52944 EAP DRM KnowledgeNotes Working Paper Series No. 8 disaster risk Management in east asia and the pacific HealtH By Inaam Haq, Shiyong Wang, and John C. Langenbrunner1 Strategy and principleS for recovery and reconStruction © The World Bank/Mara Warwick International experience shows that in the aftermath of a natural disaster, a transition strategy for restoring and maintaining health care services should be devel- oped while planning for rebuilding a better health care system over the next 5­10 years. A rapid assessment should be carried out to determine the population pro- file and the epidemiological profile. The health needs of the people in the affected areas should be assessed without delay and periodically reassessed, with particular attention to existing and newly emerged vulnerable populations. The needs identified should be addressed in both the transition and reconstruction strategies. The transition phase should prioritize a rapid restoration and revitalization of an undisrupted supply of essential health care services. Reconstruction is often better led and coordinated by a strong national or provincial authority as this improves implementation effectiveness and equity. The roles and responsibilities should be clearly designed for different levels of government, sectors, communities, and individuals. Transparency and involvement of affected populations and communities will not only enhance design but also ensure effective implementation of the reconstruction plans. In addition, reconstruction of the health sector needs to be sequenced with other sectors (e.g., housing and infrastruc- ture) to ensure functionality. The Wenchuan Earthquake provides an opportunity for health sector reform in China. First, it is better that recon- struction address the immediate key issues faced by the health sector such as health financing to reduce out-of-pocket expenditures among the affected population; provide better health insurance coverage and benefits; and improve This working paper series is produced by the East Asia and Pacific Disaster Risk Management Team of the World Bank, with support from the Global Facility for Disaster Reduction and Recovery (GFDRR). This note was prepared for the Government of China as part of a series of good practice notes on post-disaster recovery following the Wenchuan Earthquake that struck on May 12, 2008. Content was coordinated by the China and Mongolia Sustainable Development and Country Management Units of the World Bank. The focus is on sector-specific lessons from past post- earthquake recovery programs in different countries around the world. 2 disaster risk Management in east asia and the pacific Hospitals and other health facilities need to leadership of and coordination by the government were be constructed to higher standards to ensure evident during the emergency, ensuring placement of health care teams and temporary hospitals to cover af- their integrity and functionality when another fected populations. Other lessons included: earthquake hits. A risk-based, all-hazards n Strategy and design: Pakistan used a transition strategy approach for emergency preparedness and to ensure access to basic services and employed mul- response should be practiced. tiple approaches, including mobile services, outreach using community-based workers, and facility-based services. The strategy balanced short- and longer- term needs. n Planning: A damage and loss assessment provided the foundation for future planning and implemen- accessibility to the poor and other vulnerable popula- tation. Detailed assessments also helped in reducing tion subgroups. Second, the future health care system redundancies and facilitated decisions to rationalize should be designed to be prepared for and responsive to the number of facilities to be reconstructed. all major hazards. As mentioned in the Overall Recon- n Implementation: The government focused on guar- struction and Disaster Risk Reduction notes, the build- anteeing essential care during the recovery phase. ing standards and codes for earthquake-prone zones are Reforms focused on things that were easily doable critical. Hospitals and other health facilities need to be rather than trying to address complicated issues. constructed to higher standards to ensure their integrity and functionality when another earthquake hits. A risk- n The nongovernmental sector was used effectively by based, all-hazards approach for emergency prepared- ensuring strategic placement of their services. ness and response should be practiced. Third, the exist- n The process guaranteed public participation, trans- ing health care system in the affected areas may need parency, and accountability in both the relief and re- to be rationalized and streamlined to meet the changed covery phases. needs. To this end, duplications in the public health care system may be reduced. n Epidemics were prevented by utilizing early warning systems to track diseases that could cause epidemics international experience (e.g., cholera and typhoid) with a response mecha- nism. pakistan A key lesson from Pakistan's response to the South Asia turkey Earthquake in 2005 was how effective coordination helps A key lesson learned following the 1999 Marmara to ensure efficient implementation in a country where Earthquake in Turkey was the state's proactive approach the public sector system is normally neither efficient nor and openness to innovations in the field of disaster risk effective. An