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<a href=International Journal of Disaster Risk Reduction 6 (2013) 118 128 Contents lists available at S c i e n c e D i r e c t International Journal of Disaster Risk Reduction journal homepage: w w w . e l s e v i e r . c o m / l o c a t e / i j d r r 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 , Jayant K. Routray Disaster Preparedness, Mitigation and Management, Asian Institute of Technology, Bangkok, Thailand 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 abstract Primary health care (PHC) centers are very important to provide health facilities and services at the local level. The role of PHC centers becomes crucial during the flood and other natural disasters. PHC is an essential health care which is scientifically sound, 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 model is developed in the context of Sudanese PHC and validated further to add value and 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 safe in emergencies on the World Health Day, 2009, to highlight 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, including flood, is the disruption of the health services either through direct damage of 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 Corresponding author. Tel.: þ 66 896628465. E-mail addresses: st110489@ait.ac.th , hitha2000@gmail.com (H.B. Abbas) . 2212-4209/$ - see front matter & 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijdrr.2013.10.002 flooding is the disruption of health care services [3] . The supporting systems are important for functional continuity of the health facilities [4 , 5] . Their importance could clearly be shown during Hurricane Katrina in August, 2005, when health facilities stopped functioning due to non-operating generators and impossibility of providing supplies through the flooded road network. Arboleda and colleagues have shown the importance of including the analysis of infrastructure systems in the vulnerability analysis of health facilities as they significantly affect the functions of those facilities [6] . Loss of health facilities' functions was encountered during and after the tsunami disaster in 2004 in Maldives, Indonesia Thailand and Sri Lanka. Those facilities are most needed at the time of crisis to serve victimized people, especially the ones within 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 experienced dysfunction due to the flood of 2008 [8] . There are evidences that the prevalence of the interruption of treatment for patients with chronic diseases is proportional " id="pdf-obj-0-7" src="pdf-obj-0-7.jpg">

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International Journal of Disaster Risk Reduction

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<a href=International Journal of Disaster Risk Reduction 6 (2013) 118 128 Contents lists available at S c i e n c e D i r e c t International Journal of Disaster Risk Reduction journal homepage: w w w . e l s e v i e r . c o m / l o c a t e / i j d r r 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 , Jayant K. Routray Disaster Preparedness, Mitigation and Management, Asian Institute of Technology, Bangkok, Thailand 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 abstract Primary health care (PHC) centers are very important to provide health facilities and services at the local level. The role of PHC centers becomes crucial during the flood and other natural disasters. PHC is an essential health care which is scientifically sound, 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 model is developed in the context of Sudanese PHC and validated further to add value and 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 safe in emergencies on the World Health Day, 2009, to highlight 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, including flood, is the disruption of the health services either through direct damage of 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 Corresponding author. Tel.: þ 66 896628465. E-mail addresses: st110489@ait.ac.th , hitha2000@gmail.com (H.B. Abbas) . 2212-4209/$ - see front matter & 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijdrr.2013.10.002 flooding is the disruption of health care services [3] . The supporting systems are important for functional continuity of the health facilities [4 , 5] . Their importance could clearly be shown during Hurricane Katrina in August, 2005, when health facilities stopped functioning due to non-operating generators and impossibility of providing supplies through the flooded road network. Arboleda and colleagues have shown the importance of including the analysis of infrastructure systems in the vulnerability analysis of health facilities as they significantly affect the functions of those facilities [6] . Loss of health facilities' functions was encountered during and after the tsunami disaster in 2004 in Maldives, Indonesia Thailand and Sri Lanka. Those facilities are most needed at the time of crisis to serve victimized people, especially the ones within 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 experienced dysfunction due to the flood of 2008 [8] . There are evidences that the prevalence of the interruption of treatment for patients with chronic diseases is proportional " id="pdf-obj-0-58" src="pdf-obj-0-58.jpg">

