Disaster Recovery Guidance Series Health Sector Recovery Contributors List Alice Mortlock, (Lead Author) Disaster Risk Management Specialist, The Global Facility for Disaster Reduction and Recovery, The World Bank Dr. Alex Camacho Vasconez, Emergency Preparedness and Disaster Risk Reduction, Pan American Health Organization Patricia Bittner, Independent Consultant, Disaster Risk Reduction Dr. Celso Bambaren Alatrista, Health Emergencies, Pan American Health Organization Dr. Yuki Matsuoka, Head of Japan Office United Nations Office for Disaster Risk Reduction and Coordinator, International Recovery Platform Secretariat Dr. Gerald Potutan, Researcher, International Recovery Platform Secretariat Timothy A. Bouley, MD., Health and Climate Specialist, World Bank Climate Group, The World Bank Group Dr. Chadia Wannous, Senior Advisor, United Nations Office for Disaster Risk Reduction Margot Christeller, Director, Leaver Ltd. Carolyn Gullery, General Manager, Planning and Funding, Canterbury District Health Board, New Zealand Dr. Alistair R.G. Humphrey, MPH, FAFPHM, FRACGP, Medical Officer of Health (Canterbury), Canterbury District Health Board, New Zealand Dr. Jonathan Abrahams, Director of Public Health in Emergencies, World Health Organization Dr. Ryoma Kayano, Technical Officer, World Health Organization Tekabe Ayalew Belay, Senior Economist (Heath), The World Bank Group Carl Taylor, JD, Executive Director, Frazier Institute for Health and Risk Analytics; XCH, LLC Jacob Vawter, International Relations Specialist, U.S. Federal Emergencies Management Agency Gerilee Bennett, Director, Inter-Agency Coordination Division, U.S. Federal Emergencies Management Agency Dr. Tamara Mancero, Health Emergencies Focal Point, Pan American Health Organization, Mexico Dr. Yanet López, Health Emergencies, Pan American Health Organization, Mexico Cover photo: © Dominic Chavez/World Bank About this Guidance Note The recovery phase is an opportunity to Build Back Better by Disasters and emergencies often have integrating disaster risk reduction into development measures, as disproportionate impacts on a country’s health outlined in the Sendai Framework for Disaster Risk Reduction. During system1 and the overall health of women, recovery, cross-cutting issues can be incorporated into operations men, girls, and boys. Disasters can cripple more easily and less expensively than if introduced at a later stage. health facilities (by destroying infrastructure For example, including gender equality and women’s empowerment, or leaving a facility unable to function due to community engagement, and resilience to climate change in the loss of critical components such as power and recovery process can reduce gender inequality, gain community buy- water), leading to their inability to provide in, and support the development of climate-smart health systems. lifesaving medical care. The interruptions of routine public health programs, such as vaccination campaigns, are common in the ■■ Medium-term reconstruction efforts. wake of a disaster, setting back gains to overall public health. Health workers are often unable The three tables on the following pages to perform their duties because they have been summarize areas of work within each health personally affected or are unable to reach their sector recovery phase and presents key workplace. Financial resources earmarked milestones, including where multilateral for health may be directed to other priorities. agencies and other support may assist recovery Recognizing these realities as countries move efforts. to post-disaster recovery will help to maintain The suggested milestones are aligned with three pre-disaster levels of health and may offer functions: opportunities to introduce measures to improve ■■ Lead—health officials have or take control to the overall resilience of the health system. make things happen. This Guidance Note (the Note) for Post- ■■ Support—health officials work with other Disaster Health Sector Recovery is intended to recovery leaders to assist them in their provide action-oriented guidance to local and recovery work. central government health sector officials who face post-disaster challenges related to health ■■ Enable—health officials share resources sector recovery. It lays out the policy, planning, and tools (for example, people, systems, financial, and implementation decisions and platforms, data, and physical assets) that activities that go into developing and putting will help others to lead their components of into effect a Health Sector Recovery Plan. recovery. Additionally, common pitfalls are outlined as This Note is accompanied by an extensive well as ways to overcome them. Reading List that is available on the Global While recovery is not a linear process, the Note Facility for Disaster Reduction and Recovery’s is structured around three phases: (GFDRR) Recovery Hub website, under the Health section ‘Knowledge Documents’ ■■ Immediate, or initial recovery efforts as the (reference to this list is made throughout this sector transitions from response to recovery. Note by *).2 ■■ Short-term, or recovery planning and initial implementation. 1 The World Health Organization defines health systems as: (i) all the activities whose primary purpose is to promote, restore, and/or maintain health; (ii) the people, institutions, and resources arranged together in accordance with established policies; to improve the health of the population they serve, while responding to people’s legitimate expectations and protecting them against the cost of ill-health through a variety of activities whose primary intent is to improve health. 2 http://www.gfdrr.org/health#knowledge. 3 4 Health Sector Recovery Milestones by Phase of Recovery3 Immediate Recovery Milestones and Support: Make Safe, Provide, Plan, and Repair Area Milestones Support for Milestones LEAD Sources of experts include the International Recovery Platform Seek assistance from, preferably (IRP), Pan American Health Organization (PAHO), World pre-identified, experts in health sector Bank (WB), World Health Organization (WHO), regional recovery as required. development banks, and Ministries of Health or District Health Boards who have faced similar recovery efforts. Consult with multilateral agencies or bilateral partners about Assistance technical or financial assistance for the transition from response to health sector recovery. Consult, and if possible, partner with organizations that work on women´s (and health) issues to ensure the specific health needs and vulnerabilities of women and men, girls and boys are addressed. LEAD A post-disaster needs assessment* and a risk assessment will Identify damages, losses, and needs as well generate inputs for the Health Sector Recovery Plan. For as gaps in baseline information, potential example, these assessments produce information on damaged emerging problems, and new vulnerable health facilities, losses associated with the reduction in health populations as defined in accordance service delivery, and associated community needs. with Annex 1 of the International Health Additional sector-specific investigations of damages, losses, and Regulations. needs might need support from the central government. Study lessons learned from other health Additional investigations of damages, losses, and needs sector recovery experiences. disaggregated by sex and age, if not addressed in the post- Information disaster needs assessment or in additional sector-specific Gathering investigations, might be needed. Consult and disseminate lessons learned and best practices (for an outline of relevant case studies and lessons, see IRP Guidance Note on Health*). Use local informal and formal health and community networks to identify community health needs and concerns. Consult with both women and men to ensure recovery is designed to meet their respective needs and accords with what is culturally and socially appropriate. 