effective coordination mechanism was op- management, including the creation of the Turkish Ca- erationalized to coordinate multiple partners during the tastrophe Insurance Pool. Other lessons that are impor- emergency, transition, and reconstruction phases. The tant from a health sector perspective included: Health 3 n The establishment of an effective institutional frame- work and approach to capacity building for disaster risk management institutions. n The provision of a budget allocation for the entire duration of the reconstruction period rather than on an annual basis minimized the uncertainties and facilitated the government to move swiftly with the reconstruction program. overall leSSonS learned © The World Bank reconstruction planning Reconstruction planning begins when the damage and loss assessment (DLA) is conducted. International ex- perience suggests that the DLA is a process, rather than a one-time event, and often goes hand-in-hand with transitional recovery and longer term reconstruction ef- disease prevention efforts; and, (viii) examining and forts. It is critical to standardize the methodology of the designing seismically safe health care facilities. DLA across sectors to allow integrated assessments and reconstruction planning for all sectors. Timeliness and n Reconstruction within the framework of health care re- precision must be balanced when conducting a DLA. forms: The DLA should explore and identify chal- Damage and loss assessments for the health sector lenges faced by the sector requiring reforms and should cover the following key areas: implement them as part of the reconstruction effort, e.g., how to rationalize primary and secondary health n Damage overview and recovery needs: The impact of care facilities as part of the reconstruction effort, and/ the earthquake on health care systems and on human or opportunities to restructure the management of health should be assessed, and rough costs of damage primary health care services. and for reconstruction estimated. n Cost estimates: Estimates should include costs for (i) n Reconstruction and recovery strategy: The DLA should facility cleanup; (ii) health infrastructure and related help in (i) designing an overall approach and the key equipment; (iii) public health campaigns and trau- principles for the reconstruction strategy; (ii) under- ma mitigation efforts; (iv) human capital needs; (v) standing access to primary and secondary health care medical waste management; and, (vi) increases in the services by different groups; (iii) targeting popula- costs of health care treatment. tions with special needs; (iv) designing detailed needs assessments and mapping of vulnerable populations; The overall coordination mechanism and institutional (v) understanding coordination within the health arrangements for reconstruction should be designed sector and between different sectors; (vi) under- before implementation commences. Consultation with standing the capacity of the health sector and health different stakeholders and affected communities is im- care workforce; (vii) assessing health promotion and perative in the planning and implementation stages of 4 disaster risk Management in east asia and the pacific Hospitals and other health facilities need to services (e.g., basic surgical care, laboratory and other be constructed to higher standards to ensure diagnostic services, and inpatient care). their integrity and functionality when another n Appropriateness: Adoption of new service delivery earthquake hits. A risk-based, all-hazards models to respond to new health care needs if the previous system was outdated. approach for emergency preparedness and response should be practiced. n Efficiency: Greater overall efficiency with savings used to finance some of these measures. The most urgent need is to ensure access to an essential health care package and public health programs that re- duce vulnerabilities and save lives. Primary health care (PHC) services should be easily accessible at the tem- recovery and reconstruction. A cost plan and timetable porary resettlement sites while secondary care services should be developed and publicized in order to improve could be provided at designated sites. Early warning alert accountability and minimize corruption. In addition, a and response systems for epidemics or any other public thorough analysis on environmental impact, econom- health emergency prevention should be revitalized and ic and technical inputs, and human resource capacity strengthened. It is imperative to make sure that (i) the should be carried out to ensure that the health sector poor and other vulnerable population subgroups have plan for recovery and reconstruction is practical. access to free health care; (ii) emerging mental health problems are addressed properly; and, (iii) a package of recovery and reconstruction heath services for the disabled is provided. implementation Recovery and reconstruction should be divided into two In the Chinese context, it may be appropriate to main- phases, with different priorities for each: (i) transition tain health care services free of charge and phase these and (ii) recovery and reconstruction. The duration of out over time. An exit strategy based upon the dam- each phase will differ from country to country and de- age and loss assessment, careful cost modeling, and pends on a number of factors, including the commit- per-capita payments could be developed. While the es- ment and political will