Sunteți pe pagina 1din 11

International Journal of Disaster Risk Reduction 6 (2013) 118128

Contents lists available at ScienceDirect

International Journal of Disaster Risk Reduction


journal homepage: www.elsevier.com/locate/ijdrr

A semi-quantitative risk assessment model of primary health


care service interruption during flood: Case study of Aroma
locality, Kassala State of Sudan
Haitham Bashier Abbas a,n, Jayant K. Routray b
a
Disaster Preparedness, Mitigation and Management, Asian Institute of Technology, Bangkok, Thailand
b
Regional and Rural Development Planning, and Disaster Preparedness, Mitigation and Management (Interdisciplinary Academic
Programme), Asian Institute of Technology, Bangkok, Thailand

a r t i c l e in f o abstract

Article history: Primary health care (PHC) centers are very important to provide health facilities and
Received 24 January 2013 services at the local level. The role of PHC centers becomes crucial during the flood and
Received in revised form other natural disasters. PHC is an essential health care which is scientifically sound,
7 October 2013
socially acceptable, universally accessible through affordable cost, and geared towards self
Accepted 7 October 2013
reliance, and based on practical methods and technology. This paper attempts to develop a
Available online 21 October 2013
semi-quantitative risk assessment model for primary health care service interruption
Keywords: during flood. The model is developed in the context of Sudanese PHC and validated
Primary health care further to add value and confirm its application in a wider context.
Risk assessment
& 2013 Elsevier Ltd. All rights reserved.
Service interruption
Flood
Sudan

1. Introduction flooding is the disruption of health care services [3]. The


supporting systems are important for functional continuity of
The WHO has initiated the campaign of making hospi- the health facilities [4,5]. Their importance could clearly be
tals safe in emergencies on the World Health Day, 2009, to shown during Hurricane Katrina in August, 2005, when health
highlight how health facilities and their services are crucial facilities stopped functioning due to non-operating generators
to the community in times of disasters as they work to save and impossibility of providing supplies through the flooded
lives, treat the injured and ensure continuous health care in road network. Arboleda and colleagues have shown the
post-disaster and accordingly they deserve to be protected importance of including the analysis of infrastructure systems
because of their high serving and economic values [1]. in the vulnerability analysis of health facilities as they
One of the major impacts of disasters, including flood, is significantly affect the functions of those facilities [6]. Loss of
the disruption of the health services either through direct health facilities' functions was encountered during and after
damage of the health facilities, inaccessibility, or affected the tsunami disaster in 2004 in Maldives, Indonesia Thailand
health workers, besides the damage of supporting systems and Sri Lanka. Those facilities are most needed at the time of
like logistics, communications, power and water supply [2]. crisis to serve victimized people, especially the ones within
The most commonly reported health system impact after the affected areas [7]. In Bangladesh, about 53% health
facilities went out of function during 2007 cyclone (SIDR),
and about 51.7% of the health care facilities in Orissa, India
n
Corresponding author. Tel.: 66 896628465.
experienced dysfunction due to the flood of 2008 [8]. There
E-mail addresses: st110489@ait.ac.th, are evidences that the prevalence of the interruption of
hitha2000@gmail.com (H.B. Abbas). treatment for patients with chronic diseases is proportional

2212-4209/$ - see front matter & 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijdrr.2013.10.002
H.B. Abbas, J.K. Routray / International Journal of Disaster Risk Reduction 6 (2013) 118128 119