3 The International Recovery Platform (IRP) defines the recovery phase as “The restoration, and improvement where appropriate, of facilities, livelihoods and living conditions of disaster-affected communities, including efforts to reduce disaster risk factors. The recovery task of rehabilitation and reconstruction begins soon after the emergency phase has ended, and should be based on pre-existing strategies and policies that facilitate clear institutional responsibilities for recovery action and enable public participation. Recovery programmes, coupled with the heightened public awareness and engagement after a disaster, afford a valuable opportunity to develop and implement disaster risk reduction measures and to apply the ‘build back better’ principle.” Immediate Recovery Milestones and Support: Make Safe, Provide, Plan, and Repair (cont.) Area Milestones Support for Milestones LEAD IRP, PAHO, WB, and WHO can advise governments on Activate a preferably pre-prepared and developing a pre-prepared and high-level Post-Disaster high-level Post-Disaster Health Sector Governance and Leadership Framework and on appropriate Governance and Leadership Framework associated legislation. that outlines roles, responsibilities, and Community and health networks have strong grassroots commitments after a disaster event. knowledge of health issues to support the identification and Confirm, in the context of the event, the channeling of resources to address the different health needs of Leadership, right institutions and people are in place or women and men in the communities. For example, community Governance and address the gaps. clinics, health departments, local governments, nongovernmental Coordination organizations (NGO), and the private sector. Confirm the lead agency to ensure critical recovery decisions and clear The coordination and definition of roles and responsibilities communications. during recovery should be supported by national legislation or a Memorandum of Understanding (before a recovery plan Clarify and communicate health sector formalizes the roles or preferably before the disaster occurs in recovery roles. the leadership framework). Develop accountability and transparency Financial accountability should be achieved through regular mechanisms for policy, planning, legal, independent audits of comprehensive financial information. and operational actions and financial information. LEAD Use local informal and formal health and community networks Approve and implement the cross-key to identify community health needs and concerns. These needs agency communications plan, ideally and concerns will inform the communications plan. developed and drafted with partners’ Identify/develop communication templates* for high-concern, pre-disaster as part of the Post-Disaster risk, crisis, and change management situations. Governance and Leadership Framework, to provide consistent and clear communications to partners and all affected residents. Under this plan, key messages Communications are identified and agreed among sector recovery leaders (single source of truth). Those responsible for communicating should be aware of gender issues. ENABLE Support and provide women, men, girls, and boys with relevant information to initiate self-recovery at the community and individual level, including psychosocial recovery *. Pay attention to vulnerable groups. LEAD/SUPPORT A post-disaster needs assessment*, in conjunction with any pre- Confirm funding needs and allocations for planned Post-Disaster Recovery Framework*, can determine health sector recovery. Confirm any cost- overall recovery funding needs. A more in-depth health sector Funding sharing arrangements. assessment might be required, including for mental health support. International financing institutions can advise on adapting public financial management systems to support the government and provide international best practices. 5 6 Immediate Recovery Milestones and Support: Make Safe, Provide, Plan, and Repair (cont.) Area Milestones Support for Milestones ENABLE Human resources, training, and procurement should be Address the capacity and capability of the supported by the central government. Human health workforce for their own recovery Support the workforce’s well-being throughout each phase of Resources needs and well-being. recovery; staff and their families often are impacted by the disaster itself, and recovery work will conflict with their business as usual requirements. LEAD The European Union, United Nations, World Bank, and regional If not drafted pre-disaster, investigate, agencies can assist the government in developing a disaster scope, and draft a Health Sector Recovery recovery framework*, which might inform a Health Sector Plan using best practice templates from Recovery Plan. support agencies. For example, post- There are guides and tools to undertake health and disaster recovery framework*. environmental impact assessments*. Multilateral agencies can If developed pre-disaster, complete the advise on the most appropriate health impact assessments for pre-prepared Health Sector Recovery the context. Strategy Plan template. Adjust the draft to suit the Risk assessment mapping information is available through the and Planning disaster context. U.S. Federal Emergency Management Agency*. Test that the right legal instruments for health sector recovery are available or seek help if required. Catalyze social, health, and environmental impact assessments described in the draft Health Sector Recovery Plan. Identify planning documents for recovery objectives and map hazard. LEAD The lead recovery agency should provide guidance on Confirm with health sector partners appropriate consultation mechanisms that are to be used for on the appropriate mechanisms to use stakeholder engagement on the draft health sector recovery for consulting stakeholders on the draft plan. Consultation recovery plan. The consultations might be carried out with other sector Agree to a gender-sensitive approach for recovery consultations, including a broader post-disaster consulting affected communities, engaging recovery framework. with both affected women and men. LEAD Local agencies might provide relevant indicators when Investigate recommended recovery developing an M&E framework and IRP, PAHO, WB, and WHO indicators for the M&E plan. might have templates/examples to support relevant M&E frameworks*. Draft or activate the pre-prepared M&E Monitoring Include recovery indicators disaggregated by sex and age, where framework that reflects the recovery plan and Evaluation vision, goals, and activities. Identify where possible. (M&E) baseline information is missing. SUPPORT Share the M&E framework with other recovery leaders. Immediate Recovery Milestones and Support: Make Safe, Provide, Plan, and Repair (cont.) Area Milestones Support for Milestones LEAD Understanding and allocating the cost of immediate repairs Identify priority health sector repairs with required for infrastructure and lifelines will take time. In this partners. immediate period, a cost indemnity agreement should be designed and agreed between the central government and lead SUPPORT local infrastructure owners to guarantee immediate repair Make functional buildings safe and identify action. possible buildings for demolition. International health organizations or the American Society for Initiate repairs to critical infrastructure, Healthcare Engineering can advise on repair prioritization where able. Infrastructure criteria. Re-establish health sector lifelines, Qualified engineers and contractors will need to support ‘make including power, sewerage, and piped water safe’ decisions, asbestos, and health and safety regulations for network. premises. LEAD/SUPPORT Central governments should consider advising the health sector Identify and initiate interim health sector on temporary accommodation options. accommodations, and communicate options to affected population. Develop an exit strategy for temporary accommodations. Keep in mind temporary structures often become permanent. LEAD Seek support from or resource-sharing with neighboring/ Address immediate health and safety issues, undamaged health facilities. meet health needs, and re-establish critical Prior to any disaster, explore a mutual aid/assistance health services. arrangement with neighboring facilities and support networks. New health risks, often derived from water The arrangement sets expectations and commitments, including issues (cholera, hepatitis, etc.), accompany financial recoupment*. disasters and require immediate attention. Train health professionals on gender and Health Service its implications for health, including on Delivery gender-based violence (GBV) prevention and response. GBV can spike in the aftermath of disasters. Ensure the health needs of women and men are assessed and met. Focus on reproductive, maternal, newborn, and adolescent health. Make health facilities accessible for both women and men. Understand the respective barriers to ensure equal access. 