of the government and the fi- sential package of public health services and activities nancial and technical capacity of the country. The tran- should be fully financed by the government, funding essential clinical services could combine payments by sition phase usually takes 3­12 months; recovery and health insurance schemes, government subsidies, and reconstruction takes 1­3 years or longer. The strategy out-of-pocket payments aimed at less than 20 percent should design the future vision for the sector. The key of out-of-pocket expenses for the general population. principles for recovery and reconstruction of the health However, for the poor and other vulnerable population sector should include: subgroups, free health care services are highly recom- n Equity: Expansion of service provision to under- mended. served areas, the poor, and other vulnerable popula- Medium and long-term recovery and reconstruction: tion subgroups. Broader health care system issues (e.g., utilization and n Effectiveness: Increasing access to and quality of key quality of health care services) should be addressed in Health 5 this phase. Disasters often provide an opportunity for the health sector to reorganize and reform. Establish- ment of new hospitals, health care centers, and public health institutions should be rationalized to reduce un- necessary redundancy and unhealthy competition. The concept of the World Health Organization (WHO) Safe Hospitals Initiative should be embraced to build health care facilities to meet higher standards. This ini- tiative has been implemented in California, Mexico, and other Latin American countries. Independent reviewers should be hired to review the quality of the design of all © The World Bank health care facilities to ensure increased preparedness for the next disaster. Special requirements for hospitals and other health care facilities should be met because these (especially secondary and tertiary facilities) must remain functional immediately after a disaster occurs. This is premised on essential supporting infrastructure (e.g., New services should be launched to address the emerg- communications, electricity, transport, water supply, and ing health needs. For instance, post­traumatic stress sewage systems) also remains functional after disasters. syndrome and depressive disorder are two mental health The current public health emergency protocols and rel- problems that may affect a large number of survivors. evant plans at all levels should be revised based upon These conditions often manifest one to three months the lessons learned from the Wenchuan Earthquake, following the event, and are more likely to be concen- and embrace the concept of all-hazard preparedness. It trated among women, children, the disabled, and other is generally agreed that there are four elements for ef- vulnerable population subgroups. The magnitude of this fective disaster prevention and preparedness: (i) an ac- vulnerability can be quite sizeable: For the countries af- curate analysis of hazards and vulnerable populations; (ii) fected by the 2004 Asia Tsunami, WHO estimates that formulation of disaster preparedness and response plans; 20­40 percent of the affected population suffered mild (iii) communicating prevention and preparedness to the psychological distress, 30­50 percent exhibited moder- public as well as key decision makers; and, (iv) regular ate or severe distress, and 10­15 percent had mental drills and exercises to test and improve the plans. disorders. International experience suggests that mental Discontinued health care services in the affected areas health and psychosocial support services are typically should be gradually revitalized in this phase. Special at- delivered through four levels of care: (i) self- and fam- tention should be given to mental health, prevention ily care; (ii) community mental health services; (iii) care and control of non-communicable diseases, and services and support outside the formal health sector; and, (iv) for the vulnerable and the disabled. Financing mecha- mental health care through primary health care. nisms need to be designed and implemented to protect against catastrophic health care costs during the post- Because of changed profiles of disease and health care crisis period. issues, loss of health care workers, and innovations to 6 disaster risk Management in east asia and the pacific In Pakistan, based on the outcome of the DLA, n Medium to long term (12­36 months): This included the reconstruction of seismically safe facilities and a health sector reconstruction strategy was options for addressing key issues faced by the sector, designed with two overlapping phases, building including low utilization of health care services and upon the ongoing work and learning lessons inadequate quality of care. Key points included: from the relief effort. · Rationalizedreconstructionofseismicallysafefa- cilities with integration of smaller units into larger facilities, facilities closed or relocated, and upgrad- ing some facilities based on population size. · Anessentialpackageofservicesdefinedanddeliv- ered using an integrated approach. · Emphasis on the needs of vulnerable population be piloted, the existing health care system management subgroups, including undertaking a vulnerability likely needs to be reviewed and strengthened. A human assessment. resource development plan and proper institutional ar- · Strengtheningofthemanagementandorganiza- rangements should be