to the magnitude of damage to the health facility [9]. Similar town, with a total area of about 14,000 km2 and a popula-
damages were reported in Ecuador and Peru, 19971998, tion of 82,000. The population density in the area is
Bolivia, 2002, Argentina 2003, and in Australia [10,11]. 12 person/km2 and there are of 55 villages [20]. Health
The importance of low scale health centers can be realized services are delivered through one rural hospital in Aroma
by understanding their roles in delivering the services of the with 57 beds. There are nine functioning health centers
Primary Health Care (PHC) [12]. Despite their relatively less and 22 basic health units, three of which are not function-
cost, PHC centers have roles and values to rural communities ing. No private health service is available in the area.
comparable to those of bigger hospitals. Those values make In total there are two doctors, 14 assistant health personals,
their protection cost effective and necessitate the integration 13 medical assistants, 46 environmental health officers and
of their safety in any health risk reduction plan. However, workers, and 25 certified midwives. There is no psychiatrist,
despite their importance and obvious vulnerability to floods dentist, radiologist nor anesthesiologist in the area. Only
not many original research papers are found in the literature seven villages have at least one midwife (13%) and 76% of
to tackle the issue of the safety and risk assessment of those the population live less than 5 km from the nearest health
low scale facilities [8]. In Sudan the five year strategy for the facility.
Ministry of Health has clearly identified the importance of the Kassala state is under the risk of annual flooding which
continuous provision of health care during disasters as one of significantly affects communities in the area with a five year
the main strategic objectives, to which the safety of health interval. The most devastating floods occurred in 1975,
facilities is a key element [13]. The problems of PHC in 1983, 1988, 1993, 1998, 2003, and 2007, when 47,075 people
developing countries are almost the same; an evaluation were affected [21]. The Gash River is the main source of
report in India diagnosed the PHC problems which are flood hazard as neither its course nor the timing of water
associated with insufficient human resources, inadequate rise can easily be predicted. Despite this high risk, people
infrastructures and drugs, and lack of community participa- refuse to be either evacuated or relocated [22]. The state is
tion and quality health care [14]. Other factors that affect the frequently hit by disease outbreaks of malaria, Dengue
service delivery at the level of public health centers are fever, meningitis and diarrhea. One factor that increases
coverage, availability of human resources with different the likelihood of disease outbreak is the high indices of
required specializations, incomplete package of services, vectors' density [23]. Kassala has the highest malnutrition
shortage in equipment, and the dysfunctional referral system rates in the country, the global acute malnutrition (GAM) is
[15]. Access to PHC is a major determinant of service delivery 29%, infant mortality rate is 56/1000 and maternal mortality
affect the utilization of services and flow of functions and ratio (MMR) is 140/10,000 live births. Those high indicators
services provided by the facilities. Accessibility is a multi- are mainly due to limited access to basic antenatal care and
dimensional concept that includes geographical accessibility, the deficiency of skilled birth attendants. Birth under
availability, affordability, accommodation and acceptability, medical supervision in public hospitals is about 13.3%, in
as explained by the model developed by Penchansky [16]. addition to the widely practiced female genital mutilation
In addition health can be seen as a commodity that is also which is estimated to be as high as 90% [24]. The health
affected by supply and demand factors such as quality of care in the state is not up to the national standards with low
health care services, affordability, appropriateness of health accessibility to health services [25].
personnel and social values and norms [17]. Risk of service interruption during flood emergency can
The health system in Sudan is a decentralized system be a source of hazard to community health. As the
with three tiers of care at primary, secondary and tertiary resources are limited especially at the lower level of
levels. About 33% of the population has no access to health government structure, there is a need for prioritization
facilities, the minimum PHC package is provided by 19% of to identify those health centers which deserve the urgent
PHC facilities. 39.8% of the PHC facilities are not functional actions for risk reduction. Another point to be considered
because of human resource shortages and 34.7% because of is that the study area is under the annual risk of flooding
the physical infrastructure condition [18]. PHC facilities and with such capacities and vulnerabilities the health
include primary health care centers (PHCC), primary care facilities would be facing an extensive risk of service
health care units (PHCU), dressing stations (DS), dispen- interruption if no immediate actions are taken. Therefore
saries, and health centers. Rural hospitals are considered there is a need for simplified and practical assessment
part of the PHC level and serve as secondary referral level procedure and tools that can be applied by the staff of the
health facilities. Specialized and general hospitals are the health centers and the local authorities. This goes in line
tertiary level and are located in states' capital. About 41% with the role of the health staff at their centers and
of the total health visits take place in primary health community [26,27]. Such a simplified method is important
centers, with a variation on the use of Family Health Units to avoid the complexity of sophisticated and lengthy
and dispensaries with a range of 181% in urban and rural procedures without jeopardizing the utility and validity
areas. About 52.2% of urban centers provide the minimum of the assessment model.
package compared to 3.8% of the rural centers and 21.9% of This paper refers to the definition of risk assessment as
the family health units [19]. a methodology to determine the nature and extent of risk
by analyzing potential hazards and evaluating existing
1.1. Background conditions of vulnerability that together could potentially
harm exposed people, property, services, livelihoods and
The study area is the North Delta Gash Locality in the environment on which they depend and defines
Kassala State of Eastern Sudan, 120 km north of Kassala vulnerability as the characteristics and circumstances of
120 H.B. Abbas, J.K. Routray / International Journal of Disaster Risk Reduction 6 (2013) 118128

a community, system or asset that make it susceptible to operating procedures, and human resources [31].
the damaging effects of a hazard [28]. Fig. 1 conceptua- With this background the objective of this paper is to
lizes the different risk determinants and their interaction. assess the risk of service interruption at the level of
However following the era of 1990s the concept of coping primary health care centers during flood emergency in
capacity and its interaction with other risk elements has the North Delta Gash locality, Kassala State of Sudan.
been introduced [29].
Different methods have been followed to assess the risk 1.2. Methods
and vulnerability of the facilities. In Jamaica the process of
facility vulnerability assessment was developed by Rogers in This is an explorative, analytical study based on primary
2000, by using the disaster history, structural and operational health care facilities in Sudan. All the health facilities that
vulnerability as variables. The hazards were weighted from 1 provide primary health care services in the study area were
to 5 to generate a Hazard Priority Score based on the experts' selected. Thus, all nine functioning health centers (out of
opinions [30]. The PAHO suggested a set of indicators to assess 13), including those run by NGOs have been included in the
the safety of health facilities. Those indicators have covered sample. Health facilities lower than the health centers have
the structural vulnerabilities like location, building design and been excluded. Table 1 shows the utilization (multiple
materials, non-structural vulnerabilities like architectural ele- visits) rate for each health center, which is defined as the
ments, equipment and lifelines, and functional vulnerabilities number of all patients consulted in the health center in one
such as induce accessibility, equipment and supplies, standard year to the total service area population. The calculated

Capacity Flood hazard

Structural
damage by
Technical staff previous floods
Ambulance service Isolation by
Laboratory services flood
Free service treatment Isolation
package period
Essential drugs Inundation of
Emergency plan HC
Functioning Vulnerability
Safe Stores
PHC center
Communication
Distance to the
Power supply
HC
Safe water supply
Walking time
Drug supply
to the HC
Community
Type of
participation
building
Service Interrution material
Non structural
components
Current status
of the building
Community

Fig. 1. Conceptual framework.

Table 1
Primary health centers and serviced population in Aroma locality.

Health center Area Serviced Average number Utilization rate % of utilization in reference
population of visits /year to national average of 3

Shahid Abdulbasit Aroma 6,173 9,490 1.51 50%


Akala Akla 3,832 3,285 0.81 27%
Gammam (GOAL) Gammam 2,900 4,745 1.65 55%
Tendlai Tendlai 4,930 4,745 0.97 32%
Health Insurance Center Aroma 4,060 9,125 2.22 74%
Red crescent Center Togli 3,654 9,125 2.46 82%
Makali Makali 4,705 2,920 0.66 22%
Digain Digain 3,480 4,745 1.38 46%
Mossassa Aroma 4,640 4,745 1.03 34%
Aggregate Aroma locality 38,374 52,925 1.38 46%
Table 2
Study variables and scales of measurement.

