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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
article info
Article history: Received 24 January 2013 Received in revised form 7 October 2013 Accepted 7 October 2013 Available online
21 October 2013
Keywords: Primary health care Risk assessment Service interruption Flood Sudan
2212-4209/$ - see front matter & 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijdrr.2013.10.002
abstract
Primary health care (PHC) centers are very important toprovidehealthfacilitiesandservicesatthelocallevel.TheroleofPHC
centers becomes crucial duringthefloodandothernaturaldisasters.PHCisanessentialhealthcarewhichisscientificallysound,
socially acceptable, universally accessible through affordable cost, and geared towards self reliance, and based on practical
methods and technology. This paper attempts to develop a semi-quantitative risk assessment model for primary health care
service interruption during flood. The modelisdevelopedinthecontextofSudanesePHCandvalidatedfurthertoaddvalueand
confirm its application in a wider context.
& 2013 Elsevier Ltd. All rights reserved.
1. Introduction
The WHO has initiated the campaign of making hospi- tals safeinemergenciesontheWorldHealthDay,2009,tohighlight
how health facilities and their services are crucial to the community in times of disasters as they work to save lives, treat the
injured and ensure continuous health care in post-disaster and accordingly they deserve to be protected because of their high
serving and economic values [1].
One of the major impacts of disasters,includingflood,isthedisruptionofthehealthserviceseitherthroughdirectdamageof
the health facilities, inaccessibility, or affected health workers, besides the damage of supporting systems like logistics,
communications, power and water supply [2]. The most commonly reported health system impact after
flooding is the disruption of healthcareservices[3].Thesupportingsystemsareimportantforfunctionalcontinuityofthehealth
facilities[4,5].TheirimportancecouldclearlybeshownduringHurricaneKatrinainAugust,2005,whenhealthfacilitiesstopped
functioning due to non-operating generators and impossibilityofprovidingsuppliesthroughthefloodedroadnetwork.Arboleda
and colleagues have shown the importance of including the analysis of infrastructure systems in the vulnerability analysis of
healthfacilitiesastheysignificantlyaffectthefunctionsofthosefacilities[6].Lossofhealthfacilities'functionswasencountered
during and after the tsunami disaster in 2004 inMaldives,IndonesiaThailandandSriLanka.Thosefacilitiesaremostneededat
the time of crisis to serve victimized people, especially the ones within the affected areas [7].InBangladesh,about53%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.
E-mail addresses: st110489@ait.ac.th,
experienced dysfunction due to the flood of 2008 [8]. There are evidences that the prevalence of the interruption of
hitha2000@gmail.com (H.B. Abbas).
treatment for patients with chronic diseases is proportional
International Journal of Disaster Risk Reduction 6 (2013) 118128