7 8 Immediate Recovery Milestones and Support: Make Safe, Provide, Plan, and Repair (cont.) Area Milestones Support for Milestones ENABLE WHO, the private sector, the central government, and NGOs Ensure medical or other supply might be well placed to support the development of a medical arrangements are functioning and bringing supplies and logistics plan. Medicines, in needed supplies. Supplies, and Technology SUPPORT Where these arrangements are not functioning, co-develop medical supplies and logistics plans with partners. SUPPORT The Department of Water and Sanitation (or equivalent) or local Initiate support to local and central government might lead. While initiated early, it can take years government authorities to allow clean to complete. Implementation drinking water supply and support the return of beaches and rivers to normal health levels for swimming. Short-term Recovery Milestones and Support: Begin to Rebuild, Return Services, and Reduce Obstacles Area Milestones Support for Milestones LEAD Investigate other sources of quality data, supported by Confirm baseline information for decision-making discussions with the private sector and NGOs. monitoring and evaluation. The central government should provide data-sharing Information SUPPORT protocol and agreement templates. Gathering Develop data-sharing protocols and agreements with agencies that have access to and stewardship of required data. SUPPORT The lead recovery agency should establish a project Leadership, Buy-in to coordinated project management office and management office to develop governance and Governance, tools to align activities and to reduce duplication. It coordination templates and monitor recovery and will also facilitate communications and collaboration activities. Coordination and support real-time information flows between and among critical health facilities. LEAD Messaging will need to be checked and updated in Update the public health sector communications consultation with partners. Communication plan as required to ensure consistent and up-to-date Ensure the communications plan reaches both women messages. and men. This might require different measures, messages, and communication tools. Short-term Recovery Milestones and Support: Begin to Rebuild, Return Services, and Reduce Obstacles (cont.) Area Milestones Support for Milestones SUPPORT International financing organizations can advise on Identify funding opportunities, including joint funding opportunities and a financial plan for collaborations to pool resources. This includes cost- implementing resilience and betterment measures. sharing agreements, where appropriate. National government should provide recovery leads Funding Develop a draft framework for whole of health sector with a joint draft framework for ‘whole of health sector recovery funding and financing and related template recovery’ funding and financing and related template agreements for implementation with partners. agreements for implementation with partners. Develop a funding plan for implementing resilience and betterment measures for the health sector. ENABLE Staff support from undamaged facilities or Evaluate gaps in workforce capacity and capability; international health organizations might be utilized Human upscale or add workforce skills to meet recovery to provide training or resolve capacity and capability Resources objectives. gaps. Evaluate and support the well-being of the workforce. Psychologists can provide tips for people and workforces impacted by disaster*. LEAD The review of the current policy, regulatory Review the current policy and regulatory environment environment, and the development of any new to ascertain its appropriateness to enable post-disaster regulations or policies might be led by the Ministry of health sector recovery. Health, but it needs to be undertaken in consultation with local authorities and health agencies. Promote new policy or regulatory requirements, where necessary, to affect positive and timely recovery. Assess whether the current policy and regulatory environment is sufficiently gender-sensitive to meet Approve the health sector recovery plan to direct and the needs of women and men. to coordinate recovery activities and agencies involved in recovery. Multilateral agencies can provide quality technical Strategy and assurance to support decision-making, including Planning Outline and analyze key planning decissions for the urban planning exercises (see IRP Guidance Note on health care sector, such as planning for land-use and Pre-Disaster Recovery Planning*). settlement patterns. Decide on the suitability of health sector land for rebuilding, including for hospitals, clinics, and laboratories. Work with recovery leaders across the whole of recovery to develop a coherent built environment (land, lifeline infrastructure, and critical social infrastructure) recovery prioritization model that ensures the coordinated financing and repair of all forms of infrastructure, including health infrastructure. 9 10 Short-term Recovery Milestones and Support: Begin to Rebuild, Return Services, and Reduce Obstacles (cont.) Area Milestones Support for Milestones SUPPORT A wider engagement strategy should be developed by Develop an engagement framework to ensure the the central government and used by the health sector health sector recovery plan reflects engagement inputs. recovery lead agency (see IRP Guidance Note on the Private Sector*). LEAD Engage residents on the health sector’s future and Consultation on the nature and coordination of recovery activities (draft recovery plan). Design the engagement strategy to effectively and equally engage women and men. ENABLE Engage private sector health providers to identify their recovery needs and to consider ways for the government to support the private sector. SUPPORT Partners, regional and international financial Re-assess initial needs and the recovery plan (inputs, institutions, private sector (for example, insurance outputs, outcomes, results, etc.). Modify the process as agencies), and research institutions might be able to required by results. Disaggregate the indicators by sex provide M&E technical assistance or the required data. Monitoring and age. and Evaluation LEAD Reconfirm and communicate on health recovery indicators. Strengthen efficiency and effectiveness of institutional arrangements where M&E reveals gaps and weaknesses. SUPPORT Use PAHO/WHO’s Hospital Safety Index to inform Provide oversight for the demolition of, and repairs to, reconstruction efforts.4 health sector infrastructure. The ministry responsible for buildings safety and the SUPPORT Ministry of Health could provide joint advice on Decide on long-term repairs and on health sector demolition and health and safety guidelines. Infrastructure infrastructure delivery. Sector recovery lead or a coordinating recovery authority should make the decisions on repairing or demolishing health sector infrastructure. If the infrastructure is insured, insurance companies assess the damages and make payouts to public and/or private health sector agencies. 