Category Variable Interpretation according to the risk Scale of measurement

Hazard Size of previous damage Size of damage due to flooding in the last 20 years or since the construction Minor 0 Moderate damage 1 Major damage 2
date damage
(flood severity)
Past history of isolation The health center has been isolated by the flood in the last five years No 0 Yes 1
(access)

H.B. Abbas, J.K. Routray / International Journal of Disaster Risk Reduction 6 (2013) 118128
Number of isolation days Mean period of isolation of the health center per flooding event No 0 Up to 48 hours (golden 1 More than 48 h 2
hour)
Likelihood of inundation Flood water enters the service areas and interrupt/disrupt the normal Unlikely 0 Likely 1
function
in the health center (height)
Vulnerability Distance from health center % of served population live in less than 5 km from the health center 100% 0 Less than 100% 1
Time to health center % of people who walk less than 15 min to the health center 100% 0 Less than 100% 1
Type of the structure Building material of the walls and roof of the health center RCC 0 Brick walls 1 Mud walls with traditional 2
roof
Need for renovation Referring to the current situation of the health center No 0 Yes 1
Nonstructural building The condition of doors, windows, lighting fixtures, roof, furniture, Good 0 Satisfactory 1 Not good 2
elements appliances, electronics, Equipment, stored items
Capacity Technical staff per 5000 Rate of the number of the available technical staff to the recommended 8 and more 0 Less than 8 1
population number (national standard 58). Includes; nurses, midwives, vaccination,
nutrition
Ambulance service The health center (community) has the means to transfer the needy Yes 0 No 1
patients to the higher level health facilities
Availability of laboratory The health center provides the essential lab tests. Blood test for malaria, Fully 0 Partially 1 None 2
services hemoglobin and white cell count, and urine test for glucose, pus cells and
protein
Availability of free service The health center provides the basic PHC service package; treatment of Fully 0 Partially 1 None 2
package common endemic diseases, minor injuries, vaccination, nutrition, IMCI,
antenatal care
Availability of the essential The health center has the essential drugs and supplies as described in the Fully 0 Partially 1 None 2
drugs national list of the essential drugs
Presence of emergency plan The health center has a written emergency plan document describing the Yes 0 No 1
preparedness, response to different scenarios of flood emergency
Availability of safe stores The health center has a safe storage place where drugs and equipments can Yes 0 No 1
be safely kept during flood and rainy season emergency
Communication The health center has a functioning mean of communication during a flood Yes 0 No 1
(cell phone service)
Power supply The health center has a reliable source of power supply during a flood Yes 0 No 1
(generator)
Safe water supply The health center has an adequate safe water supply during flood Yes 0 No 1
emergencies
Drug supply The health center has an adequate supply of drugs and consumables Yes 0 No 1
propositioned before flood season
Community participation The role of the community in the protection of the health center before and Active 0 Moderate 1 Passive 2
during flood emergency as judged by the health workers

121
122 H.B. Abbas, J.K. Routray / International Journal of Disaster Risk Reduction 6 (2013) 118128

utilization rate of PHC centers in the study area is 1.38 visits health center. Each was given a weight of 0.25 out of the
per person per year, which is 46% of the expected utilization total hazard weight. Vulnerability has five variables: per-
rate in Sudan. Utilization rate is important to help prioritiz- centage of serviced population who live within a radius of
ing the planned interventions according to the size of 5 km from the health center, percentage of serviced
service population and their utilization of the services population who walk for 15 min to the health center, the
provided by the health center. type of the building materials, and need for renovation and
The selection of indicators for this model is based on nonstructural component of the health center. Each vari-
the set of indicators used for assessment of hospital safety able has a weight of 0.20 out of the total vulnerability
manual prepared and used by PAHO as shown in Table 2. weight. The third index is the capacity which has 12
The selection of indicators has been guided by various variables: number of technical staff, availability of ambu-
literatures and also making use of those relevant in the lance service, laboratory service, and free primary health
local context of Sudan. Experts and field practitioners' care package, availability of the essential drugs, presence
consultation, through a workshop, was recommended for of an emergency plan, the presence of alternative sources
a equal weighting system giving equal priority to hazard, of power and water supply, reliable means of communica-
vulnerability and capacity components. Another factor that tion and availability of safe stores. The other two variables
affects the selection of variables for this study is the are the positioning of adequate drug supply in the health
availability or lack of data which among the known center before the rainy season and the community role in
limitations to the selection process [32]. protecting the health center before and during the flood.
A check list and questionnaire were developed to Each variable carries a weight of 0.08 out of the total
collect data from the health centers. Data were collected capacity weight.
at the site of the center where health workers were The composite indices for hazard, vulnerability and
interviewed. Secondary data were retrieved from the capacity were calculated using the equations;
state's and the locality's records. The data from the check-
HCI H 1 W1 H 2 W2 H n Wn Hi Wi 1
lists were then entered into the model frame designed in
an Excel spreadsheet, first by converting it into a scale of
01 for variables with two options and for those with VCI V 1 W1 V 2 W2 V n Wn Vi Wi 2
three, the scale was from 0, 1 or 2, both for quantitative
and qualitative variables. As hazard and vulnerability have CCI C 1 W1 C 2 W2 C n Wn Ci Wi 3
a positive impact on the risk, their lower levels were given
where HCI, VCI and CCI are the Hazard Composite Index,
lower scale values and the reverse is true for the higher
Vulnerability Composite Index and Capacity Composite
values. On the other hand the capacity has a negative
Index, respectively. Wi is the assigned weight for each
impact on the severity of risk thus the scale was inverted
variable.
and its higher values were given lower scale values and
Hi, is the ith hazard variable with a corresponding scale
vice versa.
value of 0, 1 or 2, where i 4.
As shown in Table 3, the risk of interrupted function
was calculated based on three indices; the flood hazard,
vulnerability and the capacity of the health centre. The risk Step 1
Selection of indicators; Hazard (H), Vulnerability (V), Capacity (C)

has been given a total weight value of 3 by combining the


unit weight (1) assigned to each component of hazard, Step 2
Collection of data through a standard questionnaire survey and checklist .