to the magnitude of damage to the health facility [9]. Similar damages were reportedinEcuadorandPeru,19971998,Bolivia,
2002, Argentina 2003, and in Australia [10,11].
The importance of low scale health centers can be realized by understanding their roles in delivering the services of the
Primary Health Care (PHC) [12]. Despite their relatively less cost, PHC centers have roles and values to rural communities
comparable to those of bigger hospitals. Those valuesmaketheirprotectioncosteffectiveandnecessitatetheintegrationoftheir
safety in any health risk reduction plan.However,despitetheirimportanceandobviousvulnerabilitytofloodsnotmanyoriginal
research papers are found in the literature to tackle theissueofthesafetyandriskassessmentofthoselowscalefacilities[8].In
Sudan the five year strategyfortheMinistryofHealthhasclearlyidentifiedtheimportanceofthecontinuousprovisionofhealth
care during disasters as one of the main strategic objectives, to which the safety of health facilities is a key element [13]. The
problems of PHC in developing countries are almost thesame;anevaluationreportinIndiadiagnosedthePHCproblemswhich
are associated withinsufficienthumanresources,inadequateinfrastructuresanddrugs,andlackofcommunityparticipa-tionand
qualityhealthcare[14].Otherfactorsthataffecttheservicedeliveryatthelevelofpublichealthcentersarecoverage,availability
of human resources with different required specializations, incomplete package of services, shortage in equipment, and the
dysfunctional referral system [15]. AccesstoPHCisamajordeterminantofservicedeliveryaffecttheutilizationofservicesand
flow of functions and services providedbythefacilities.Accessibilityisamulti-dimensionalconceptthatincludesgeographical
accessibility, availability, affordability, accommodation and acceptability, as explained by the model developed byPenchansky
[16]. In addition health can be seen as a commodity that is also affectedbysupplyanddemandfactorssuchasqualityofhealth
care services, affordability, appropriateness of health personnel and social values and norms [17].
The health system in Sudan is a decentralized system withthreetiersofcareatprimary,secondaryandtertiarylevels.About
33% of the population hasnoaccesstohealthfacilities,theminimumPHCpackageisprovidedby19%ofPHCfacilities.39.8%
of the PHC facilities are not functional because of human resource shortages and 34.7% because of the physical infrastructure
condition [18]. PHC facilities include primary health care centers (PHCC), primary health care units(PHCU),dressingstations
(DS), dispen- saries,andhealthcenters.RuralhospitalsareconsideredpartofthePHClevelandserveassecondaryreferrallevel
health facilities. Specialized and general hospitals are the tertiary level and are located in states'capital.About41%ofthetotal
health visitstakeplaceinprimaryhealthcenters,withavariationontheuseofFamilyHealthUnitsanddispensarieswitharange
of 181% in urban and rural areas. About 52.2% of urban centers provide the minimumpackagecomparedto3.8%oftherural
centers and 21.9% of the family health units [19].
1.1. Background
The study area is the North Delta Gash Locality in Kassala State of Eastern Sudan, 120 km north of Kassala
H.B. Abbas, J.K. Routray / International Journal of Disaster Risk Reduction 6 (2013) 118128 119
town, with a total area of about 14,000 km2 and a popula- tion of 82,000. The population density in theareais12person/km2
and there are of 55 villages [20]. Health services are deliveredthroughoneruralhospitalinAromawith57beds.Therearenine
functioning health centers and 22 basichealthunits,threeofwhicharenotfunction-ing.Noprivatehealthserviceisavailablein
the area. In total there are two doctors, 14 assistanthealthpersonals,13medicalassistants,46environmentalhealthofficersand
workers, and 25 certified midwives. There is no psychiatrist, dentist, radiologist nor anesthesiologist in the area. Only seven
villages have at least one midwife (13%) and 76% of the population live less than 5 km from the nearest health facility.
Kassala state is under the riskofannualfloodingwhichsignificantlyaffectscommunitiesintheareawithafiveyearinterval.
The most devastating floods occurred in 1975,1983,1988,1993,1998,2003,and2007,when47,075peoplewereaffected[21].
The Gash River is the main source of flood hazard as neither its course nor the timing of water rise can easily be predicted.
Despite this high risk, people refuse to be either evacuated or relocated [22]. The state is frequentlyhitbydiseaseoutbreaksof
malaria, Dengue fever, meningitis anddiarrhea.Onefactorthatincreasesthelikelihoodofdiseaseoutbreakisthehighindicesof
vectors' density [23]. Kassala has the highest malnutrition rates in the country, the global acute malnutrition (GAM) is 29%,
infant mortality rate is 56/1000 and maternal mortality ratio (MMR) is 140/10,000 live births.Thosehighindicatorsaremainly
due to limited access to basic antenatal care and the deficiency of skilled birth attendants. Birth under medical supervision in
public hospitals is about 13.3%, in addition to the widely practicedfemalegenitalmutilationwhichisestimatedtobeashighas
90% [24]. The health care in the state is not up to the national standards with low accessibility to health services [25].
Risk of service interruption during flood emergency can be a source of hazard to community health. As the resources are
limited especially at the lower level of government structure, there is a need for prioritization to identify those health centers
which deserve the urgent actions for risk reduction. Another pointtobeconsideredisthatthestudyareaisundertheannualrisk
of flooding and with such capacities and vulnerabilities the health care facilities would be facing an extensive risk of service
interruption if no immediate actions are taken. Therefore there is a need for simplified and practical assessment procedure and
tools that can be applied by the staff of the health centers and the local authorities. This goes in line withtheroleofthehealth
staff at their centers and community [26,27]. Suchasimplifiedmethodisimportanttoavoidthecomplexityofsophisticatedand
lengthy procedures without jeopardizing the utility and validity of the assessment model.
This paper refers to the definition of risk assessment as a methodology to determine the nature and extent of risk by
analyzing potential hazards and evaluating existing conditions of vulnerability that together could potentially harm exposed
people, property, services, livelihoods and the environment on which they depend and defines vulnerability as the
characteristics and circumstances of