4 Following the 2010 Haiti Earthquake, cholera proliferated. In response, public health officials and doctors at Les Centres GHESKIO teamed up with architects and designers at MASS Design Group to build a state-of-the-art Cholera Treatment Center in Port-au-Prince. The center enables responders to treat the ill while preventing water re-contamination. The facility also incorporated elements of sustainable design to minimize energy use and environmental impact. New facilities and interventions are necessary to respond to emerging climate-related health impacts. Integrate low-carbon and environmentally friendly strategies enables a truly climate-smart approach. friendly strategies, enabling a truly climate-smart approach. Short-term Recovery Milestones and Support: Begin to Rebuild, Return Services, and Reduce Obstacles (cont.) Area Milestones Support for Milestones LEAD Other district health boards, Ministries of Health, and Review alternative health support and service delivery PAHO/WHO can provide advice on service delivery Health Service models. models and support options based on experience and Delivery lessons learned. Introduce new services, as required. All models need to be modified to suit the immediate health sector and recovery priorities. Medicines, SUPPORT Restocking supplies might depend on the private Supplies, and Re-stock all medicines, technology, and other supplies. sector/pharmaceutical companies. Technology LEAD Use PAHO/WHO’s Hospital Safety Index to guide Deliver early health sector recovery plan projects to retrofitting and reconstruction efforts*. Implementation instill confidence; use Build Back Better principles. SUPPORT Oversee the prioritization and re-establishment of fresh water supply, sanitation, and health and safety to meet community health priorities. 4 Medium- to Long-term Recovery Milestones and Support: Complete Rebuild, Restore, and Improve Area Milestones Support for Milestones Leadership, SUPPORT National government should support this milestone by Governaance, and Strengthen the institutional capacity to pursue identifying longer-term health development goals and Coordination longer-term health development goals. indicators. LEAD/SUPPORT Continue to use community and health networks to Coninue to identify the recovery concerns of both identify community needs and disseminate key Communications women and men. messages. Provide clear, agreed-upon responses via multiple outlets to reach the widest audience. SUPPORT International financing institutions can advise on ways Prepare for diminished funding in the medium- to approach issues associated with access to resources term recovery phase as donors and political and confirming additional resources. Funding interests dwindle*. Revisit the funding and finance plan developed in the first phase, as access to sources of capital change. LEAD Confirm funding resources for the next stage. ENABLE The central government and district health board Take actions to reduce staff burnout. should provide measures to prevent staff burnout Human Resources (mental health days, psychosocial support, etc.) and LEAD the processes to monitor staff at risk of burnout. Identify resources to reduce burnout in the next stage. A transition team might be required to identify next- stage resource requirements. 11 4 Following the 2010 Haiti Earthquake, cholera proliferated. In response, public health officials and doctors at Les Centres GHESKIO teamed up with architects 12 Medium- to Long-term Recovery Milestones and Support: Complete Rebuild, Restore, and Improve (cont.) Area Milestones Support for Milestones LEAD If required, and as recovery issues are identified, the Introduce policy and legal mechanisms for health central government might initiate a review of the sector improvements as needed based on issue/ National Healthcare Act or introduce new policy and solution identification. legal mechanisms. Strategy and Planning LEAD/SUPPORT A recovery-wide land-use planning recovery plan Review the National Health Care Act, as required. developed by the lead recovery agency to support land-use decisions will inform the planning decisions SUPPORT for the health sector. This will also be an opportunity Seek opportunities to encourage healthier re- for the Health Sector to support planning decissions settlement (location) or co-locations for health that encourage safer and healthier communities. facility rebuilds. SUPPORT An independent evaluator might provide stakeholders Review and report on, as part of the broader the required assurance on progress or lack of progress/ recovery program, progress toward the recovery issues and credibility. indicators and financing/funding. Report on Monitoring and Evaluate health sector recovery activities, decisions, the effectiveness of the recovery program and Evaluation and next steps to inform the transition, including recommend areas for policy and implementation lessons learned. adjustments to stay on track. The evaluation should determine whether the activities have benefitted women and men equally. SUPPORT Use PAHO/WHO’s Hospital Safety Index to inform Ensure health facilities are designed to reconstruction and retrofitting efforts in health accommodate women’s needs for privacy. facilities*. Infrastructure SUPPORT Follow design codes and building code requirements for healthcare facilities. Take advantage to build sustainability into reconstruction. LEAD Central government should support primary care Strengthen primary care services and psychosocial services by investigating smarter, more resilient support through smarter delivery models and delivery models, including climate smart models. Service Delivery innovation, including climate-smart models and Additional funding for psychosocial support is likely models that assess the different needs of women to be needed. and men for equal and effective treatment. SUPPORT/LEAD Multilateral organizations are helpful in putting a Implementation Government and strategic partners continue to program management structure in place and implement health sector recovery plan. supporting momentum. SUPPORT/ENABLE A clear plan for transition, including the associated Phase out health sector recovery operations. communications plan, should be led by the recovery Transfer recovery responsibilities, as necessary. agency lead. Transitioning Put in place new arrangements as necessary. For example, support the monitoring and evaluation of recovery and develop continuity plans for health facilities. Breaking Down this Guidance Further health service delivery and needs between Information Gathering women and men. Immediate Phase ■■ Arapid assessment of vulnerable groups To determine material, human, and resource (the elderly, women, people with disabilities, needs and priorities, the information gathering indigenous people, and youth, among process involves: others), including the mapping of existing ■■ Assessing the impact (as in, damages and and emerging vulnerable populations. Their losses) of a disaster on human health and the needs could be identified through health care system. consultations and partnerships with NGOs. ■■ Understanding the quality of post-disaster ■■ Waterquality and environmental sanitation health care. and hygiene, particularly in relief shelters. new vulnerable population ■■ Identifying ■■ Census information: Tracking destinations groups and their locatations. as people move from shelters to permanent housing, in order to maintain continuity of ■■ Identifyingnew and emerging health issues health service records. (for instance, a spike in mental health-related issues). ■■ Community wellbeing: how the community as a whole is recovering. To avoid duplication of efforts, identify the