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 href=International Journal of Disaster Risk Reduction 6 (2013) 118 128 Contents lists available at S c i e n c e D i r e c t International Journal of Disaster Risk Reduction journal homepage: w w w . e l s e v i e r . c o m / l o c a t e / i j d r r 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 , Jayant K. Routray Disaster Preparedness, Mitigation and Management, Asian Institute of Technology, Bangkok, Thailand 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 abstract Primary health care (PHC) centers are very important to provide health facilities and services at the local level. The role of PHC centers becomes crucial during the flood and other natural disasters. PHC is an essential health care which is scientifically sound, 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 model is developed in the context of Sudanese PHC and validated further to add value and 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 safe in emergencies on the World Health Day, 2009, to highlight 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, including flood, is the disruption of the health services either through direct damage of 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 Corresponding author. Tel.: þ 66 896628465. E-mail addresses: st110489@ait.ac.th , hitha2000@gmail.com (H.B. Abbas) . 2212-4209/$ - see front matter & 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijdrr.2013.10.002 flooding is the disruption of health care services [3] . The supporting systems are important for functional continuity of the health facilities [4 , 5] . Their importance could clearly be shown during Hurricane Katrina in August, 2005, when health facilities stopped functioning due to non-operating generators and impossibility of providing supplies through the flooded road network. Arboleda and colleagues have shown the importance of including the analysis of infrastructure systems in the vulnerability analysis of health facilities as they significantly affect the functions of those facilities [6] . Loss of health facilities' functions was encountered during and after the tsunami disaster in 2004 in Maldives, Indonesia Thailand and Sri Lanka. Those facilities are most needed at the time of crisis to serve victimized people, especially the ones within 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 experienced dysfunction due to the flood of 2008 [8] . There are evidences that the prevalence of the interruption of treatment for patients with chronic diseases is proportional " id="pdf-obj-0-70" src="pdf-obj-0-70.jpg">

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

abstract

Primary health care (PHC) centers are very important to provide health facilities and services at the local level. The role of PHC centers becomes crucial during the flood and other natural disasters. PHC is an essential health care which is scientifically sound, 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 model is developed in the context of Sudanese PHC and validated further to add value and 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 safe in emergencies on the World Health Day, 2009, to highlight 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, including flood, is the disruption of the health services either through direct damage of 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

n Corresponding author. Tel.: þ 66 896628465. E-mail addresses: st110489@ait.ac.th, hitha2000@gmail.com (H.B. Abbas).

2212-4209/$ - see front matter & 2013 Elsevier Ltd. All rights reserved.

flooding is the disruption of health care services [3]. The supporting systems are important for functional continuity of the health facilities [4,5]. Their importance could clearly be shown during Hurricane Katrina in August, 2005, when health facilities stopped functioning due to non-operating generators and impossibility of providing supplies through the flooded road network. Arboleda and colleagues have shown the importance of including the analysis of infrastructure systems in the vulnerability analysis of health facilities as they significantly affect the functions of those facilities [6]. Loss of health facilities' functions was encountered during and after the tsunami disaster in 2004 in Maldives, Indonesia Thailand and Sri Lanka. Those facilities are most needed at the time of crisis to serve victimized people, especially the ones within 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 experienced dysfunction due to the flood of 2008 [8]. There are evidences that the prevalence of the interruption of treatment for patients with chronic diseases is proportional

H.B. Abbas, J.K. Routray / International Journal of Disaster Risk Reduction 6 (2013) 118 128

