatically. Yet the fundamental structures of health care systems, including acute-care hospitals, have barely changed over at least a century.
Advances in technology race ahead at break-neck speed, yet the systems for delivering and financing these technologies remain stuck in a previous century.
Let me conclude by going back to the original question: are innovation and technology game-changers for the future? Yes, if we can catch these runaway horses, tame and train them.
The miracles of modern medicine unquestionably save lives. But if they are to do real good, they must work their magic in financially sustainable ways.
Technology can let the talents of clinicians shine. This bright light must shine for everyone, and not just the rich and privileged few.