a community, system or asset that make it susceptible to the damaging effects of a hazard [28]. Fig. 1 conceptua- lizes the
different risk determinants and their interaction. However following the era of 1990s the concept of coping capacity and its
interaction with other risk elements has been introduced [29].
Different methods have been followed to assess the risk and vulnerability of the facilities. In Jamaica theprocessoffacility
vulnerability assessment was developed by Rogers in 2000,byusingthedisasterhistory,structuralandoperationalvulnerability
as variables. The hazards were weighted from1to5togenerateaHazardPriorityScorebasedontheexperts'opinions[30].The
PAHO suggested a set of indicators to assess the safety of health facilities. Those indicators have covered the structural
vulnerabilities like location, building design and materials,non-structuralvulnerabilitieslikearchitecturalele-ments,equipment
and lifelines, and functional vulnerabilities such as induce accessibility, equipment and supplies, standard
H.B. Abbas, J.K. Routray / International Journal of Disaster Risk Reduction 6 (2013) 118128 120
Capacity
Technical staff
Ambulance service
Laboratory services
Free service treatment package
Essential drugs
Emergency plan
Safe Stores
Communication
Power supply
Safe water supply
Drug supply
Community participation
Functioning PHC center
Service Interrution
Community
Fig. 1. Conceptual framework.
Table 1 Primary health centers and serviced population in Aroma locality.
Health center Area Serviced
population
Average number of visits /year
Utilization rate % of utilization in reference
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%DigainDigain3,4804,7451.3846%MossassaAroma4,640
4,745 1.03 34% Aggregate Aroma locality 38,374 52,925 1.38 46%
operating procedures, and human resources [31].
With this background the objective of this paperistoassesstheriskofserviceinterruptionatthelevelofprimaryhealthcare
centers during flood emergency in the North Delta Gash locality, Kassala State of Sudan.
1.2. Methods
This is an explorative, analytical study based on primary health care facilities in Sudan. All thehealthfacilitiesthatprovide
primary health care services in thestudyareawereselected.Thus,allninefunctioninghealthcenters(outof13),includingthose
runbyNGOshavebeenincludedinthesample.Healthfacilitieslowerthanthehealthcentershavebeenexcluded.Table1shows
the utilization (multiple visits) rate for each health center, which is defined as the number ofallpatientsconsultedinthehealth
center in one year to the total service area population. The calculated
Flood hazard
Structural damage by previous floods
Isolation by flood
Isolation period
Inundation of HC
Vulnerability
Distance to the HC
Walking time to the HC
Type of building material
Non structural components
Current status of the building

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
date (flood severity)
Minor damage
0 Moderate damage 1 Major damage 2
Past history of isolation The health center has been isolated by the flood in the last five years
(access)
No 0 Yes 1
Number of isolation days Mean period of isolation of the health center per flooding event No 0 Up to 48 hours (golden
hour)
1 More than 48 h 2
Likelihood of inundation Flood water enters the service areas and interrupt/disrupt the normal
function in the health center (height)
Unlikely 0 Likely 1
Vulnerability Distance from health center % ofservedpopulationliveinlessthan5kmfromthehealthcenter100%0Lessthan
100% 1 Time to health center % ofpeoplewhowalklessthan15mintothehealthcenter100%0Lessthan100%1Typeofthe
structure Building material of the walls and roof of the health center RCC 0 Brick walls 1 Mud walls with traditional
roof
2
Need for renovation Referring to the current situation of the health center No 0 Yes 1 Nonstructural building elements
The condition of doors, windows, lighting fixtures, roof, furniture, appliances, electronics, Equipment, stored items
Good 0 Satisfactory 1 Notgood 2
Capacity Technical staff per 5000
population
Rate of the number of the available technical staff to the recommended number (national standard 58). Includes; nurses,
midwives, vaccination, nutrition
8 and more 0 Less than 8 1
Ambulance service The health center (community) has the means to transfer the needy
patients to the higher level health facilities
Yes 0 No 1
Availability of laboratory services
The health center provides the essential lab tests. Blood test for malaria, hemoglobin and white cell count, and urine test for
glucose, pus cells and protein
Fully 0 Partially 1 None 2
Availability of free service package
The health center provides the basic PHC service package; treatment of common endemic diseases, minor injuries, vaccination,
nutrition, IMCI, antenatal care
Fully 0 Partially 1 None 2
Availability of the essential drugs
The health center has the essential drugs and supplies as described in the national list of the essential drugs
Fully 0 Partially 1 None 2
Presence of emergency plan The health center has a written emergency plan document describing the
preparedness, response to different scenarios of flood emergency
Yes 0 No 1
Availability of safe stores The health center has a safe storage place where drugs and equipments can
be safely kept during flood and rainy season emergency
Yes 0 No 1
Communication The health center has a functioning mean of communication during a flood
(cell phone service)
Yes 0 No 1
Power supply The health center has a reliable source of power supply during a flood
(generator)
Yes 0 No 1
Safe water supply The health center has an adequate safe water supply during flood
emergencies
Yes 0 No 1
Drug supply The health center has an adequate supply of drugs and consumables
propositioned before flood season
Yes 0 No 1
Community participation The role of the community in the protection of the health center before and
during flood emergency as judged by the health workers
Active 0 Moderate 1 Passive 2

