Design and Health World Health Design

Dialogue: Think Globally Act Locally

Eric De Roodenbeke, director-general, International Hospital Federation
More must be done to help hospital managers understand the economic and clinical value of good design within their local cultural context, new International Hospital Federation director-general tells Prof Per Gunnar Svensson.

In ‘pure’ economic terms, healthcare is no different from any other industry or business, in respect that it is a scarce resource, subject to the laws and fluctuations of supply and demand. Many health economists also theorize that healthcare is derived from the wider demand for health, such that individuals will allocate their resources in order to both consume and produce health, with the ultimate aim of improving their ‘health stock’.

It is perhaps appropriate, therefore, that a health economist has taken the helm at the International Hospital Federation (IHF), one of the most significant healthcare management organisations in the world, with an agenda to develop the role of hospitals within the broader context of public health, particularly in underserved communities.

Founded in 1929 with a membership encompassing national hospital associations, government health ministries and other health institutions and individuals in over 100 countries, the IHF is responsible for around 50,000 hospital facilities and the welfare of more than three billion people. Leading such an organisation requires political skill, fi nancial acumen and a strategic vision, but most importantly it requires a passion for global health improvement, qualities possessed in abundance by the IHF’s new director-general.

When WHD asked Design & Health president and former IHF director-general, Prof Per Gunnar Svensson to interview  his successor, Eric De Roodenbeke, about his refl ections on the relationship between design and health, we hoped for an appreciation of the economic as well as the clinical case for good design – and we weren’t disappointed.

Per Gunnar Svensson: How important is design and architecture to effective health service provision?

Eric De Roodenbeke: A hospital is a living organism, where construction projects are an every day occurrence, as part of a continuous cycle of improvement in the environment, either through new buildings or refurbishments. But when we talk about design, we must consider more than its value in improving the aesthetic quality of our surroundings. Design is also concerned with the creation of an efficient and effective product. When we purchase a car, its appearance may rank top of our wish list, but comfort and fuel consumption are also important.

P-GS: How important is flexibility in hospital design to accommodate future changes in technology, work patterns and practices?

EDR: Rapid changes are occurring in patient care, medical technology and clinical practice, and the built environment can be a major constraint on how we respond to these changes. Outpatient treatment is more important today than it was before, so the transition to accommodate this change requires dramatic organisational changes. The issue of flexibility, which for example, allows for the manipulation of room sizes is one of the most difficult challenges facing hospital designers.

P-GS: How important is research and the idea of ‘evidence-based’ design in international hospital developments?

EDR: These discussions are very important. From my experience of working in developing countries, I have observed that hospital design is closely related to the local environmental context. The design response in a developed country can in no way be replicated in a sub-Saharan country, because the environments are so different, not only from a climatic perspective, but also culturally and in terms of the available resources. Nevertheless, it would be useful to have research-based material from which the best examples and practices could be drawn to avoid a reinvention of the wheel, and shorten the preparation time for new projects. The World Health Organisation (WHO) and the World Bank have published documents on primary healthcare facilities in low income countries that demonstrate that there is a lot of work to be done in the fi eld of hospital design, planning and construction.

P-GS: Almost 70 abstracts were submitted for next year’s 6th World Congress for Design & Health in Singapore, but the majority addressed issues in middle and high income countries, with very few tackling the developing world.

EDR: This may be due to the existence in most developing countries of a turnkey hospital system/model, built by foreign agencies. It might be interesting, for example, to contact development agencies, such as the Japanese International Cooperation Agency (JICA), which has experience in international hospital development projects in low-income countries, and request them to prepare a summary document of hospital construction projects in low income countries such as Laos, Cambodia, Philippines.

P-GS: That is an excellent idea. The experience of development agencies could be invaluable to our agenda at Design & Health in the developing world.

EDR: When I worked for the French Development Cooperation on a project for the development of a pediatric hospital in Ouagadougou (Burkino Faso), we established a twinning programme with a French hospital, and the architect was able to capture the local culture and social environment in the design. He also used his knowledge from another hospital construction project undertaken in Burkino Faso to design a ‘bio-climatic’ structure, which involved a covering over the building that reduced the impact of the heat, and enabled a reduction In operating costs.

P-GS: How important are the connections between design and culture, and in particular the use of art, music and colours to reflect the local social context?

EDR: There are two elements. Firstly, the design of the hospital should refl ect the local culture in respect of the building materials used, and the fi nishing, such as the colours used and the furnishing of the environment. The other important aspect is that the hospital should be at the centre of the local community, hosting activities and social events, that convey the facility to be a positive place of social connection, rather than one of suffering and disease. As a hospital manager in France, we organised art exhibitions which attracted visitors other than patients and served as a means of integrating with the local community. It is important therefore to consider at the conception stage of a design how areas such as the entrance hall can be used for social and cultural activities, without compromising the core functions of the hospital.

P-GS: What is the role of design in addressing issues such as public health or healthcare-associated infections (HAIs)?

EDR: In the case of HAIs, the material type you use as well as the overall design can have an impact. Things are changing too in the operating theatre, where practices used to be designed around a ‘clean’ and ‘dirty’ circuit. Today, this has been replaced by the use of mobile containers with improved infection control measures. In the case of intensive care, design must take account of hygiene in relation to the flow of patients, health workers and visitors.

