Disaster Prevention and Management: An International Journal

Hospital resilience in the aftermath of Typhoon Haiyan in the Philippines

Charlie Labarda, Meredth Del Pilar Labarda, Exaltacion Ellevera Lamberte,
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Charlie Labarda, Meredth Del Pilar Labarda, Exaltacion Ellevera Lamberte, "Hospital resilience in the aftermath of Typhoon
Haiyan in the Philippines", Disaster Prevention and Management: An International Journal, https://doi.org/10.1108/
DPM-02-2017-0025
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 Hospital resilience in the aftermath of Typhoon Haiyan in the Philippines

1. Introduction

Super-typhoon Yolanda (international name: Haiyan; hereafter Typhoon Haiyan)

caused massive damage to the central part of the Philippines in November 2013 with

about 16 million people affected (McPherson et al., 2015). The extent of human,

material and environmental damage overwhelmed local governments and seriously

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disrupted their capacity to deliver humanitarian response in the aftermath of the

disaster. At the forefront of disaster response was the provision of adequate public

health services to address physical injuries, illnesses, potential disease outbreaks,

short- and long-term psychological effects, and death. In such post-disaster settings,

resilient health facilities particularly hospitals, are considered critical for a responsive

local health system (Farmer and Carlton, 2006; Mulyasari et al., 2013).

1.1 Disaster and resilience in health systems

When disasters occur, they expose the fragility of health systems to disruptive forces

(Watson et al., 2012). In the context of climate change and the corresponding global

increase in the frequency and severity of disasters, the development of resilient

health facilities like hospitals gains urgency (WHO, 2015a). But what is a resilient

health system? One descriptive approach refers to the capability of various health

stakeholders, institutions, and populations to prepare for and effectively respond to

crises— i.e. maintain its core functions when disaster strikes, harvest lessons during

the crisis, and utilize such knowledge to adapt to changing conditions (Kruk et al.,

2015). Thus, health systems are considered resilient if they produce good health

outcomes in the face of a crisis and in its aftermath. The World Health Organization

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 (WHO) Operational framework for building climate resilient health systems adopted

the approach of the Intergovernmental Panel on Climate Change (IPCC), by framing

climate-resilient health systems as able to anticipate, respond, cope, recover and

adapt to shocks and stresses while improving health of populations amid climate

variability (WHO, 2015b).

Disasters as disruptive events compromise the ability of hospitals to provide

continuity of urgently needed health services to affected populations. Even if

disasters are low probability events, when they happen they pose enormous
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pressure on local communities and the public health infrastructure (Achour et al.,

2015; Farmer and Carlton, 2006). Structural damage to health facilities and loss of

human and material resources in disasters, coupled with the surge in volume of

patients needing care, strains the public health system’s capacity to provide services

(Albanese et al., 2008; Ardalan et al., 2013). The observed surge in demand for

healthcare services in disasters is well documented in literature (Achour et al., 2016;

Barbera and Macintyre, 2007; Hick et al., 2004; Hick et al., 2009; Watson et al.,

2013). Various strategies to strengthen surge capacity during disaster have been

proposed (Kelen et al., 2009; Paturas et al., 2010). However, these strategies are

anchored on the need for a tiered health care response that require cooperation and

coordination at the various levels of the health care system that presents its own set

of challenges (Barbera and Macintyre, 2007; Walsh et al., 2015). The uneven state

of preparedness among hospital facilities at various levels of care further exacerbate

the consequences of disaster (Barbera et al., 2009). In recognition of the vital role of

resilient health systems in the context of disasters, both the 2005 and 2015 World

Conferences on Disaster Reduction have pushed for the promotion of safe and

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 resilient hospitals as a key component in disaster reduction (UNISDR, 2008; Bagaria

et al., 2009; UNISDR, 2015).

1.2 What is hospital resilience?

A conceptual framework for health system resilience adapted by the WHO (2015b),

viewed resilience as a function of two key components: vulnerability and adaptive

capacity (see Figure 1). Hospital resilience therefore depends on decreased

vulnerability to the shocks brought by disasters and increased adaptive capacity

brought by improved choices and opportunities. To promote resilience, the six

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building blocks of a functioning health system needs to be strengthened: leadership

and governance; health workforce; health information system; essential medical

products and technologies; service delivery; and financing (WHO, 2015b).