points at which data are being collected and ■■ Schools, businesses, housing, transportation, establish data collaboration protocols and and the availability of the workforce all data-sharing agreements.5 Where data impact recovery of health facilities. Health collection resources are scarce, consider facilities do not operate in a vacuum. They assigning a mandate (and resources) to rely on the same power, water, workforce, research institutions to identify risks, conduct security, communications, and infrastructure surveys, assess the health impact, etc. Promote as other businesses. information sharing; hoarding of data can be Establish or re-establish a Health Management detrimental to recovery objectives. Information System (HMIS) that collects and Examples of the information to be collected and agglomerates relevant, reliable sex- and age- evaluated include: disaggregated data and provides a sound ■■ Baselinedata (disaggregated by age and sex) on local health conditions and services and Assessing the impact of a disaster on human health and the how the health system responded to existing health care system is key to understanding post-disaster needs (to expose weaknesses and support access to primary and secondary health care services, Build Back Better principles during recovery). assessing health promotion and disaster prevention efforts, Where there is no sex-disaggregated data, targeting resources, and identifying opportunities to enhance focus groups have proven to be an effective and upgrade health. measure to identify disparities in access to 5 Data-sharing agreements would stipulate ongoing ownership of the shared data and set out ways to create metadata standards so that data layers can be agglomerated in a useful manner for policymakers. 13 14 information basis for both short- and longer-term private sector, and partners (to empower forecasting, insight-development, and planning. local institutions and reduce duplication of efforts). Short- to Medium-Term Phase Conduct ongoing research to identify needs ■■ Identifykey health sector stakeholders and and issues, understand their implications, test partners, including community health clinics underlying assumptions and priorities, allocate and health networks, that have grassroots in resources, and monitor progress. Use this the community. Identify key stakeholders information to guide recovery activities and and partners that can ensure women and decisions, such as where to rebuild a destroyed men´s different needs and vulnerabilities health facility. are properly understood and addressed such as NGOs working specifically on gender Leadership, Governance, equality and women’s empowerment. and Coordination ■■ Identifycoordination entities within the Immediate Phase health sector. Good leadership, governance, and coordination ■■ Agree with partners on institutional and is a fundamental building block of any health sector recovery. Key steps include (not in any coordination arrangements, instruments, specific order): and accountabilities. Even though certain coordination strategies, mechanisms, and current governance and ■■ Investigate platforms may exist, new ones may need to be leadership arrangements to see where they developed or modified to focus on recovery can best be maintained and leveraged. activities and ensure consultation needs. ■■ Preferably,activate a pre-prepared and high- ■■ Consider informal coordination mechanisms: level Post-Disaster Health Sector Governance between local government and the and Leadership Framework that outlines community, within government (local and roles, responsibilities, and commitments after central), and between government and the a disaster event. international community. Agree on ■■ When procedures and criteria for collaboration such a framework has not been through a formal agreement such as a developed or the scale of the disaster exceeds Memorandum of Understanding. such a framework, it may be necessary to review leadership frameworks used by others ■■ Ensure coordination of health, nutrition, and their associated lessons and to develop and water and sanitation agencies, given the recommendations for how to best build on cross-cutting nature of the issues each will existing arrangements. be addressing. Focus on monitoring illnesses ■■ Identify and on adopting timely measures to avoid and get a mandate for a health risks of epidemics. sector recovery lead (such as, the Ministry of Health). Ensure the lead agency has the Short- to Medium-Term Phase capacity and capability to provide the A coordinated project management system necessary leadership. is critical for efficient workstreams and ■■ Clarify health sector recovery roles and imperative for aligning all actors. This will responsibilities, including those of the facilitate communication and collaboration and municipality, the district health board, the support real-time information flows between and among critical health facilities. As the Public health and sanitation campaigns can recovery progresses, strengthening institutional disseminate information on safe drinking water, capacities to pursue longer-term health vector control, and other health and safety development goals is important. In particular, issues (asbestos awareness, etc.)*. Depending there may be greater opportunities for joint on potential health risks, material on action to achieve common goals, including with tuberculosis, malaria, and dengue prevention; the private sector. HIV awareness and prevention; and hygiene promotion can be prepared and distributed. When multiple actors are involved, recovery may be delayed and efforts duplicated. It is Public campaigns should also address issues critical to have a concerted health sector related to gender-based violence since they are recovery approach, led by the government often present in post-disaster situations and a where possible, to focus on funding and major cause for severe mental health issues. resources. The role of external actors is Short- to Medium-Term Phase important, but it must be managed within If not already available, key partners can develop the overall context of recovery. a health system communications plan* that includes, among other areas, a gender-sensitive Communication community-level awareness program. It could Immediate Phase detail which health services are affected and One trusted source of truth and where to receive service support. Additional communications should be established material could be widely disseminated on immediately. Someone from the affected emergency preparedness and other safety community or country, representing both measures, hygiene promotion, disease awareness central and local government, is ideal. An open and prevention (* for an example related to Zika and transparent relationship with the media, virus infection), immunization, etc. in which accurate, clear, timely, and up-dated information is provided, will help to ensure Funding the public receives the information needed to Immediate Phase manage expectations, reduce uncertainty, and Health recovery strategies and plans must be defuse rumors. linked to available resources. Realistic cost Communication on health sector and broader estimates for recovery, based on damage, loss, recovery efforts should support the hearing and needs assessments* and a framework for impaired and the blind. Interpreters are critical allocating and monitoring funding are required for those with communication challenges, to embark on recovery activities and to cover including those who do not understand the higher-than-expected operating costs as well local language. An online mechanism will help as resilience and improvement measures. to widely disseminate existing issues, concerns, Determine funding available through the public and gaps in knowledge; support a clear vision and private sectors, including international of damages and resulting needs; coordinate agencies. An agreed-upon funding framework in volunteers; provide a space for technical this phase will save time and efforts and help to manuals to guide the recovery process; and focus action where it is most needed. It will also share joint-agency messages on recovery efforts, identify where additional funding is needed. service delivery, and health information. Advice can be prepared before a disaster so that it Key steps to the funding process include: requires minimal adaptation. ■■ Clarify insurance expectations. 