P-GS: How important is it to invest heavily in hospital design?

EDR: The biggest financial drains on a hospital are the running costs, and comparatively, the cost of design is relatively small. A primary goal of Design & Health should be to demonstrate the economic value, as well as the aesthetic and functional value of a well-designed hospital.

P-GS: Under your leadership, will the IHF continue to address the issues associated with healthcare design and architecture in your publications and at your events?

EDR: Maintaining continuity in an organisation is of vital importance, and I have no intention of breaking with this tradition. Construction is a part of the every day life of hospital, so design is a central topic at the very heart of the hospital sector.

Prof Per Gunnar Svensson, president, International Academy for Design & Health
The future plans of Design & Health are to reach out beyond the healthcare environment into sectors such as schools, prisons and the workplace, as there is a developing research-base to suggest that these environments also have an impact on our health and well-being.

EDR: A distinction should perhaps be made between a structure with a public function, such as hospitals, schools and prisons, and facilities with a commercial function, such as offi ce or retail environments. The guiding design principles and motivations for these two facility types are very different. In the example of prisons, the movement of occupants is restricted for long periods, but in a retail environment, the flow is fluent and for a short period. In terms of the architectural response, lessons could be learnt from across different sectors. WHD and the Design & Heath World Congress could help enormously to facilitate this knowledge transfer.

P-GS: On a broader level, better public health and an effective hospital system is an important economic and social driver. What motivated you to apply for the post of director-general of the IHF?

EDR: I have spent 25 years of my life in hospital management, designing health systems and policies, and providing expertise to hospitals for various population groups, and especially the poorest groups. The IHF is central to improving the dialogue among and between providers in both the public and private sector with health system decision and policy makers.

Health service providers and related industries must be a part of the forces driving, anticipating and responding to a rapidly evolving environment and growing public expectations. At a national level, Ministries of Health, national hospital federations, professional bodies and the health providers themselves are responsible for an effective healthcare delivery system. There is also a need, however, to act and advocate at an international level to respond to the global challenges that exist beyond national borders. National organisations also need to be supported with evidence and knowledge of best practice from around the world.

P-GS: Can you share with us your vision for the IHF?

EDR: My ideas are in harmony with the vision statement adopted by the IHF Governing Council in 2006. Therefore, I will be promoting the IHF as a world leader in facilitating the exchange of knowledge in health sector management with the aim of improving the quality of patient care. The emphasis on management has to be understood in a broad sense to sustain the performance of health service delivery organisations in respect of their responsiveness, efficiency, effectiveness, equity, quality and fairness in fi nancing, as described in WHO’s World Health Report 2000. This should lead to a world of healthy communities served by well managed hospitals and health services where all individuals attain their highest potential for health. This should be a goal for each and every country and for the international community.

P-GS: What will be your main priorities in the first six months?

EDR: In tribute to my predecessor, Prof Per Gunnar Svensson, my first priority will be to build on the existing strengths of the IHF, which has grown through a partnership approach both in terms of volume and diversity of activities in recent years. As the executive of the Governing Council, I will work closely with Council members to achieve the priorities they have set out for the IHF, and be accountable to the Council for the results of our activities. Direct and open relations with IHF members will be my priority, and to develop an understanding of their own priorities.

P-GS: Do you anticipate any changes?

EDR: Major changes will result from the decisions of the Governing Council, so it is a little too early to predict a new direction. However, I do believe the IHF will take advantage of my previous experience in the developing world. One of the IHF’s priorities has been to increase membership and activities in poor countries, especially Africa. Having worked on this continent for the last 18 years, there is an important need for expertise in the area of hospitals within health service reforms for low income and transition countries.

P-GS: What will be the style of your approach to achieving your vision?

EDR: Thinking out of the box has always been central to my activities. When I started to work in French public hospitals in 1983, I co-founded an association to promote marketing in public hospitals and ever since I believe that health service delivery organisations should fulfi l public interest goals regardless of legal statute.  The latest World Bank publication from Alex Preker et al, Public ends, private means: strategic purchasing of health services demonstrates that everything can be improved, but only if all possible solutions are considered without dogma. What counts is that healthcare resources are used effectively to provide the most equitable health service of high quality to those who need it.

Prof Per Gunnar Svensson is president of the International Academy for Design & Health and former director-general of the International Hospital Federation.

Eric de Roodenbeke
2008 Director General of the International Hospital Federation
2007 Senior Health Specialist, Global Workforce Alliance, World Health Organisation
2004 Senior Health Specialist, World Bank
2001 Director of University Hospital of Tours, France
1999 Senior Officer (Hospital & Health Financing), French Ministry of Foreign Affairs
1996 Senior Officer (Hospital Policy), French Ministry of Cooperation
1994 Deputy Director, University Hospital of Nantes, France
1989 Project Director, Burkino Faso Hospital, West Africa
1984 Deputy Director, Epinal-Vosges General Hospital Education: PhD Health Economics, University of Paris 1, Sorbonne, France


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