health utilization rate of PHC centers in the study area is 1.38 visits
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
5km 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- lists were then entered into the model frame designed in
HCI 14 H
1
W
1
H
2
W
2
...H
n
W
n
14 H
i
W
i
1
an Excel spreadsheet, first by converting it into a scale of 01 for variables with two options and for those with
VCI 14 V
1
W
1
V
2
W
2
...V
n
W
n
14 V
i
W
i
2
three, the scale was from 0, 1 or 2, both for quantitative and qualitative variables. As hazard and vulnerability have
CCI 14 C
1
W
1
C
2
W
2
...C
n
W
n
14 C
i
W
i
3
a positive impact on the risk, their lower levels were given lower scale values and the reverse is true for the higher values. On
the other hand the capacity has a negative impact on the severity of risk thus the scale was inverted and its higher values were
given lower scale values and vice versa.
where HCI, VCI and CCI are the Hazard Composite Index, Vulnerability Composite Index and Capacity Composite Index,
respectively. W
i
is the assigned weight for each variable. H
i
AsshowninTable3,theriskofinterruptedfunctionwascalculatedbasedonthreeindices;thefloodhazard,vulnerabilityand
the capacity of the health centre. The risk has been given a total weightvalueof3bycombiningtheunitweight(1)assignedto
each component of hazard, vulnerability and capacity. Within each component there are sets of variables which have equal
weights. Flood hazard is the potential for inundation thatinvolvesrisktolife,health,property,andnaturalfloodplainresources
and functions. It is comprised of three elements: severity, probability of occurrence, and speed of onsetofflooding[33].Four
proxy indicators have been selected to define the flood hazard, these are,relativesizeofpreviousdamagebyflood,pasthistory
of isolation of the health center by flood water,numberofisolationdaysandthelikelihoodofinundationoftheoperationalarea
within the
, is the ith hazard variable with a corresponding scale value of 0, 1 or 2, where i144.
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 122
Step 1
Selection of indicators; Hazard (H), Vulnerability (V), Capacity (C)
Step 2
Collection of data through a standard questionnaire survey and checklist .
Step 3
Assigning weights to selected indicators to reflect their relative importance
Step 4
Calculation of the composite index values for H, V, C and risk
Step 5
Categorization of risk into three levels (low, moderate and high)
Step 6
Model validation through a workshop involving the experts through a presentation, question and answering session followed by
a short questionnaire with a scaling technique to measure the validity
Fig. 2. Methodology workflow diagram.

, V
i
is the ith vulnerability variable with a corresponding scale value of 0, 1 or 2, where i145.
C
i
, is the ith capacity variable with a corresponding scale value of 0, 1 or 2, where i1412.
The risk foreachhealthcenterwasthencalculatedbythesummationoftheHCI,VCIandCCIvalues,outofamaximumrisk
of 3. A risk scalewasdevelopedtocategor-izeandinterprettherisk.Itwasclassifiedinto3cate-gories:lowrisk,moderaterisk
and high risk.
Summary of the methodology followed in this paper is shown in Fig. 2.
2. Results and discussion
The hazard component is mainly determined by the isolation of the centers by flood water as it contributes about 32%,
followed by the days of isolation with 28% and leastbythesizeofpreviousdamagewhichis15%.Allhealthcentershavebeen
isolated by the flood water,
H.B. Abbas, J.K. Routray / International Journal of Disaster Risk Reduction 6 (2013) 118128 123
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
secivres\ytilicaF erutcurtsarfnignidliuB
r freezers for vaccines preservation aloS7:otohP CCHPdlO1:otohP
sorciM8:otohP CCHPdlO2:otohP cope operating with sun light
9:otohP CCHPnredoM3:otohP PHCC dependent on solar power
seitilicafnoitatinasdnaretaW01:otohP CCHPnredoM4:otohP
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.
mainly due to poor drainage systems. Seven health centers are likely to be inundated as they had been inundated by previous
flood events and their different departments and stores were flooded. However despite the fact that the flood height was never
been above one foot,itcreatedchaosandhinderedthenormalfunctionoftheinundatedcenters.Similarconsequenceshavebeen
encountered in Jahore, Malaysia in 2009 where 14% of the health facilities stopped functioning mainly due to inundation and
isola- tion by flood water [34].
Only one center had experienced significant damage by flooding in the last five years, two had never faced any degree of
damage andsixoutoftheninecentershadminordamages.Thetypeanddesignofbuildingsaresuitabletothelocalenvironment
as reported by the Head of Department of Preventive Medicine in Kassala State. The structuralvulnerabilityasreflectedbythe
type of building materials showed that none of the health centers in the study area is of type 3 which is mud and local materials