15 16 ■■ Confirm additional funding needs beyond a tracking (M&E) and ■■ Establish existing baselines. Information obtained accountability system, including fraud checks through assessments should include costs for and independent audits. infrastructure, human resource, materials, allocation and channeling of financial ■■ Initiate and health treatment costs. Highlighting resources. costs for Build Back Better, where possible, is ■■ Developan exit strategy for financing free recommended. medical services, in parallel with the above ■■ Integratetransparency and accountability of steps. decisions and financial management into the recovery phase. One way to achieve this is Short-Term Phase by integrating public participation of women If not tackled during the immediate phase, and men in decision-making processes. This identify and agree with key institutions the financing requirements to fund repairs or to will pay off in terms of better planning, re-establish critical health sector programs and improved implementation, and reduced systems and to Build Back Better. While the corruption. government should finance essential public ■■ Establish criteria and principles agreed upon health services and activities, mechanisms with partners to prioritize the allocation of could help cover essential clinical services funds. These priorities need to be considered (health insurance, government subsidies, and a and understood alongside other recovery limit on out-of-pocket payments). For example, priorities. Consider the following questions: government should note opportunities to – Who are the beneficiaries of this engage and leverage charitable funding for assistance? larger health sector recovery needs. Free – What are the needs of the women and health services are recommended for poor and men, girls and boys who will receive the vulnerable populations. assistance? Medium-Term Phase – For what purpose, how much, and in what In the medium term, funding may begin to dry form will assistance be provided? up or be re-directed, hampering sustainable – What conditions and obligations are recovery efforts. Audits and evaluations of attached to the assistance? funding mechanisms and allocations will – How will compliance and outcomes be need to be undertaken and any funding needs monitored? identified and addressed. ■■ Confirm cost-sharing arrangements and schedules. Development partners and the Human Resources private sector provide both financial and Immediate Phase in-kind assistance. Clearly signaling what is The rapid identification and mobilization of needed from partners may increase what is trained health workers is critical to immediate offered. Development partners will have recovery efforts. Maintain a roster of female technical experience that governments may and male experts and establish a mechanism utilize. The schedule for the cost-sharing to determine if staff have been affected by the arrangements sets out the process for managing disaster. Ensure all are clear on responsibilities and resolving what is known and unknown. and procedures, adequate resources (human ■■ Mobilizefunds for health sector recovery and and financial) are available, and management develop systems for delivering funding. support is provided. In addition to medical and health staff, experts in hospital administration profiles and other health factors. Lastly, design may be required to support the training and a human resources development plan and make operational preparedness of administrators. the necessary institutional arrangements. Administrators will confront such issues as a lack of emergency supplies, loss of power, and Strategy and Planning missing client account information. Immediate Phase Although government procurement and human As part of the wider recovery effort, consider resources procedures should be well planned the implications of policies, regulations, and and transparent, procurement rules must also laws that oversee standards and control be flexible and agile. Some health workers will regulatory enforcement. For example, poor develop mental disorders after an emergency, enforcement of building codes often increases while others will experience psychological the adverse impact of a disaster on health distress. Those with pre-existing mental services. Legislation or regulations may enable disorders often need more help. Ensure local governments to use revenues from other workers have access to psychosocial support areas to reconstruct, repair, and rehabilitate to cope with losses of and disruption to damaged infrastructure; a decree could allow normal routines. Where healthcare delivery public health services to coordinate public and has been halted due to the disaster, engage private health networks. the health workforce in recovery efforts. This To meet recovery objectives, a recovery plan will help health facilities retain their skilled for the sector needs to be developed in employees while offering employees continued coordination with a wider recovery plan. The employment until the facility is back to development of a sector recovery plan includes operational status. the following steps: Short-Term Phase ■■ Involve partners in drafting the Health Sector Give staff adequate time and space to re-charge Recovery Plan. Start by defining what recovery and to support their own individual recovery looks like for the health sector. Establish the efforts; recovery is a marathon not a sprint. This desired recovery outcomes (vision and goals); may be an opportune time to take advantage principles, priorities, and status of plan; of the recovery phase to develop new plans definition of ‘vulnerable affected populations’; for training and deploying medical workers and components of recovery. that better meet the needs of the population. For example, capacity building in disease ■■ Consider the social, health, legal, and surveillance and training in psychosocial environmental impact implications of the support may need to be improved at this stage. plan’s components. Ensure both women and men are trained in ■■ Haveany legal component of the plan the lead agency and provide gender-sensitive approved at the highest government level. activities to build capacity. disaster preparedness and risk ■■ Identify Medium-Term Phase reduction opportunities for the health sector During this phase, ensure health workers have to reduce exposure and vulnerability. continued access to psychosocial support and flexible work opportunities. Review and, if necessary, strengthen the management of the current health system to meet changing disease 17 18 Short-Term Phase and rehabilitation and that housing, public During this phase, if not achieved earlier, buildings, and community facilities are approve the Health Sector Recovery Plan to accessible to all. initiate recovery activities and to coordinate Consultation with the agencies involved. Policy initiatives designed to enhance existing health services Immediate to Short- and Medium-Term Phases should be considered and put forth by the Engage residents on the future of the health leadership, in coordination with all partners sector and on the nature and coordination of and with public participation of both women recovery activities, including the draft Health and men (see next section on consultation). Sector Recovery Plan. Ownership helps ensure Consider developing policies on: Build Back beneficiary satisfaction and align partner and Better; what