119

to the magnitude of damage to the health facility [9]. Similar damages were reported in Ecuador and Peru, 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 values make their protection cost effective and necessitate the integration of their safety in any health risk reduction plan. However, despite their importance and obvious vulnerability to floods not many original research papers are found in the literature to tackle the issue of the safety and risk assessment of those low scale facilities [8]. In Sudan the five year strategy for the Ministry of Health has clearly identified the importance of the continuous provision of health 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 the same; an evaluation report in India diagnosed the PHC problems which are associated with insufficient human resources, inadequate infrastructures and drugs, and lack of community participa- tion and quality health care [14]. Other factors that affect the service delivery at the level of public health centers are coverage, availability of human resources with different required specializations, incomplete package of services, shortage in equipment, and the dysfunctional referral system [15]. Access to PHC is a major determinant of service delivery affect the utilization of services and flow of functions and services provided by the facilities. Accessibility is a multi- dimensional concept that includes geographical accessibility, availability, affordability, accommodation and acceptability, as explained by the model developed by Penchansky [16]. In addition health can be seen as a commodity that is also affected by supply and demand factors such as quality of health care services, affordability, appropriateness of health personnel and social values and norms [17]. The health system in Sudan is a decentralized system with three tiers of care at primary, secondary and tertiary levels. About 33% of the population has no access to health facilities, the minimum PHC package is provided by 19% of PHC facilities. 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), dressing stations (DS), dispen- saries, and health centers. Rural hospitals are considered part of the PHC level and serve as secondary referral level health facilities. Specialized and general hospitals are the tertiary level and are located in states' capital. About 41% of the total health visits take place in primary health centers, with a variation on the use of Family Health Units and dispensaries with a range of 181% in urban and rural areas. About 52.2% of urban centers provide the minimum package compared to 3.8% of the rural centers and 21.9% of the family health units [19].

1.1. Background

The study area is the North Delta GashLocality in Kassala State of Eastern Sudan, 120 km north of Kassala

town, with a total area of about 14,000 km 2 and a popula- tion of 82,000. The population density in the area is 12 person/km 2 and there are of 55 villages [20]. Health services are delivered through one rural hospital in Aroma with 57 beds. There are nine functioning health centers and 22 basic health units, three of which are not function- ing. No private health service is available in the area. In total there are two doctors, 14 assistant health personals, 13 medical assistants, 46 environmental health officers and 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 risk of annual flooding which significantly affects communities in the area with a five year interval. The most devastating floods occurred in 1975, 1983, 1988, 1993, 1998, 2003, and 2007, when 47,075 people were affected [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 frequently hit by disease outbreaks of malaria, Dengue fever, meningitis and diarrhea. One factor that increases the likelihood of disease outbreak is the high indices of 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. Those high indicators are mainly 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 practiced female genital mutilation which is estimated to be as high as 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 point to be considered is that the study area is under the annual risk 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 with the role of the health staff at their centers and community [26,27]. Such a simplified method is important to avoid the complexity of sophisticated and 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 dependand defines vulnerability as the characteristics and circumstances of

  • 120 H.B. Abbas, J.K. Routray / International Journal of Disaster Risk Reduction 6 (2013) 118 128

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 the process of facility vulnerability assessment was developed by Rogers in 2000, by using the disaster history, structural and operational vulnerability as variables. The hazards were weighted from 1 to 5 to generate a Hazard Priority Score based on the experts' 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-structural vulnerabilities like architectural ele- ments, equipment and lifelines, and functional vulnerabilities such as induce accessibility, equipment and supplies, standard

operating procedures, and human resources [31]. With this background the objective of this paper is to assess the risk of service interruption at the level of primary health care 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 the health facilities that provide primary health care services in the study area were selected. Thus, all nine functioning health centers (out of 13), including those run by NGOs have been included in the sample. Health facilities lower than the health centers have been excluded. Table 1 shows the utilization (multiple visits) rate for each health center, which is defined as the number of all patients consulted in the health center in one year to the total service area population. The calculated

Capacity • Technical staff • Ambulance service • Laboratory services • Free service treatment package •
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
Functioning
PHC center
Service Interrution Community Fig. 1. Conceptual framework.
Service Interrution
Community
Fig. 1. Conceptual framework.
Flood hazard • Structural damage by previous floods • Isolation by flood • Isolation period •
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 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%

H.B. Abbas, J.K. Routray / International Journal of Disaster Risk Reduction 6 (2013) 118 128

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 (flood severity)

damage

 

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

Unlikely

0 Likely

1

Vulnerability Distance from health center

function in the health center (height) % 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 roof

2

 