Table 4 Weighted variables against the scale of occurance for hazard, vulnerability and capacity.
Health center Hazard Vulnerability
Size of damage due to previous flooding
History of isolation by flood
Days of isolation
Likelihood of inundation
Accessibility Structural Non
structural Distance from health center
Time to health center
Type of the structure
Need for renovation
Shahid Abdulbasit .00 .00 .25 .00 .20 .20 .10 .20 .20 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
variables (y)
6.17 4.3
Percentage (x/y*100) 15% 32% 28% 25% 14% 14% 14% 33% 26%
Health center Capacity
Technical staff
Ambulance service
Availability of laboratory services
Availability of free service package
Availability of the essential drugs
Presence of emergency plan
Availability of Stores
Communication Power supply
Safe water supply
Drug supply
Community participation
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 for all variables (y)
6.77
Percentage (x/y*100) 0% 11% 34% 4% 7% 9% 8% 0% 9% 7% 6% 4%

mainly and that seven have brick walls and waterproof roofs
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 5km and less than 15min 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 M5Digain0.880.300.631.81M6Mossassa0.630.500.501.63M7Tendlai0.630.30
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.
H.B. Abbas, J.K. Routray / International Journal of Disaster Risk Reduction 6 (2013) 118128 125

Table 6 Model validation with scaling technique.


Respondents Component 1 Component 2 Component 3
Conceptual framework Data Selection of right variables for measurement
Flood hazard concept
Vulnerability concept
Capacity of PHC
Risks/Potential threats
Aggregate Use of
secondary data by PHC
Relevance of data
Aggregate Flood
hazard
Vulnerability Capacity of
PHC
Aggregate
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 maximum and minimum weight to risk components
Weight distribution of variables following the principle of equal importance to all within a component
Calculation of Indices Aggregate Risk
Index Values
Recommendation Limitation
of the study
Overall applied value of the risk assessment model
Aggregate
Hazard Index
Vulnerability Index
Capacity Index
Risk Index
a 3 3 4 4 4 4 3.7 434544.1b3443533.743343.53.8c4443433.7454343.8d3444443.845454.54.3e55
5 5 5 5 5 5 5 5 5 5 4.6 f 5 444444.245444.34.3g4344454555554.5Mean3.83.84.13.84.343.94.34.44.14.4
4.3 4.3
Note: Five-point scale was used, with 1 as the least and 5 as the highest level of validation.