[Figure 1 here]

Despite the emergence of “hospital resilience” as an important concept in

disaster resilience, drawing out its meaning in operational terms remains a

challenge. The Philippine’s Department of Health (DOH) released a set of indicators

of a safe hospital in emergencies and disasters (DOH, 2009). Several other

international organizations have released their own versions of indicators for safe

hospitals (PAHO-WHO, 2010; Heidaranlu et al., 2015). The WHO (2015c) through its

Safe Hospital Initiative released the Hospital Safety Index (HSI) to improve the

functioning of hospitals in emergencies and disasters. The HSI is a comprehensive

checklist covering four modules: hazards and role of hospital in emergency and

disaster management; structural safety; nonstructural safety; and disaster and

emergency management. This was in response to the challenge to develop a

common framework for evaluating hospital resilience across health systems and

cultures (Albanese et al., 2008). For example, a study of four disaster frameworks

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 and eleven evaluation instruments for hospital preparedness revealed the lack of an

established framework for hospital resilience (Zhong et al., 2014a). A synthetic

framework based on the above study proposed eight domains, with 43 key

indicators, of hospital resilience (Zhong et al., 2015). The developed instrument was

validated in a sample of hospitals in China to measure variability in disaster

resilience among hospitals (Zhong et al., 2014b). However, the utility of such

measures of hospital resilience needs to be investigated across countries and health

systems, especially in actual disaster experiences. Are they reflective of realities and
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processes at work in the context of actual disasters? Providing more evidence on the

usefulness of such measures may establish some common framework for assessing

hospital resilience.

This study used the WHO conceptual framework for resilience (2015b) as

theoretical foundation to assess the performance of hospital facilities amid the

disaster generated by the devastating storm surges of Typhoon Haiyan.

1.3 Research objectives

This was an exploratory study of hospital facilities in a post-disaster setting to

analyze resiliency in the health sector. It had the following objectives: to conduct

case study on hospitals’ disaster preparedness along key measures of hospital

resilience; to describe the impact of Typhoon Haiyan on case hospitals delivery of

services to meet the demand for emergency health services and medical care of

survivors; and to draw out lessons on hospital resilience in disasters.

2. Methods

A survey of case hospitals’ level of preparedness before the typhoon was done

retrospectively using a self-report survey questionnaire with a hospital resilience

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 index as outcome (Zhong et al., 2015). A self-report instrument was used to measure

disaster preparedness, instead of a more objective evaluation checklist like the WHO

Hospital Safety Index, due to the retrospective nature of the study and the challenge

posed by a full technical assessment in a post-disaster setting. Second, key

informant interviews using semi-structured questionnaire were conducted among five

key hospital staff members from each case hospitals in the city using a chain-referral

sampling technique to identify key hospital staff during the immediate period

following the disaster (Wasserman et al., 2005; Sadler et al., 2010). All respondents
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were involved in respective facility’s post-disaster response. Institutional ethics

review was done through [masked for blind review]. Informed consent from

participants were secured.

2.1 Hospital facilities

The hospital sampling frame for the study was taken from the list of 21 affected

hospitals in Eastern Visayas on the eastern seaboard of the Philippines, where

Haiyan made its first landfall (DOH, 2014). A purposive sampling approach was

utilized to identify key health facilities that were impacted by the disaster. Selected

case hospitals were two health facilities in Tacloban City severely damaged by storm

surges as they were near the city’s coastline. The case study covered two tertiary

level hospitals—one public and one private-run facility. The public hospital was the

hub of health emergency care and services in the region in the aftermath of Typhoon

Haiyan. On the other hand, although heavily damaged by storm surges, the private

hospital delivered emergency care and services in the immediate period following

the disaster. This study used a mixed methods approach.

2.1.1 Case public hospital

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 The public hospital covered in this case study was established about a century ago

as a provincial hospital. From a bed capacity of 14, it developed into a level 3

teaching and training hospital with a 275-bed capacity serving a population of about

4 million in the catchment area of Eastern Visayas (DOH, 2014). About 106 doctors,

154 nurses, 1 midwife and 128 auxiliary staff serve an average of 450 patients each

day (DOH, 2014). The public case hospital was one of the worst hit health facilities

by the typhoon due to its proximity to Cancabatoc Bay where the storm surges

occurred. In the aftermath of the disaster, it was decided to transfer the public
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hospital from its current location in a no-build zone to a safer place in the northern

part of the city (DOH, 2014).