Need for renovation Referring to the current situation of the health center

No

0

Yes

1

Nonstructural building

Ambulance service

The condition of doors, windows, lighting fixtures, roof, furniture,

hemoglobin and white cell count, and urine test for glucose, pus cells and

Good

0

Satisfactory

1

Not good

2

Capacity

elements Technical staff per 5000

appliances, electronics, Equipment, stored items 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 The health center (community) has the means to transfer the needy

Yes

0 No

1

Availability of laboratory services

patients to the higher level health facilities The health center provides the essential lab tests. Blood test for malaria,

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 Yes

 

0 No

1

Availability of safe stores

preparedness, response to different scenarios of flood emergency 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

Safe water supply The health center has an adequate safe water supply during 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)

Yes

0 No

1

emergencies 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

  • 122 H.B. Abbas, J.K. Routray / International Journal of Disaster Risk Reduction 6 (2013) 118 128

utilization rate of PHC centers in the study area is 1.38 visits per person per year, which is 46% of the expected utilization rate in Sudan. Utilization rate is important to help prioritiz- ing the planned interventions according to the size of service population and their utilization of the services provided by the health center. The selection of indicators for this model is based on the set of indicators used for assessment of hospital safety manual prepared and used by PAHO as shown in Table 2. The selection of indicators has been guided by various literatures and also making use of those relevant in the local context of Sudan. Experts and field practitioners' consultation, through a workshop, was recommended for a equal weighting system giving equal priority to hazard, vulnerability and capacity components. Another factor that affects the selection of variables for this study is the availability or lack of data which among the known limitations to the selection process [32]. A check list and questionnaire were developed to collect data from the health centers. Data were collected at the site of the center where health workers were interviewed. Secondary data were retrieved from the state's and the locality's records. The data from the check- 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 three, the scale was from 0, 1 or 2, both for quantitative and qualitative variables. As hazard and vulnerability have 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. 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 has been given a total weight value of 3 by combining the unit weight (1) assigned to 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 that involves risk to life, health, property, and natural floodplain resources and functions. It is comprised of three elements: severity, probability of occurrence, and speed of onset of flooding[33]. Four proxy indicators have been selected to define the flood hazard, these are, relative size of previous damage by flood, past history of isolation of the health center by flood water, number of isolation days and the likelihood of inundation of the operational area within the

health center. Each was given a weight of 0.25 out of the total hazard weight. Vulnerability has five variables: per- centage of serviced population who live within a radius of 5 km from the health center, percentage of serviced population who walk for 15 min to the health center, the type of the building materials, and need for renovation and nonstructural component of the health center. Each vari- able has a weight of 0.20 out of the total vulnerability weight. The third index is the capacity which has 12 variables: number of technical staff, availability of ambu- lance service, laboratory service, and free primary health care package, availability of the essential drugs, presence of an emergency plan, the presence of alternative sources of power and water supply, reliable means of communica- tion and availability of safe stores. The other two variables are the positioning of adequate drug supply in the health center before the rainy season and the community role in protecting the health center before and during the flood. Each variable carries a weight of 0.08 out of the total capacity weight. The composite indices for hazard, vulnerability and capacity were calculated using the equations;

HCI ¼

H 1 W 1 þ H 2 W 2 þ þ H n W n ¼ H i W i ð1Þ

VCI

¼

V 1 W 1 þ V 2 W 2 þ þ V n W n ¼ V i W i ð2Þ

CCI ¼ C 1 W 1 þ C 2 W 2 þ þ C n W n ¼ C i W i

ð3Þ

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 , is the i th hazard variable with a corresponding scale value of 0, 1 or 2, where i ¼ 4.

• Selection of indicators; Hazard (H), Vulnerability (V), Capacity (C) Step 1 • Collection of data
• Selection of indicators; Hazard (H), Vulnerability (V), Capacity (C)
Step 1
• Collection of data through a standard questionnaire survey and checklist .
Step 2
• Assigning weights to selected indicators to reflect their relative importance
Step 3
• Calculation of the composite index values for H, V, C and risk
Step 4
• Categorization of risk into three levels (low, moderate and high)
Step 5
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.