vulnerability and capacity. Within each component there


are sets of variables which have equal weights. Flood Step 3
Assigning weights to selected indicators to reflect their relative importance
hazard is the potential for inundation that involves risk to
life, health, property, and natural floodplain resources and Step 4
Calculation of the composite index values for H, V, C and risk
functions. It is comprised of three elements: severity,
probability of occurrence, and speed of onset of flooding Step 5
Categorization of risk into three levels (low, moderate and high)
[33]. Four proxy indicators have been selected to define
the flood hazard, these are, relative size of previous Model validation through a workshop involving the experts through a
presentation, question and answering session followed by a short questionnaire
damage by flood, past history of isolation of the health Step 6 with a scaling technique to measure the validity
center by flood water, number of isolation days and the
likelihood of inundation of the operational area within the Fig. 2. Methodology workflow diagram.

Table 3
Weights assigned to different variables.

Wt Risk 3

Component Hazard Vulnerability Capacity


Max wt 1 1 1

Variables H1 H2 H3 H4 V1 V2 V3 V4 V5 C1 C2 to C12
Variables wt 0.25 0.25 0.25 0.25 0.2 0.2 0.2 0.2 0.2 0.08 0.08
H.B. Abbas, J.K. Routray / International Journal of Disaster Risk Reduction 6 (2013) 118128 123

Vi, is the ith vulnerability variable with a corresponding mainly due to poor drainage systems. Seven health centers
scale value of 0, 1 or 2, where i5. are likely to be inundated as they had been inundated by
Ci, is the ith capacity variable with a corresponding scale previous flood events and their different departments and
value of 0, 1 or 2, where i12. stores were flooded. However despite the fact that the
The risk for each health center was then calculated by flood height was never been above one foot, it created
the summation of the HCI, VCI and CCI values, out of a chaos and hindered the normal function of the inundated
maximum risk of 3. A risk scale was developed to categor- centers. Similar consequences have been encountered in
ize and interpret the risk. It was classified into 3 cate- Jahore, Malaysia in 2009 where 14% of the health facilities
gories: low risk, moderate risk and high risk. stopped functioning mainly due to inundation and isola-
Summary of the methodology followed in this paper is tion by flood water [34].
shown in Fig. 2. Only one center had experienced significant damage by
flooding in the last five years, two had never faced any
2. Results and discussion degree of damage and six out of the nine centers had
minor damages. The type and design of buildings are
The hazard component is mainly determined by the suitable to the local environment as reported by the Head
isolation of the centers by flood water as it contributes of Department of Preventive Medicine in Kassala State. The
about 32%, followed by the days of isolation with 28% and structural vulnerability as reflected by the type of building
least by the size of previous damage which is 15%. All materials showed that none of the health centers in the
health centers have been isolated by the flood water, study area is of type 3 which is mud and local materials

Few selected photographs of the PHCC with facilities and services are presented from photo 1 to photo 12
to provide the reality of primary health facility situation in Sudan
Building infrastructure Facility\ services

Photo: 1 Old PHCC Photo: 7 Solar freezers for vaccines preservation

Photo: 2 Old PHCC Photo: 8 Microscope operating with sun light

Photo: 3 Modern PHCC Photo: 9 PHCC dependent on solar power

Photo: 4 Modern PHCC Photo: 10 Water and sanitation facilities

Photo: 5 continuity of health service during flooding Photo: 11 availability of generator at few PHCC

Photo: 6 Temporary clinic - Sudan Red Crescent Photo: 12 Basic lab services

Photo 1. Few selected photographs of the PHCC with facilities and services are presented from photo 1 to photo 12 to provide the reality of primary health
facility situation in Sudan.
124
Table 4
Weighted variables against the scale of occurance for hazard, vulnerability and capacity.

Health center Hazard Vulnerability

Size of damage due to History of isolation Days of Likelihood of Accessibility Structural Non
previous flooding by flood isolation inundation structural
Distance from Time to health Type of the Need for
health center center structure renovation

Shahid Abdulbasit .00 .00 .25 .00 .20 .20 .10 .20 .20

H.B. Abbas, J.K. Routray / International Journal of Disaster Risk Reduction 6 (2013) 118128
Akla .13 .25 .25 .25 .20 .20 .00 .20 .10
Gammam .13 .25 .25 .25 .00 .00 .10 .00 .00
Tendlai .00 .25 .25 .13 .00 .00 .00 .20 .10
Health Insurance .00 .25 .00 .13 .20 .20 .10 .20 .20
Sudanese Red Crescent .13 .25 .25 .25 .00 .00 .10 .20 .20
Makali .13 .25 .25 .13 .00 .00 .10 .00 .00
Digain .13 .25 .25 .25 .00 .00 .00 .20 0.1
Mossassa .25 .25 .00 .13 .00 .00 .10 .20 .20
Total (x) .9 2 1.75 1.52 .6 .6 .6 1.4 1.1
Aggregate of all centers for all 6.17 4.3
variables (y)
Percentage (x/y*100) 15% 32% 28% 25% 14% 14% 14% 33% 26%