2.1.2 Case private hospital

The private hospital covered in this study also suffered extensive damage due to the

storm surges brought by Typhoon Haiyan. Originally founded by faith-based

missionary groups from a US-based Protestant denomination, it was passed on to

the local church for management and subsequently owned by a prominent national

Protestant denomination in the Philippines. For a hundred years it existed as a

teaching and training hospital. It was a level 3 teaching and training hospital, with a

125-bed capacity. A total of 100 consultants, 15 resident physicians, 140 nurses, 4

midwives, 2 dentists and 290 auxiliary staff provided medical and support services to

patients coming from all over the region (DOH, 2014).

Immediately after the disaster, the private case hospital was operated by the

Médecins Sans Frontières (MSF) and provided emergency and basic medical

services for free to patients. However, due to the decision by the national office to

build a different hospital facility under a new legal entity, the private hospital ceased

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 operations a few months thereafter. It is now under the management of the national

office but registered as a new health facility and limited to outpatient care.

2.2 Survey instrument and data collection

A self-report survey questionnaire on hospital disaster preparedness was used to

asses each case hospital along eight domains (Zhong et al., 2014b). Areas of

hospital preparedness before Typhoon Haiyan made landfall was explored and they

included the following: hospital safety, hospital disaster leadership and cooperation,

hospital disaster plan, emergency stockpiles and supply management, emergency

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staff, emergency critical care, emergency training and drills, recovery, and

reconstruction.

A semi-structured interview instrument with 11 items was used for the face-to-

face interviews with key hospital staff that provided leadership during the disaster.

Sample items included: “Briefly describe your official role and function in the

hospital/agency and in the delivery of health services?”; “What were the most

memorable experiences that you had in the aftermath of ST Yolanda/Haiyan in terms

of best practices as a hospital?” and “Please describe your experiences before the

typhoon, during the typhoon and immediately after the disaster.”

2.3 Data analysis

The survey data from completed hospital questionnaires were encoded and set up in

tabular format. Descriptive statistics analysis was done on resilience measures with

means, frequencies and percentages used to compare case hospitals disaster

preparedness along the identified domains. Interviews were transcribed and

analyzed qualitatively by authors. Because the interviews were conducted using

semi-structured interview instrument, predetermined thematic areas were covered in

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 the coding process (Phillips, 2014; Miles et al., 2014). Themes, both predetermined

and emergent from the interviews were analyzed.

3. Results

3.1 Hospital resiliency index

Table 1 below summarized the scores for hospital resilience of public and private

case hospitals. Each domain of hospital resilience measured key indicators that were

scored either 0 or 1 given their absence or presence, respectively, in a case hospital.

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A composite score for each domain was derived by summing all scores from the

component indicators. Total scores were computed for both case hospitals from the

sum of all domain scores. A hospital resiliency index was computed using the total

score divided highest possible score. Case public hospital had resiliency index of .72

while case private hospital had resiliency index of .28. Thus, the hospital resiliency

index of case public hospital was greater compared to case private hospital.

[Table 1 here]

3.2 Hospital disaster response in the context of Typhoon Haiyan

Given the different hospital resiliency index between case public hospital and case

private hospital, what were the actual experiences of the respective case hospitals

during the disaster? Was hospital resilience manifested in each health facility in the

form of decreased vulnerability and increased capacity and opportunities along the

building blocks of the WHO operational framework of climate resilient health

systems?

3.2.1 Vulnerabilities to disaster shocks and stress

Reduction of vulnerability to disaster exposure and sensitivity to the impact of

disasters involve a capacitated workforce, climate-proof infrastructure, adequate

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 response to emergencies, functional surveillance system, and good leadership and

governance structures (WHO, 2015b). Themes on vulnerability to shocks extracted

from the interviews provided some insights into the resilience of hospitals in the

midst of actual disaster.

Health workforce capacity was limited by ineffective disaster training

preparations. Almost all the respondents in the public case hospital had received

some form of disaster-related trainings except for the respondent from the dietary

section. However, the trainings were not up to date with no provision for continuing
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capacity building and enhancement. It was worse for the private hospital where most

respondents did not have any recent disaster-specific training. One frontline service

department did send people to train on disaster preparedness prior to Typhoon

Haiyan. However, it was not cascaded to the rest of the hospital or integrated into

existing disaster preparedness plans.