full PHC package of service and the other seven centers provide partial services. None of the centers have an emergency plan
which is an important tool of emergency management and should be considered as part of the preparedness of those facilities.
Similarly, none hasameansofreferringpatientsinneedforahigherlevelofcare,whichisexpectedknowingthatonly17.4%of
the health centers in the state have this kind of service [44]. In many flood proneareasinthePhilippines,factorsthataffectthe
normal functions of the health care facilities were identified as; physical damage, shortages in human resources, supplies and
essential medicines, and need for renovation to restore their normal functions [45]. Other factors are: Increased number of
referrals; system disrup- tions such as electricity, lack of standard operating proce- dures, and lack of communication with the
administrative authorities [3]. Primary health care services were inter- rupted or stopped functioning following the flooding in
1993 in 13 counties in Iowa of the USA, either due to direct impact of the facilities or indirect impact on supportive systems [46].
Table 5 shows the individual riskvalueforeachhealthcenteraswellastheshareofhazard,vulnerabilityandcapacityonthe
total risk. Among the studied health centers eight out of nine are havingamediumriskandonecenterhasahighriskofservice
interruption during flood. The magnitudes of risk range from 2.16 to 1.4 out of 3. The risk of service interruption in the study
area is mainly defined by the hazardous components with 39.47%, vulnerability 27.50%, and capacity with 33.04%. The table
also shows the ranking of the health centers according to the risk values from the highest to the lowest.
2.1. The process of validating the model
Model validation is well-known in social sciences but relatively new for disaster management. Philosophically validationis
defined as a purely logical problem, dealing with the internal consistency of a set of propositions with respect to a set oflogic
rules;adefinitionreferredtoasverificationinthemodelingliterature[47].Totesttheeasinessandtheapplicabilityofthemodel,
a half day workshop was conducted in Khartoum, Sudan in which seven disasterprofessionalswithdifferentbackgroundswere
invited. The group of expertsconsistedofmedicalpractitioners,academicians,INGOs,pharmacists,logisticcoordinators,public
health consultants, information man- agers, epidemiologists anddisastermanagementconsul-tants.Theapproachwaspresented
to the audiences, followed by a question and answer session for further clarification. Then a five-point scaling technique was
used in a structured questionnaire. In the five-point scale 1 represents the least and 5 represents the best situation,meaningthe
degree of the validity of themodelvariesfrom1to5.Itcoveredtheconceptualframework,data,selectionoftherightindicators
formeasuringhazard,vulnerabilityandcapacity,methodandtechniquesusedandinterpretationmade.AscanbeseeninTable6,
the respondents have given values for eachofthevalidatedcomponentsasfollows:4.2fortheconceptualframework,4.4,asthe
highest value, for data and for the selection of
H.B. Abbas, J.K. Routray / International Journal of Disaster Risk Reduction 6 (2013) 118128 127
the right measurement indicators, 3.9formethodsandtechniqueasthelowestvalueand4.3forinterpretation.Theaverageofall
components is 4.3 out of 5, which means that it is highly reliable. In conclusion the participants found value for model
application in real life.
3. Conclusion and recommendations
Theriskofserviceinterruptionatthehealthcentersduringfloodhasbeenassessedsemiquantitativelytorankthemaccording
to the expected risk. The risk of service interruption in the studied health centers ranges from 2.16 to 1.4 out of3.Eightofthe
health centers are under amediumrisklevelandoneisunderahighriskofserviceinterruption.However,factorslikethesizeof
the serviced population and the utilization rate should be considered in making the decision for intervention.
Urgently in the short term the capacities of the health centers in the study area need to be augmented by addressing the
problems of water and power supply, prepositioning of drugs and medicines, provision of full services and development of
emergency plan within those facilities. For the medium term renovationandinfrastruc-turesrepair,includingdrainagesystems,
should be carriedout.Asforthelongterminterventions,thedesign,build-ingmaterialsandlocationsofnewfacilitiesshouldbe
flood resilient, besides the strengthening of the other sectors astheirperformancewillbereflectedonthefunctionsofthehealth
system.
The conceptual framework and method described in this paper have been verified, evaluated and validated. The model
described by this paper can be used and also future adjustments may be considered depending on the nature of the problems
addressed when applied in the field. The differences in geography, demographics and level of ser- vice in each case should be
considered when applying the procedure elsewhere.
3.1. Limitations and utility of the study
This paper provides a useful simplified and practical assessment procedure and tool that can beappliedbynone-specialized
staff of the health centers and the local authorities, to estimate swiftly andefficientlythepotentialriskofserviceinterruptionat
those health centers.
Among the limitations of this study is that the list of variables used is not exhaustive besides many are difficult to be
quantified and hence numerically expressed. Also this paper assesses only floodhazardsusingproxyindica-torsratherthanthe
conventional hazard assessment and hazard mapping. The limited number of the health centers in the study area hindered the
utilization of many useful statistical tests for in depth analysis of the results. How- ever suchlimitationsshouldnotpreventthe
use of such methods of risk assessment [29].
Acknowledgments
We would like to thank the Ministry of Health, Kassala State for their support and sharing of the secondary data.

WeappreciatethesupportofAITforfundingthiswork.Wewouldliketothankallhealthworkersandgroupsofexpertsfortheir
active involvement in this research, provision of their opinions and suggestions to validate and improve this work. Finally we
extend our appreciation to Mr.TylorBurrowsfromAITLanguageCentreforhiseffortsincheckingandeditingthewritingstyle
of this paper.
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