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) 118 128

123

V i , is the i th vulnerability variable with a corresponding scale value of 0, 1 or 2, where i ¼ 5. C i , is the i th capacity variable with a corresponding scale value of 0, 1 or 2, where i ¼ 12. The risk for each health center was then calculated by the summation of the HCI, VCI and CCI values, out of a maximum risk of 3. A risk scale was developed to categor- ize and interpret the risk. It was classified into 3 cate- gories: low risk, moderate risk 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 least by the size of previous damage which is 15%. All health centers have been isolated by the flood water,

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, it created chaos and hindered the normal function of the inundated centers. Similar consequences have been 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 and six out of the nine centers had minor damages. The type and design of buildings are suitable to the local environment as reported by the Head of Department of Preventive Medicine in Kassala State. The structural vulnerability as reflected by the 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

Few selected photographs of the PHCC with facilities and services are presented from photo 1 to
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 Micros
cope 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

H.B. Abbas, J.K. Routray / International Journal of Disaster Risk Reduction 6 (2013) 118 128

Table 4

Weighted variables against the scale of occurance for hazard, vulnerability and capacity.

Health center

Hazard

Vulnerability

 

Days of

 

Likelihood of

Accessibility

Structural

Non

 

inundation

 

structural

 
 

Size of damage due to previous flooding

History of isolation by flood

isolation

 

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

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 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 for all variables (y)

6.77

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) 118 128

125

and that seven have brick walls and waterproof roofs while two have RCC (reinforced concrete) roofs. However that does not reflect the current situation of the building and the need for renovation was reported in seven centers which amounts to approximately 33% of the vulnerability of the buildings. There has not been much improvement in Kassala State following the health facilities' survey con- ducted by the Federal Ministry of Health in 2008 when only 10% of the health centers were found to be in good conditions and needed no renovation [44] (Photo 1). About 67% of the population live within 5 km of the health center and walk for a maximum of 15 min. Distance to the health service is a main indicator which is fre- quently used in accessibility studies. It is the straight line between a home and the health center [35]. The national standards in Sudan set it a maximum of 5 km and 30 min walking time to PHC centers to enhance accessibility to health services and to shorten the time period for emer- gency cases in order to minimize morbidity and mortality. Improved access to health care can reduce infant and maternal mortality and morbidity in rural areas [36]. In Sudan the average time to the nearest health care facility ranges between 15 and 29 min [37] and in Kassala State was found that 87% of population live within 5 km [44]. Those findings are different than those shown in some rural areas in Kenya, where distance and time to the health care centers in addition to affordability were the main factors affecting accessibility to health care. All facilities were found to be serving more than 5000 people, less than 10% living within 5 km and less than 15 min from the nearest health facilities [38]. In Yemen a study showed evidences that related the vaccination status of children to the distance and walking time from home to the health centers [39]. Similarly it has been shown that the longer the time to the health center the higher the relative risk of the child's death [40]. One study from South Africa showed significant effect of distance on accessibility [41]. All centers lack the patients' referral service, 89% do not have emergency plans. On the other hand all the centers have a convenient means of communication during flood emergency and satisfactory human resources. About 87% of the health centers provide the full package of the free primary health care service and all report moderate to high degree of community participation in protecting the health centers during flood times. The overall capacity is