Health center Capacity

Technical Ambulance Availability of Availability of free Availability of the Presence of Availability Communication Power Safe Drug Community
staff service laboratory services service package essential drugs emergency plan of Stores supply water supply participation
supply

Shahid Abdulbasit .00 .08 .08 .00 .08 .08 .08 .00 .08 .08 .08 .00
Akla .00 .08 .08 .08 .08 .08 .08 .00 .08 0.00 .08 .04
Gammam .00 .08 .08 .00 .04 .08 .08 .00 .08 .00 .00 .00
Tendlai .00 .08 .08 .04 .04 .08 .08 .00 .08 .08 .00 0.04
Health Insurance .00 .08 .17 .00 .04 .08 .08 .00 .08 .08 .08 .04
Sudanese Red Crescent .00 .08 .17 .04 .04 .08 .08 .00 .08 .08 .08 .04
Makali .00 .08 .33 .04 .04 .08 .08 .00 .08 .08 .00 .04
Digain .00 .08 .67 .04 .04 .08 .08 .00 .08 .08 .00 .04
Mossassa .00 .08 .67 .04 .08 .00 .00 .00 .08 .08 .08 .00
Total (x) .00 .72 2.33 .28 .48 .64 .56 0 .64 .48 0.4 .24
Aggregate of all centers 6.77
for all variables (y)
Percentage (x/y*100) 0% 11% 34% 4% 7% 9% 8% 0% 9% 7% 6% 4%
H.B. Abbas, J.K. Routray / International Journal of Disaster Risk Reduction 6 (2013) 118128 125

and that seven have brick walls and waterproof roofs mainly affected by the lack of laboratory services, reliable
while two have RCC (reinforced concrete) roofs. However sources of power supply, ambulance service, emergency
that does not reflect the current situation of the building plans, and safe stores.
and the need for renovation was reported in seven centers Health services cannot fully perform their functions
which amounts to approximately 33% of the vulnerability with their own capacities only, but they are in need of the
of the buildings. There has not been much improvement in support of other sectors and services like communication,
Kassala State following the health facilities' survey con- water and power [42]. Following the implementation of
ducted by the Federal Ministry of Health in 2008 when the Modernized National Surveillance by the Federal
only 10% of the health centers were found to be in good Ministry of Health and private communication companies'
conditions and needed no renovation [44] (Photo 1). partnership in 2009 all health facilities down to the level
About 67% of the population live within 5 km of the of health centers have been provided with a free of charge
health center and walk for a maximum of 15 min. Distance communication system to increase the percentage and
to the health service is a main indicator which is fre- shorten the time of reporting, which has been reflected
quently used in accessibility studies. It is the straight line by finding that all the studied centers have reliable means
between a home and the health center [35]. The national of communication even during flood emergencies. On the
standards in Sudan set it a maximum of 5 km and 30 min other hand as shown in the results and as observed in the
walking time to PHC centers to enhance accessibility to field visits, seven of the health centers lack regular safe
health services and to shorten the time period for emer- water supply and eight of them have no reliable electricity
gency cases in order to minimize morbidity and mortality. supply. The main reason for lacking water supply is the
Improved access to health care can reduce infant and high fees. However only 57% of the health centers in the
maternal mortality and morbidity in rural areas [36]. In State are connected to the public network and the rest has
Sudan the average time to the nearest health care facility to buy their daily needs for water. For power supply the
ranges between 15 and 29 min [37] and in Kassala State centers connected to the national network represent only
was found that 87% of population live within 5 km [44]. 53% and the other facilities depend on alternative sources
Those findings are different than those shown in some such as generators and solar energy. Field visits showed
rural areas in Kenya, where distance and time to the health that some of the health centers depend on solar energy to
care centers in addition to affordability were the main preserve vaccines in the cold chain fridges provided by the
factors affecting accessibility to health care. All facilities UNICEF. Six health centers have all the essential drugs
were found to be serving more than 5000 people, less than recommended by the national standards, while they were
10% living within 5 km and less than 15 min from the found partially in the other three centers. The national
nearest health facilities [38]. In Yemen a study showed policy for health disaster management in Sudan stresses
evidences that related the vaccination status of children to the importance of positioning of medicines and supplies in
the distance and walking time from home to the health areas under flood risk ahead of the rainy season [13].
centers [39]. Similarly it has been shown that the longer However despite the annual risk of flooding in the study
the time to the health center the higher the relative risk of area more than 55% of health centers do not receive their
the child's death [40]. One study from South Africa showed needs before the rainy season. By comparison in South East
significant effect of distance on accessibility [41]. Europe, 72.4% of the health facilities have essential med-
All centers lack the patients' referral service, 89% do not icines and emergency supply stockpiles in place before-
have emergency plans. On the other hand all the centers hand [43]. All the studied health centers reported a
have a convenient means of communication during flood positive and interactive community participation in pro-
emergency and satisfactory human resources. About 87% tecting those centers before, during and after the flood
of the health centers provide the full package of the free emergency with varying degrees of participation from
primary health care service and all report moderate to moderate to strong (Table 4).
high degree of community participation in protecting the No shortage regarding human resources has been
health centers during flood times. The overall capacity is found in any center, though only two centers provide the

Table 5
Composite indices of hazard, vulnerability, capacity and risk.