Response to emergencies through established protocols for disaster were

ineffective. Days prior to landfall of Typhoon Haiyan, most were already aware that a

big storm was on its way, but no sense of urgency was established even in the

hospital facilities. Key informants from the case public hospital, who were critical

personnel to their facility’s disaster response, were mostly not on duty when

Typhoon Haiyan made landfall in the city and brought devastating storm surges.

With the loss of road networks, transport problems and communication failure, many

of them faced extreme difficulty reporting for duty at the hospital. A few made it to the

hospital on foot a few hours after the typhoon. Some opted not to report for a few

days to secure their family and attend to providing food, water, and shelter for loved

ones. Similar narrative was seen in the stories of the private case hospital.

Preparations for the typhoon were the usual preparations for a typical storm, since

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 there was no institutional memory of a Category 5 storm like Typhoon Haiyan.

Equipment were secured by transferring them to safer locations on higher floors with

protective cover. But there was lack of urgency in the preparations, with many staff

not really expecting the worst. There was no indication that people were aware of the

danger that a strong typhoon posed. One informant recalled that “I did not even

remember the word ‘surge’—not even on television.” Some physician informants

were still doing their patient rounds late into the evening, a few hours before

Typhoon Haiyan made landfall in the Philippines.

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Leadership vacuum was evident in the disaster governance structure of the

Incident Command System (ICS). In case public hospital, preparations started 3

days before landfall with manpower, medical supplies and equipment readied in

anticipation of the surge. Despite all the preparations, one informant narrated a

scene of chaos and absence of a cohesive functioning incident command system.

“When I arrived, all I saw were debris. I even thought that all was gone7 I went in

and I saw the chaos.” There was no apparent center that held everything in place.

People who were supposed to function in the roles designated for them in the health

emergency management system did not show up, so others were assigned to take

over (DOH, 2008). One informant narrated that they were operating in silos with no

overall coordination. Ad hoc structures and processes took over in the absence of

clear leadership structure and organization. Similarly, informants from the private

case hospital narrated a similar approach to preparations for the typhoon. The

management committee of the hospital met a day prior to Typhoon Haiyan to discuss

preparations. Emergency measures were discussed during the meeting like allowing

the hospital to be used as an evacuation center, and preparations for the transfer of

patients from the top floor to the ground floor in case the roofs were destroyed. But

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 these measures did not withstand the violent winds and devastating surges when the

typhoon made landfall in the city. The scene inside the hospital was chaotic, as

people from the nearby community sought refuge in the hospital. The internal crisis

generated by the typhoon made it difficult for the hospital to resume operations until

an external partner (i.e. MSF) took over its facilities and offered emergency health

services.

3.2.2 Adaptive capacity in choices and opportunities

Despite the abovementioned challenges in the immediate period before and after the
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disaster struck, both case hospitals showed resilience in terms of continued delivery

of health services, albeit with different outcomes in the long term. Themes on

adaptive capacity emerged from the stories of resilience during Typhoon Haiyan.

Factors identified by key informants as key in the recovery of the hospital to deliver

health services were the following: commitment of staff and employees beyond the

call of duty, readiness to serve even amid terrible circumstances, ingenuity in the use

of remaining resources, and the presence of external support from the larger

community and other health sector partners who helped in many ways.

Workforce volunteerism was a major source of resilience. The public case

hospital never stopped functioning amid the disaster. Even though many did not

immediately return to work, about 20% of the staff went on duty, especially those

who were at the hospital at the time of the storm’s landfall who did not abandon their

posts. This was perceived as part of the resiliency of the hospital staff, rooted in the

local Filipino bayanihan tradition. As reported by informants, many medical staff

volunteered to stay in the hospitals for weeks so they could continuously deliver

emergency and urgent medical care to survivors. It was noted that many who stayed

were trained emergency medical technicians (EMT). The same phenomenon was

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 seen among non-medical staff. The dietary section continued to provide food not

only for the patients but for the staff as well. Despite the lack of resources and staff

at the dietary department, they provided food for all the people in the hospital—staff,

patients, and volunteers. They looked for and raised resources to provide support.