mainly affected by the lack of laboratory services, reliable sources of power supply, ambulance service, emergency plans, and safe stores. Health services cannot fully perform their functions with their own capacities only, but they are in need of the support of other sectors and services like communication, water and power [42]. Following the implementation of the Modernized National Surveillance by the Federal Ministry of Health and private communication companies' partnership in 2009 all health facilities down to the level of health centers have been provided with a free of charge communication system to increase the percentage and shorten the time of reporting, which has been reflected by finding that all the studied centers have reliable means of communication even during flood emergencies. On the other hand as shown in the results and as observed in the field visits, seven of the health centers lack regular safe water supply and eight of them have no reliable electricity supply. The main reason for lacking water supply is the high fees. However only 57% of the health centers in the State are connected to the public network and the rest has to buy their daily needs for water. For power supply the centers connected to the national network represent only 53% and the other facilities depend on alternative sources such as generators and solar energy. Field visits showed that some of the health centers depend on solar energy to preserve vaccines in the cold chain fridges provided by the UNICEF. Six health centers have all the essential drugs recommended by the national standards, while they were found partially in the other three centers. The national policy for health disaster management in Sudan stresses the importance of positioning of medicines and supplies in areas under flood risk ahead of the rainy season [13]. However despite the annual risk of flooding in the study area more than 55% of health centers do not receive their needs before the rainy season. By comparison in South East Europe, 72.4% of the health facilities have essential med- icines and emergency supply stockpiles in place before- hand [43]. All the studied health centers reported a positive and interactive community participation in pro- tecting those centers before, during and after the flood emergency with varying degrees of participation from moderate to strong (Table 4). No shortage regarding human resources has been 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%

126

H.B. Abbas, J.K. Routray / International Journal of Disaster Risk Reduction 6 (2013) 118 128

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

Vulnerability

Capacity of

Risks/Potential

Aggregate Use of

 

Relevance of

Aggregate Flood

Vulnerability Capacity of

Aggregate

concept

concept

PHC

threats

secondary data by PHC

data

hazard

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

45

 

5

54

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

 

Assignment of

Calculation of Indices

 

Aggregate Risk

Recommendation Limitation Overall

Aggregate

components

maximum and

 

Index

 

of the

applied value

 

Weight distribution of variables following the

 

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) 118 128

127

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 has a means of referring patients in need for a higher level of care, which is expected knowing that only 17.4% of the health centers in the state have this kind of service [44]. In many flood prone areas in the Philippines, factors that affect the 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 risk value for each health center as well as the share of hazard, vulnerability and capacity on the total risk. Among the studied health centers eight out of nine are having a medium risk and one center has a high risk of service 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 validation is defined as a purely logical problem, dealing with the internal consistency of a set of propositions with respect to a set of logic rules; a definition referred to as verification in the modeling literature [47]. To test the easiness and the applicability of the model, a half day workshop was conducted in Khartoum, Sudan in which seven disaster professionals with different backgrounds were invited. The group of experts consisted of medical practitioners, academicians, INGOs, pharmacists, logistic coordinators, public health consultants, information man- agers, epidemiologists and disaster management consul- tants. The approach was presented 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, meaning the degree of the validity of the model varies from 1 to 5. It covered the conceptual framework, data, 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 respondents have given values for each of the validated components as follows: 4.2 for the conceptual framework, 4.4, as the highest value, for data and for the selection of

the right measurement indicators, 3.9 for methods and technique as the lowest value and 4.3 for interpretation. The average of all 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

The risk of service interruption at the health centers during flood has been assessed semi quantitatively to rank them according to the expected risk. The risk of service interruption in the studied health centers ranges from 2.16 to 1.4 out of 3. Eight of the health centers are under a medium risk level and one is under a high risk of service interruption. However, factors like the size of 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 renovation and infrastruc- tures repair, including drainage systems, should be carried out. As for the long term interventions, the design, build- ing materials and locations of new facilities should be flood resilient, besides the strengthening of the other sectors as their performance will be reflected on the functions of the health 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 be applied by none-specialized staff of the health centers and the local authorities, to estimate swiftly and efficiently the potential risk of service interruption at 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 flood hazards using proxy indica- tors rather than the 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 such limitations should not prevent the 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.

  • 128 H.B. Abbas, J.K. Routray / International Journal of Disaster Risk Reduction 6 (2013) 118 128

We appreciate the support of AIT for funding this work. We would like to thank all health workers and groups of experts for their active involvement in this research, provision of their opinions and suggestions to validate and improve this work. Finally we extend our appreciation to Mr. Tylor Burrows from AIT Language Centre for his efforts in checking and editing the writing style of this paper.

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