Rank Health center Hazard Vulnerability Capacity Risk Level of risk

1 Akala 0.88 0.70 0.58 2.16 H


2 Sudanese Red Crescent 0.88 0.50 0.58 1.96 M
3 Health Insurance 0.38 0.90 0.58 1.86 M
4 Shahid Abdulbasit 0.25 0.90 0.67 1.82 M
5 Digain 0.88 0.30 0.63 1.81 M
6 Mossassa 0.63 0.50 0.50 1.63 M
7 Tendlai 0.63 0.30 0.58 1.51 M
8 Makali 0.76 0.10 0.63 1.48 M
9 Gammam 0.88 0.10 0.42 1.40 M
Percentage to total risk 39.47% 27.50% 33.04% 100%

Scale: Low risk (L): 1, Moderate risk (M): 2, High risk (H): 3.
126
Table 6
Model validation with scaling technique.

Respondents Component 1 Component 2 Component 3

H.B. Abbas, J.K. Routray / International Journal of Disaster Risk Reduction 6 (2013) 118128
Conceptual framework Data Selection of right variables for measurement

Flood hazard Vulnerability Capacity of Risks/Potential Aggregate Use of Relevance of Aggregate Flood Vulnerability Capacity of Aggregate
concept concept PHC threats secondary data hazard PHC
data by PHC

a 4 5 4 4 4.3 4 5 4.5 5 4 5 4.7


b 4 3 5 4 4 5 4 4.5 4 3 5 4
c 4 3 5 3 3.8 5 3 4 4 3 5 4.
d 4 5 4 5 4.5 3 5 4 5 5 5 5
e 4 4 4 4 4 5 5 5 4 4 4 4
f 5 4 5 4 4.5 5 4 4.5 4 4 4 4
g 5 5 4 4 4.5 4 4 4 5 5 5 5
Mean 4.3 4.1 4.4 4 4.2 4.4 4.3 4.4 4.4 4 4.7 4.4

Respondents Component 4 Component 5 Average of


Method and Techniques Interpretation all
components
Assignment of Weight distribution of Calculation of Indices Aggregate Risk Recommendation Limitation Overall Aggregate
maximum and variables following the Index of the applied value
minimum weight principle of equal Hazard Vulnerability Capacity Risk Values study of the risk
to risk importance to all within a Index Index Index Index assessment
components component model

a 3 3 4 4 4 4 3.7 4 3 4 5 4 4.1
b 3 4 4 3 5 3 3.7 4 3 3 4 3.5 3.8
c 4 4 4 3 4 3 3.7 4 5 4 3 4 3.8
d 3 4 4 4 4 4 3.8 4 5 4 5 4.5 4.3
e 5 5 5 5 5 5 5 5 5 5 5 5 4.6
f 5 4 4 4 4 4 4.2 4 5 4 4 4.3 4.3
g 4 3 4 4 4 5 4 5 5 5 5 5 4.5
Mean 3.8 3.8 4.1 3.8 4.3 4 3.9 4.3 4.4 4.1 4.4 4.3 4.3

Note: Five-point scale was used, with 1 as the least and 5 as the highest level of validation.
H.B. Abbas, J.K. Routray / International Journal of Disaster Risk Reduction 6 (2013) 118128 127

full PHC package of service and the other seven centers the right measurement indicators, 3.9 for methods and
provide partial services. None of the centers have an technique as the lowest value and 4.3 for interpretation.
emergency plan which is an important tool of emergency The average of all components is 4.3 out of 5, which means
management and should be considered as part of the that it is highly reliable. In conclusion the participants
preparedness of those facilities. Similarly, none has a found value for model application in real life.
means of referring patients in need for a higher level of
care, which is expected knowing that only 17.4% of the 3. Conclusion and recommendations
health centers in the state have this kind of service [44]. In
many flood prone areas in the Philippines, factors that The risk of service interruption at the health centers
affect the normal functions of the health care facilities during flood has been assessed semi quantitatively to rank
were identified as; physical damage, shortages in human them according to the expected risk. The risk of service
resources, supplies and essential medicines, and need for interruption in the studied health centers ranges from 2.16
renovation to restore their normal functions [45]. Other to 1.4 out of 3. Eight of the health centers are under a
factors are: Increased number of referrals; system disrup- medium risk level and one is under a high risk of service
tions such as electricity, lack of standard operating proce- interruption. However, factors like the size of the serviced
dures, and lack of communication with the administrative population and the utilization rate should be considered in
authorities [3]. Primary health care services were inter- making the decision for intervention.
rupted or stopped functioning following the flooding in Urgently in the short term the capacities of the health
1993 in 13 counties in Iowa of the USA, either due to direct centers in the study area need to be augmented by
impact of the facilities or indirect impact on supportive addressing the problems of water and power supply,
systems [46]. prepositioning of drugs and medicines, provision of full
Table 5 shows the individual risk value for each health services and development of emergency plan within those
center as well as the share of hazard, vulnerability and facilities. For the medium term renovation and infrastruc-
capacity on the total risk. Among the studied health tures repair, including drainage systems, should be carried
centers eight out of nine are having a medium risk and out. As for the long term interventions, the design, build-
one center has a high risk of service interruption during ing materials and locations of new facilities should be
flood. The magnitudes of risk range from 2.16 to 1.4 out of flood resilient, besides the strengthening of the other
3. The risk of service interruption in the study area is sectors as their performance will be reflected on the
mainly defined by the hazardous components with 39.47%, functions of the health system.
vulnerability 27.50%, and capacity with 33.04%. The table The conceptual framework and method described in
also shows the ranking of the health centers according to this paper have been verified, evaluated and validated. The
the risk values from the highest to the lowest. model described by this paper can be used and also future
adjustments may be considered depending on the nature
2.1. The process of validating the model of the problems addressed when applied in the field. The
differences in geography, demographics and level of ser-
Model validation is well-known in social sciences but vice in each case should be considered when applying the
relatively new for disaster management. Philosophically procedure elsewhere.
validation is defined as a purely logical problem, dealing
with the internal consistency of a set of propositions with 3.1. Limitations and utility of the study
respect to a set of logic rules; a definition referred to as
verification in the modeling literature [47]. To test the This paper provides a useful simplified and practical
easiness and the applicability of the model, a half day assessment procedure and tool that can be applied by
workshop was conducted in Khartoum, Sudan in which none-specialized staff of the health centers and the local
seven disaster professionals with different backgrounds authorities, to estimate swiftly and efficiently the potential
were invited. The group of experts consisted of medical risk of service interruption at those health centers.
practitioners, academicians, INGOs, pharmacists, logistic Among the limitations of this study is that the list of
coordinators, public health consultants, information man- variables used is not exhaustive besides many are difficult
agers, epidemiologists and disaster management consul- to be quantified and hence numerically expressed. Also
tants. The approach was presented to the audiences, this paper assesses only flood hazards using proxy indica-
followed by a question and answer session for further tors rather than the conventional hazard assessment and
clarification. Then a five-point scaling technique was used hazard mapping. The limited number of the health centers
in a structured questionnaire. In the five-point scale 1 in the study area hindered the utilization of many useful
represents the least and 5 represents the best situation, statistical tests for in depth analysis of the results. How-
meaning the degree of the validity of the model varies ever such limitations should not prevent the use of such
from 1 to 5. It covered the conceptual framework, data, methods of risk assessment [29].
selection of the right indicators for measuring hazard,
vulnerability and capacity, method and techniques used
and interpretation made. As can be seen in Table 6, the Acknowledgments
respondents have given values for each of the validated
components as follows: 4.2 for the conceptual framework, We would like to thank the Ministry of Health, Kassala
4.4, as the highest value, for data and for the selection of State for their support and sharing of the secondary data.
128 H.B. Abbas, J.K. Routray / International Journal of Disaster Risk Reduction 6 (2013) 118128