The same volunteerism was seen in the private hospital, where key

informants reported that all nurses and medical residents on duty during the typhoon

stayed on the following day to help in transferring patients and taking care of those

coming in. Despite extensive physical damage to the hospital, emergency health
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services like suturing, birth deliveries, first aid treatment, and cardio-pulmonary

resuscitation (CPR) procedures were given to disaster victims. One informant

proudly pointed out, “even if we were not trained, it was the commitment of the staff”

that made it possible to continue providing emergency medical services in the most

difficult circumstances. Nurses who struggled to survive by holding on to the railings

for three hours during the storm surges immediately went to the hospital to help right

after the typhoon. Such commitment to serve were shown by the staff to provide the

best care they could give under the circumstances. True to its founding mission to

help the sick and needy, the private case hospital provided services for free until

their remaining supplies were used up. Emergency service delivery was continued

by linking with partners ready and able to deliver the services for free.

Continued service delivery facilitated by external support. People on the

ground, most of them survivors, coordinated and facilitated the relief efforts of

organizations and groups coming in. Most of the resources poured into the recovery

and reconstruction efforts were sourced from institutional partnerships and

relationships between public hospital and donors. Due to the extensive damage

suffered by the private case hospital, the priority was to clean the premises in order

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 to deliver emergency health services. Staff assisted by soliciting help and networking

with other groups outside of the city to help the hospital and was facilitated by

extensive use of social media. When the MSF took over the private hospital to

provide emergency health services, conduct obstetrical deliveries and surgical

operations, many worked as volunteers and staff of the said international non-

government organization (INGO).

Health financing and available medical technology were contributory to quick

recovery. Public hospital staff were used to the challenges of working in a low-
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resource setting so that the impact to morale probably was not as bad compared to

those used to a high-resource environment. The public case hospital was the only

major hospital facility immediately operational and functional after the disaster, thus it

received a lot of resources from national partners and from the international donor

community. They had adequate resources to restore services to pre-disaster levels,

in fact even better than before in terms of medical equipment and financial

resources. Human resources were also rapidly brought back to adequate levels a

few weeks after the disaster, with teams of national and international health workers

augmenting the local workforce. The lack of such massive financing and provision of

medical technology and supplies forced the private hospital to cease operations

shortly after the disaster.

Partnerships and collaborations were essential to restoration of health

services. Many international relief and development organizations came and helped

the case public hospital. These included the United Nations Children's Fund

(UNICEF), Spanish Agency for International Development Cooperation (AECID),

Oxfam International (Oxfam) and multilateral institutions like United Nations

Population Fund (UNFPA) and World Health Organization (WHO). Both hard and

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 soft assistance in terms of resources and capacity training were provided. The WHO

initially held office in the public hospital, which offered many opportunities for the

case public hospital to develop strategic partnerships and collaborations. On the

other hand, there were several organizations who assisted in the recovery efforts of

the case private hospital. The major partner was MSF who took over the delivery of

health services. MSF employed staff of the hospital, gave jobs to local people and

provided services that were given to the community for free. The twinning initiative of

the DOH to assign an external partner to each hospital in the city was also deemed
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strategic by many informants. MSF was assigned to case private hospital through

this twinning strategy. Several NGOs also paired with the hospital to provide medical

services and clean water to the community for several weeks. Finances and medical

equipment were donated to the hospital to restore its capacity to function. Several

religious organizations sent volunteers and medicines for delivery of basic health

services. Support also came from the public sector as the city government and the

Korean government was instrumental in the effort to clean up the hospital from the

debris that covered it.

Information system strengthened by social networks and social capital. Most

of the partnerships and assistance offered to the public case hospital were forged at

the institutional level. As the end-receiver facility in the region, the hospital was in a

unique position to provide critical health services in the immediate aftermath of the

typhoon. It also provided the physical space and infrastructure for several national

and international health sector stakeholders to deploy their initial response to the

disaster. On the other hand, the private case hospital linked to donor community

through previous contacts, friendship networks and through connections with various

religious organizations. Social media was also a powerful tool to bring the situation of

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 the private case hospital to the attention of many people all over the world, not only

in the Philippines. The mass media was also instrumental because of the extensive

international coverage of the disaster.

4. Discussion

4.1 Comparison of resilience index in public vs. private hospital

A comparison of the hospital resilience scores between case public and private

hospital showed significant difference between them. Public hospital’s resilience

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index of .72 was higher compared to private hospital’s resilience index of .28.

The use of the hospital resilience index yielded the significant finding that

resilience scores of the two case hospitals were remarkably different. In almost all

domains, the public hospital scored higher compared to the private hospital. This

converged with the findings through face-to-face interviews that revealed how these

resilience measures played out in actual events as the disaster unfolded.