assistance (if any) should be government interventions while provided to the private health sector assistance; implementation and evaluation benefit transfer of staff in affected areas and facilities; from the inputs of both women and men. direct purchase of goods, services, and Community-visioning practices, where equipment; healthcare waste management possible, will support the health sector to clarify and disposal; access to primary health care; and to meet recovery objectives. This is also emergency health; emergency response; etc. an opportunity to engage private sector health providers to identify and to consider possible As part of the planning process, identify and government support for their recovery needs. map hazards that could impact key health A dedicated forum (existing or new) for early infrastructure. Build on existing development consultation may prove useful. plans, for example, to curtail sprawl and to avoid substandard services (* for an example of wind hazard maps). Monitoring and Evaluation Immediate Phase Medium-Term Phase Measuring progress toward recovery goals is Investigate policy mechanisms to improve the critical when measuring the success or failure health sector (for example, guidelines for food of recovery programs and projects to meet the safety, policies to reduce child mortality, im- needs of the people impacted by a disaster. All prove maternal health, or ensure environmental partners in the process have roles in the sustainability). Review national mental health collection, analysis, and dissemination of the policies to reflect post-disaster needs. results. Develop a results-based monitoring Seek opportunities to encourage healthier and evaluation (M&E) framework to support settlements and to support zoning decisions the implementation of the Health Sector that highlight hazards, in particular planning Recovery Plan—with clear baseline information the location of health facilities that must be (where available), targets, expected outputs, rebuilt. For example, would the facility be in a and outcome indicators to identify when the flood zone or near a potentially failing nuclear recovery is on target and, ultimately, completed. power plant? In addition to determining If outside help is required to design and to suitable sites for rebuilding, this is an implement the framework, set aside a budget opportunity to resolve land ownership for this purpose. Where baseline information and tenure issues across the health sector is missing, enlist collaboration from partners infrastructure and to Build Back Better. (including the private sector) to fill the gaps. Importantly, ensure the needs of the disabled Include data disaggregated by sex and age, when are included in post-disaster reconstruction possible, for better measurement of results. Short-Term Phase permanent). Be realistic about the timing and the Donors require reporting on the recovery approach to rebuild infrastructure. In addition progress, or lack thereof, to ensure funds reach to, or in lieu of, temporary infrastructure, build those in need. This means, evaluating recovery sector settlements with infrastructure and land activities may overlap with continued baseline tenure through a participatory planning process data collection; this is fine. Evaluate recovery (* for cordon off unsafe areas and for pre-disaster activities and expenditures on a regular basis location scoping). (every 6–12 months). If necessary, adjust Initiate repairs to and reconstruction of critical the Health Sector Recovery Plan and the infrastructure, making risk reduction a priority. budget as required to overcome any identified Support the development of building guidelines gaps and weakness. If weaknesses are due to address and to codify hazard vulnerabilities. to institutional failing rather than the Plan For vulnerable infrastructure, duly record them or budget, amendment of the institutional and consider developing response and arrangement might be required. Sharing the mitigation plans. reports with partners, local governments, the private sector, and the general public is best Short-Term Phase practice. Building back better or retrofitting safer and more sustainable health infrastructure— Medium-Term Phase adhering to any revised norms or codes—is The results of the monitoring and evaluation the focus of short-term recovery. Develop a processes will inform if, how, and when public works program that takes into account transition occurs. social and environmental impact assessments. Where feasible, deliver early health sector Infrastructure recovery projects to instill public confidence. Immediate Phase Government funding may be needed to In a disaster, the health sector is central to the rehabilitate private sector health facilities response. Hospitals must be able to continue during disaster recovery. As part of this, functioning and be safe if they are to provide funding can stipulate that private sector health life-saving services. The structural collapse of facilities incorporate mitigation measures for a hospital is a worst-case scenario. More often, safer facilities and accessible and gender- they are simply unable to function due to a sensitive design for facilities. lack of manpower, damaged or lost equipment, Medium-Term Phase interruptions to the power or water supply, and/ In medium-term recovery, major health sector or limited or no access to the facility. construction projects should be underway. To assess building structures, to cordon off unsafe Often these repairs can take governments years areas, and to survey health facilities’ conditions, to initiate, delaying recovery efforts. The engage ideally pre-identified local engineers PAHO/WHO Smart Hospitals Toolkit* with disaster risk reduction expertise. The data provides a first resort to Build Back Better or collected—and combined with partner inputs— retrofit health facilities. A good business case will inform the infrastructure planning process by should be made for establishing new hospitals, prioritizing repairs, replacement, and demolition. health centers, and public health institutions to Locate temporary health facilities in safe areas reduce redundancy and unhealthy competition. that are ideally identified pre-disaster* and plan Independent reviewers can review the design for an emergency, transition, and permanent quality of healthcare facilities to ensure shelter (temporary infrastructure often becomes increased resilience in the next disaster. 19 20 ■■ Environmental health efforts should focus Health Services Delivery on disease surveillance, immunization, Immediate Phase water quality, safe food, sanitation, waste Successful recovery depends on broadening management, and related guidelines for the capacity of four levels of health service relief work. providers: community health teams, clinics/ ■■ Determine where interruptions in service birthing/nursing homes, community or delivery have occurred and ensure access to district hospitals, and higher-level hospitals. medicines (including to anti-retrovirals). The WHO has identified key elements of ■■ Disease surveillance should continue, rebuilding a disrupted health sector following particularly among vulnerable populations a disaster*: living in areas where the public health ■■ Identify the most vulnerable populations infrastructure and programs have been and respectively prioritize the resumption weakened (including in temporary shelters)*. of critical health services, including Short-Term Phase identifying delivery challenges. In most At this phase, priority health services, scenarios, life-saving care and chronic-care community health support services, a system management will top the list. Develop a to ensure the uninterrupted delivery of system for confirming that chronic patients medical care for persons with chronic illnesses are receiving appropriate medical care. or conditions, and a mechanism to redress ■■ Identify grievances related to