We appreciate the support of AIT for funding this work. [23] MA A, Sh H A. Entomological investigation of Aedes aegypti in
We would like to thank all health workers and groups of Kassala and Elgadarief. Sudan J Public Health 2008;3(2):7780.
[24] MOH. Health Annual Report 2009. Ministry of HealthKassala State.
experts for their active involvement in this research, Available from: https://docs.google.com/viewer?; http://www.
provision of their opinions and suggestions to validate kmoh-sd.com/2009.pdf.; 2010 [accessed 17.12.12].
and improve this work. Finally we extend our appreciation [25] The International Donors and Investors Conference For Eastern
Sudan. Available from: http://www.kuwait-fund.org/eastsudanconfer
to Mr. Tylor Burrows from AIT Language Centre for his
ence/images/sudan/englishconferencedocument.pdf; 2010 [accessed
efforts in checking and editing the writing style of 22.06.11].
this paper. [26] U.D. of H. and H. Services. Health Center Emergency Management
Program Expectations. Available from: http://bphc.hrsa.gov/policies
regulations/policies/pdfs/pin200715.pdf; 2007 [accessed 20.01.13].
References [27] PAHO.Disaster Mitigation for Health Facilities: Guidelines for Vul-
nerability Appraisal and Reduction in the Caribbean. Available from:
[1] WHO, World Health Day. Available from: http://www.who.int/ http://www.mona.uwi.edu/cardin/virtual_library/docs/1217/1217.
world-health-day/2009/whd2009_brochure_en.pdf; 2009 [Online]. pdf; 2000 [accessed 22.01.13].
[2] Shoaf BKI, Steven J. Public health impact of disasters. Aust J Emerg [28] UNISDR. UNISDR Terminology on Disaster Risk Reduction (2009).
Manage 2000:5863. Available from: http://www.inpe.br/crs/geodesastres/conteudo/arti
[3] Debarati Guha-Sapir, TJ, Vos, F, Phalkey, R, Marx, M. Health Impacts gos/unisdr_Terminology_on_Disaster_Risk_Reduction_2009.pdf;
of Floods in Europe; 2010. 2008 [accessed 22.01.13].
[4] Ofrin RHIN. Disaster risk reduction through strengthened primary [29] Bankoff D, Frerks G, Hilhorst G. Mapping vulnerability: disasters,
health care. Reg Health Forum 2009;13(1):2934. development, and people. London, UK: Earthscan Publications;
[5] Roukema, JS. Effects of Improved Accessibility to Health Services 2004.
Provided by Trail Bridges Final Report, Nepal; 2008. [30] OAS. Structural Vulnerability Assessment for St. Kitts and Nevis:
[6] Arboleda CA, Abraham DM, Richard JP, Lubitz R. Vulnerability Post-Georges Disaster Mitigation Project in Antigua & Barbuda and
assessment of health care facilities during disaster events. J Infra- St. Kitts & Nevis July 2001. Washington DC; 2001.
struct Syst 2009;15:14961. [31] PAHO, Hospital Safety Index: Evaluation Forms for Safe Hospitals.
[7] WHO. Why a Safe Hospitals Initiative in South-East Asia? WHO Washington DC, USA: PAHO; 2008.
South-East Asian Regional Countries. Available from: http://209.61. [32] Mller A, Reiter J, Weiland U. Assessment of urban vulnerability
208.233/LinkFiles/Hospitals_Safe_from_Disasters_SafeHospitalInitia towards floods using an indicator-based approach A case study for
tive.pdf; 2009 [accessed 13.09.12]. Santiago de Chile. Nat Hazards Earth Syst Sci 2011;11(8):210723.
[8] Phalkey R, Dash SR, Mukhopadhyay A, Runge-Ranzinger S, Marx M. [33] FEMA. Flood Risk Assessment. Floodplain Management. Available
Prepared to react? Assessing the functional capacity of the primary from: http://training.fema.gov/emiweb/edu/docs/fmc/Chapter 4
health care system in rural Orissa, India to respond to the devastat- Flood Risk Assessment.pdf; 2008 [accessed 06.10.12].
ing flood of September 2008 Glob Health Action 2012;5:110. [34] Arbaiah ARO, daud Ar, surinah A, Noorhaida U, Shaharom Namcd.
[9] Tomio HMJun, Sato Hajime. Interruption of medication among Health preparedness and response to flood disaster in Johore,
outpatients with chronic conditions after a flood. Prehosp Disaster Malaysia: challenges and lessons learned. Malays J Community
Med 2010:4250. Health Public 2009;15:12631.
[10] Boroschek, KR. Guidelines for Vulnerability Reduction in the Design [35] Perrya WGBaker. Physical access to primary health care in Andean