With regards the domain of hospital safety, component indicators were

generally non-existent in the private hospital compared to public hospital. It made the

private hospital more vulnerable to the impact of the storm surge compared to the

public hospital. The damage wrought by the storm surges on private hospital was

more severe compared to public hospital, forcing it to discharge all its patients a day

after the disaster and limiting its operations to outpatient care.

The domain of hospital disaster leadership and cooperation saw the public

hospital again with better indicators compared to private hospital. However, despite

the presence of an ICS for the public hospital, it was not fully operational and was

supplanted initially by external leadership structures. Case private hospital saw total

collapse of leadership in the aftermath of disaster with grave consequences for its

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 capacity to deliver services. This was the same case with the domain of hospital

disaster plan. Public hospital scored higher with private hospital missing on all

indicators except one—the disaster plan document. It was therefore not surprising

that the implementation of emergency protocols for the disaster was more ineffective

in the case private hospital. In terms of emergency stockpiles and supply

management, case private hospital failed to score in any indicators. This validated

the almost total loss of medical supplies and equipment during the disaster. Public

hospital fared better in terms of their supplies, partly because they were spared
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major losses during the storm surges. However, the initial surge of patients also

stretched their supplies.

Again, for both emergency staff and emergency critical care capability, public

hospital scored better in terms of indicators compared to private hospital. Thus,

delivery of health services was not disrupted in public hospital while private hospital

found it extremely challenging to provide continuous services. Public hospital was

also able to better manage its surge capacity compared to private hospital, with more

staff equipped and trained to respond during emergencies in disaster.

Overall, the public hospital scored better in terms of hospital preparedness

and appeared more resilient in the aftermath of the disaster compared to the private

hospital.

4.2 Lessons on hospital resilience

Both public and private case hospitals shared the following experiences, and realities

after the disaster. First, local hospitals were caught unprepared by the magnitude of

the disaster brought by Typhoon Haiyan, with existing disaster preparedness plans,

processes, and structures largely ineffective in dealing with the disaster aftermath.

Second, external resources in addition to the remaining internal resources were

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 critical in restoring health services in post-disaster settings and coping with the

patient surge. Third, hospital staff and departments often operated within silos

without any potent central structure connecting and coordinating the whole hospital

organization for a coherent post-disaster response, but the chaos was mitigated by

spontaneous internal self-organization driven by ad hoc leadership on the ground.

Fourth, a major realization by respondents was that the integration of disaster

preparedness into the life and culture of the hospital goes beyond drawing up plans

on paper and conduct of training workshops but must be built upon the daily life of
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the organization. Lastly, resilience and capacity to deliver emergency health services

amid disaster, was a dynamic process of coping with largely unforeseen challenges

embedded in existing social relationships located within specific socio-cultural

context that either facilitate or hinder recovery from the effects of disasters.

4.3 Recommendations to foster hospital resilience

Several recommendations with regards public health disaster preparedness can be

given based on this study. First, public health in disaster should be taken as the

responsibility of both public and private hospitals— thus the government needs to

fully support both public and private health facilities in the context of disasters.

During disaster, the distinction between private run health facilities and government

run facilities ceased to exist in terms of service delivery. Both function to provide free

emergency health services given the humanitarian imperative to save lives and

preserve health of vulnerable populations.

Second, flexibility and adaptability of disaster preparedness planning and

training to multiple disaster scenario should be the approach in fostering a climate

resilient health system. However, given the wide diversity of possible disaster that

can happen in one context, it seemed less effective to prepare for everything. Focus

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 should be heeded to high probability events with enough flexibility to adapt systems

and processes to any disaster that may happen.

Third, the conceptual construct of resilience should not be viewed as a static

concept in our theoretical framework of climate resilient health system, it should

rather be viewed as an emergent process. It is a dynamic concept of coping with

unexpected circumstances and contingent situations. As stressed by the

respondents, resiliency has many facets. There are external signs that can be seen,

but there are underlying processes as well that grounds capacity to respond in
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varying disaster situations.

Fourth, in the operational framework for health system resilience, strong

leadership and functioning governance structures should be considered as the hub

that holds the system together. In disaster context, parts of the organizations can

operate with zeal but chaos ensues if these is no proper coordination. The lack of a

central command structure that holds everything in place can drain the resources of

the organization that can best be utilized for better disaster response. As an

informant emphasized: “Although the DOH also set up their own incident command

post, HEMS (health emergency management system) also had their own command

post, there was no coordination. There should have only been one ICS.”