service delivery should the different needs of women and be operational. A focus on psychosocial men, girls and boys to provide targeted support may help reduce the effects of stress, support to all segments of the population. grief, or post-traumatic stress disorder. ■■ Explore sharing resources and technical Medium-Term Phase knowledge with nearby unaffected health During recovery, it will be crucial not only facilities, the Ministry of Health, other to have functioning health services but also nations, multilateral organizations, or to strengthen primary health care services, charitable agencies to support damaged for example, climate-smart health care facilities. Develop ideally pre-disaster initiatives. This may also be the opportunity mutual assistance agreements for the to investigate new social and health support emergency and recovery phases. and service delivery models that are equitable ■■ The Ministry of Health and other in health services delivery and in addressing responsible entities can explore interim the needs of women and men, boys and girls. care options. This includes, for example, A strengthened primary health care service mobile medicine or vaccination centers, would consider the following: telemedicine, temporary facilities in schools, ■■ Equity—expanding services to underserved and transporting the sick and injured to the areas. nearest functioning facility. It is particularly ■■ Effectiveness—increasing access to and important to make primary health care quality of key services. services accessible at temporary resettlement ■■ Appropriateness—adopting new service sites. Hospitals or other health care facilities outside the disaster-hit areas may be able to delivery models as needed. provide interim care for lifesaving surgery ■■ Efficiency—usingsavings to finance other and other critical care. primary health care measures. This could include identifying opportunities Short- to Medium-Term Phase to integrate services, such as a home-based During recovery, it is important to restock support model for stronger health outcomes medicines and re-institute health sector or identifying, engaging, and strengthening technology, defined by WHO as the ‘application existing social capital (community-based of organized knowledge and skills in the form skills, programs, and networks). Strengthening of devices, medicines, vaccines, procedures, primary health care for the next disaster also and systems developed to solve a health means taking preparedness measures such as problem and improve quality of lives.’ During simulation exercises in health facilities. The the recovery process, re-establish national community-driven approach to post-disaster vaccination programs to pre-disaster levels. recovery requires a significant investment of time and human resources, but it results Implementation in greater client satisfaction and local empowerment of both women and men if done Immediate Phase in an inclusive manner. Restoring drinking water and sanitation systems are key priorities. In the immediate Post-traumatic stress syndrome and depressive phase, bottled water can meet the population’s disorders often manifest only one to three needs as plans are made to restore key systems months after the disaster. In vulnerable to pre-disaster levels. Distribution of supplies populations, this can be treated not only with such as mosquito nets or latrine pans may be counseling, psychiatric treatment, psychotropic required to protect against malaria or address drugs, etc., but also by rebuilding communities, sanitation concerns. livelihoods, and social interaction*. Monitor water quality across the community Additionally, those who have sustained physical and environmental sanitation and hygiene injuries because of the disaster will require in relief shelters. Set up a system to track long-term rehabilitation services, including a population movements, in order to maintain referral care system. continuity of health service contacts and provision of services. Consider health Medicines, Supplies, and protection needs associated with the recovery, Technology including problems due to asbestos dust emerging from the rubble or demolition sites. Immediate Phase Distribute information to the public about the Medicines and technology are among the harmful effects of asbestos and distribute masks important building blocks for the recovery of as required. health systems *. In prolonged crises, it is common to witness interruptions in the supply of Short- to Medium-Term Phase drugs and other medical equipment and supplies. Manage facilities for healthcare waste or The re-establishment of the cold chain, and the develop temporary solutions (such as, for a (re)establishment of a central pharmaceutical temporary disposal facility within a municipal warehouse or a similar mechanism must be landfill). Consider the environmental impact carefully planned, based on the factors impeding of any temporary or permanent storage of the supply of essential drugs and supplies to healthcare waste, particularly bio-hazardous public health facilities. Consider developing a materials. Major elements of a medical waste strategy for an emergency drug supply chain disposal operation include assessment, system to address delays encountered. equipment, and training. 21 22 Transition Pre-Planning for Recovery Governments may set a time limit on the Now is the time for governments to make recovery process or may keep lead agencies in contact with this Note, before a disaster occurs, place until certain recovery objectives are met. as a part of the ongoing planning, mitigation, Whatever determination is used, there will be a response, and recovery process. Identifying the gradual phasing out of recovery organizations, owners of key functions, information sources, activities, and partnerships. It will be necessary critical resources, and contributors prior to to create a clear exit strategy or transition plan to an event will ensure a smoother and cost- ensure recovery responsibilities are transferred saving path to post-disaster implementation. where and when necessary, including financial Moreover, establishing a baseline of existing requirements/responsibilities. New institutional, healthcare capabilities and needs will allow legal, or policy arrangements may also be needed the government and partners to more quickly to support transition. Prior to the transition, identify where service gaps exist as a result of a identify health sector lessons learned from disaster. participating members and partners to support future disaster recovery efforts. Workshops should be held with all stakeholders. These lessons, if learned rather than observed, can indeed support Build Back Better principles. Overview This Guidance Note for Post-Disaster Health Sector Recovery is intended to provide action-oriented guidance to local and central government health sector officials who face post-disaster challenges related to health sector recovery. A summary of suggested milestones by phase of recovery lays out the policy, planning, financial, and implementation decisions and activities that go into developing and implementing a Health Sector Recovery Plan. Additionally, common pitfalls are outlined as well as ways to overcome them. For more information on implementing recovery programs, please visit the GFDRR Recovery Hub: https://www.gfdrr.org/recovery-hub The Global Facility for Disaster Reduction and Recovery (GFDRR) is a global partnership that helps developing countries better understand and reduce their vulnerabilities to natural hazards and adapt to climate change. Working with over 400 local, national, regional, and international partners, GFDRR provides grant financing, technical assistance, training and knowledge sharing activities to mainstream disaster and climate risk management in policies and strategies. Managed by the World Bank, GFDRR is supported by 34 countries and 9 international organizations.