of New Health Facilities, Washington, D.C.; 2004, 106p. Bolivia. Soc Sci Med 2000;50(9):117788.
[11] Michelle DND, Cretikos A, Merritt Tony D, Main Kelly, Eastwood [36] Paul BK, Rumsey DJ. Utilization of health facilities and trained birth
Keith, Winn Linda, et al. Mitigating the health impacts of a natural attendants for childbirth in rural Bangladesh: an empirical study.
disasterThe June 2007 long-weekend storm in the Hunter region Soc Sci Med 2002;54(12):175565.
of New South Wales. Med J Aust 2007;187:6703. [37] Abdel-Tawab, ME-R Nahla. Maternal and Neonatal Health Services in
[12] WHO. Primary Health Care: Report of the International on Primary SUDAN: Results of a Situation Analysis. Available from: http://www.
Health Care. Alma-Ata-USSR; 1978.
popcouncil.org/pdfs/2010RH_MNHServSudan.pdf; 2010 [accessed
[13] FMOH. Health 5 Years Strategy-Sudan 20072011; 2006.
15.10.12].
[14] MoHFE. Indian Public Health Standards (IPHS) Guidelines for Pri-
[38] Mwasi BN. Factors affecting access to rural health services, a case
mary Health Centres. Available from: http://health.bih.nic.in/Docs/
study of baringo area of kenya using GIS. Ossrea: Addis Ababa; 2010.
Guidelines/Guidelines-PHC-2012.pdf; 2012.
[39] Al-Taiar A, Clark A, Longenecker JC, Whitty CJM. Physical accessi-
[15] Pal, SP. PEO Evaluation Studies: Functioning of Community Health
bility and utilization of health services in Yemen. Int J Health Geogr
Centres (CHCs ) in India. Available from: http://planningcommis
2010;9:38.
sion.nic.in/reports/peoreport/peo/peo_chc.pdf; 1999 [accessed
[40] Okwaraji YB, Cousens S, Berhane Y, Mulholland K, Edmond K. Effect
13.04.12].
of geographical access to health facilities on child mortality in rural
[16] Roy Penchansky, Wiliam Thomas J. The concept of access: definition
and relationship to consumer satisfaction. Med Care 1981;19(2): Ethiopia: a community based cross sectional study. PLoS One 2012;7
12740. (3):e33564.
[17] Ensor, Tim, Cooper, Stephanie. Overcoming barriers to health service [41] Nteta O, Mokgatle-Nthabu M TP. Utilization of the primary health
access and influencing the demand side through purchasing. Health, care services in the tshwane region of gauteng province, South
Nutrition and Population (HNP) Discussion Paper, The World Bank. Africa. PLoS One 2010;5(11):e13909.
Available from: http://siteresources.worldbank.org/healthnutritio [42] Few, R, Ahern, M, Matthies, F, and Kovats, S., Floods, Health and
nandpopulation/Resources/281627-1095698140167/EnsorOverco Climate Change: a strategic review Floods, Health and Climate
mingBarriersFinal.pdf; 2004 [accessed 13.04.12]. Change: A Strategic Review. November; 2004.
[18] Ali, S., Musa, L., Tahir, A., Mohammed, H., Nurelhuda, N., Mustafa, M. [43] Radovic V, Vitale K, Tchounwou PB. Health facilities safety in natural
et al., Promoting access to high quality primary health care services disasters: experiences and challenges from South East Europe. Int J
in Sudan (policy brief), Khartoum, Sudan, 2012. Environ Res Public Health 2012;9(5):167786.
[19] FMOH. Sudan Primary health care survey. Khartoum, Sudan; 2010. [44] FMOH. Sudan Health Facilities Survey. Khartoum, Sudan; 2008.
[20] UNST. East Sudan Analysis and priorities; 2007. [45] WHO.WHO Health Compendium Consolidated Appeal Process 2012.
[21] Krijnen, JFA.Environmental Impact Assessment Kassala Hamash- Available from: http://www.who.int/hac/donorinfo/cap_compen
khoreib Integrated Assistance Programme. Available from: http:// dium_web_7mai2012.pdf; 2012 [accessed 19.01.13].
www.krijnen.ch/draft report sudan.pdf; 2008 [accessed 25.04.12]. [46] Michael FMB, Howard J. Infectious disease emergencies in disasters.
[22] UNICEF.North Sudan Floods Situation Report. Available from: http:// Disaster Med 1996;14(2):41321.
reliefweb.int/report/sudan/unicef-north-sudan-flood-situation-re [47] Barlas Y, Carpenter S. Philosophml roots of model validation: Two
port-external-17-jul-2007; 2007 [accessed 23.10.11]. Paradigms. Syst Dyn Rev 1990;6(2):14866.

S-ar putea să vă placă și