Lastly, the integration of disaster preparedness into the life and culture of the

hospital is necessary to make disaster preparations effective. One of the major

criticism about disaster planning is that often it is trapped into what is termed by a

respondent as a “paper plan syndrome”. It looks good on paper but there is no actual

possibility of implementing it, especially in the chaos of disaster and amid its

devastating impact on the lives of people and organizations.

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 5. Conclusions

Preliminary investigation showed the promise of using hospital resilience measures

to assess preparedness of health facilities to deliver health services in the aftermath

of disasters. Our study revealed that the case public hospital showed higher hospital

resilience index along the eight domains of hospital leadership, plan, stockpile,

safety, critical care, staff, training, and recovery. On the other hand, the private case

hospital showed lower scores along all domains of hospital resilience compared to

the public case hospital. It could be expected that given the lower resilience score of
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the private case hospital, case private hospital would find it difficult to deliver

emergency services to the affected communities. However, based on the narratives

of informants of their experiences during the disaster, it appeared that both public

and private case hospitals were initially able to deliver much needed emergency

health services in the aftermath of Typhoon Haiyan, even though both were severely

damaged by the unexpectedly high storm surges. It was in their capacity to deliver

long-term health services that they had different outcomes.

This suggests that beyond the hospital resilience index, other factors play a

role on capacity for sustained and long-term health service delivery amid disaster.

The public case hospital with help from both internal and external stakeholders

restored operations to normal or near normal levels a few weeks after the typhoon.

The private case hospital served the community for at least a week before running

out of medical supplies, financing, and human resources. The critical difference was

presence or absence of sustained support from the national government, and its

different agencies and development partners. Under the impact of a massive

disaster like Typhoon Haiyan, all the key indicators for hospital resilience become

dependent on the presence of a strong support system, particularly government

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 support. The impact of this support system will need to be considered in attempts to

measure and understand hospital resilience in disasters.

5.1 Limitations

This study on hospital resilience of two case hospitals, in the aftermath of Typhoon

Haiyan, is exploratory in nature. The retrospective design of the study made it prone

to recall bias. Further, the use of self-report measures for hospital resilience needs to

be validated by more objective measures. The lack of baseline pre-disaster

resilience indicators and the unpredictability of disasters could perhaps be

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addressed by a longitudinal study on hospital resilience in disasters in the future.

Acknowledgments

We would like to thank [masked for blind review] for the help in gathering data for

this study. Funding for this study was provided by [masked for blind review].

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 Author Biographies

Dr. Charlie E. Labarda, MD, is an Assistant Professor of Medicine in the School of

Health Sciences at the University of the Philippines-Manila, Philippines. Currently
pursuing a research PhD in The University of Hong Kong, his research interest is at
the interface of disaster public health, mental health and community health
behaviors. He is the corresponding author and can be contacted at:
charlslabarda@gmail.com
Dr. Meredith D. Labarda, MD, is an Assistant Professor of Medicine in the School of
Health Sciences at the University of Philippines, Philippines. She is currently doing
her doctoral studies on social development and health systems governance at the
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University of the Philippines-Diliman, Philippines.

Dr. Exaltacion E. Lamberte, PhD, is Research Fellow of the Social Development
Research Center and Scientist in Resident at the De La Salle University, Manila,
Philippines.

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 Figure 1. WHO Conceptual framework for health system resilience
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Source: WHO, 2015b

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 Downloaded by Cornell University Library At 07:08 08 July 2017 (PT)

Table 1. Hospital resilience index of case hospitals a

Domain (Number of indicators) Public hospital Private hospital

Composite scores

1. Hospital safety (14) 9 3

2. Hospital disaster leadership and cooperation (7) 7 4

3. Hospital disaster plan (7) 7 1

4. Emergency stockpiles and supply management (9) 4 0

5. Emergency staff (5) 3 2

6. Emergency critical care capability (31) 23 9

7. Emergency training and drills (14) 12 6

8. Recovery and reconstruction (15) 9 3

Total Score (102) 74 28

Hospital Resilience Index .72 .28

a
Based on domains of hospital resilience proposed by Zhong et al. (2014b)

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