designed and implemented. tional system, including an effective coordinated In Pakistan, based on the outcome of the DLA, a health response involving multiple partners. sector reconstruction strategy was designed with two · Community-based rehabilitation of the disabled, overlapping phases, building upon the ongoing work working with nongovernmental organizations. and learning lessons from the relief effort. The overall · Institutionalmechanismforoperationalizingrapid theme was build back better. However, for health, the emergency and disaster response. strategy envisaged a revitalized system that would en- In Turkey, a main dimension of the post-earthquake ef- sure the provision of an integrated essential package of fort supported reconstruction and interventions to con- services. tain damages in the case of similar future events. This n Short term (3­12 months): The short-term strategy comprised developing a mental health strategy and a focused on ensuring revitalization and availability of trauma program for adults, setting up community men- the basic health care services and core public health tal health centers and programs for psychological sup- programs and functions, with attention given to: (i) port, and reconstructing permanent housing and health provision of services for people living in the relief care facilities in earthquake-affected areas. camps; (ii) provision of essential services using mobile services, alternate structure--including prefabricated Measure results at each step units, and community-based workers for outreach The monitoring and evaluation (M&E) plan for health services; (iii) provision of secondary care services at reconstruction should focus on a limited number of critical the appropriate levels; (iv) provision of a special pack- indicators (e.g., Pakistan had three to five), have a clearly age of health care services for the disabled; and, (v) defined frequency and time line, and preferably be imple- making functional epidemic prevention programs, and mented by a multisectoral team comprising surveyors and strengthening/rebuilding the surveillance systems and evaluators. The findings can be used to assess results, then field epidemiology capacity. to periodically revise plans, budgets, and allocations. Health 7 recoMMendationS Build back better: The objective for recovery and recon- struction should be building the health sector back better. This means the system will have safer infrastructure (e.g., seismically safe hospitals), be prepared for key public health hazards and emergencies, and provide equitable and affordable services to vulnerable groups. Communications and coordination: Reconstruction should be led and coordinated by a strong national or local authority. Clear roles and responsibilities should be developed and assigned to the different sectors and levels of government. Affected populations and communities © Photos.com need to be consulted during the planning and implemen- tation of the recovery and reconstruction strategy. Two-phased approach: A transition strategy is needed to bridge the emergency and reconstruction phases. The transition phase should ensure access to an essen- tial health care package and public health programs that evaluation plan should focus on a few critical indica- reduce vulnerabilities and save lives. The reconstruc- tors to measure results, have a clearly defined frequency tion phase needs to restore and further-develop service and timeline, and preferably be implemented by a mul- packages and build the health care system to improved tisectoral team comprising surveyors and evaluators. A standards. budget, usually 5­10 percent of the recovery and recon- struction budget, should be set aside for this purpose. Health sector damage and loss assessment (DLA): A standardized methodology for all sectors will allow Reasonable expectations: It is highly recommended integrated assessments. The health sector DLA should that post-earthquake health sector recovery and recon- be comprehensive, balance timeliness and quality, and struction should proceed in parallel with health sector weigh current losses against future needs. reform; however, the post-disaster window of opportu- nity to introduce institutional and regulatory reforms Rapid assessment of vulnerable groups: Particular at- should be balanced with what can be practically achieved tention needs to be given to map the existing and newly in the context of an emergency recovery project. n emerged vulnerable populations in both the transition and reconstruction strategies. Service provision and end note benefits should be expanded to underserved areas, the 1 The authors would like to acknowledge Betty Hanan poor and newly emerged vulnerable population sub- and Toomas Palu for their contributions to this note. groups. The expanded package should be costed and fi- nanced; an exit strategy for financing free services to the population at-large should be developed in parallel. Measure results in every step: The monitoring and east asia and the pacific region The World Bank 1818 H St. NW, Washington, D.C., 20433 http://www.worldbank.org/eap Special thanks to the partners who support GFDRR's work to protect livelihoods and improve lives: Australia, Canada, Denmark, European Commission, Finland, France, Germany, Italy, Japan, Luxembourg, Norway, Spain, Sweden, Switzerland, United Kingdom, UN International Strategy for Disaster Reduction, USAID Office of Foreign Disaster Assistance, and the World Bank.