SOCIAL SECTOR HEALTH PDNA GUIDELINES VOLUME B ii | HEALTH CONTENTS n ACRONYMS 1 n INTRODUCTION 3 n ESTABLISHING THE ASSESSMENT PROCESS 4 n PRE-DISASTER BASELINE 12 n ASSESSMENT OF THE DISASTER’S EFFECT ON THE HEALTH SECTOR 14 n DAMAGE AND LOSS DUE TO THE DISASTER 16 n ASSESSMENT OF DISASTER IMPACT 18 n CROSS-SECTORAL LINKAGES, INCLUDING CROSSCUTTING ISSUES 20 n THE HEALTH SECTOR RECOVERY STRATEGY 21 n ANNEX 1: STEPS FOR THE PDNA PROCESS FOR THE HEALTH SECTOR 32 n ANNEX 2: ANALYTICAL MATRIX BASED ON HEALTH SECTOR RESPONSE DOMAINS AND BUILDING BLOCKS 34 n ANNEX 3: WORKSHEET ON BASELINE UNIT COSTS FOR INFRASTRUCTURE AND ASSETS TO ESTIMATE DAMAGES (EXAMPLE) 42 n ANNEX 4: WORKSHEET ON BASELINE UNIT COSTS TO ESTIMATE LOSSES (EXAMPLE) 43 n ANNEX 5: DISTRICT DATA COLLECTION FORM (EXAMPLE) 44 n ANNEX 6: WORKSHEET TO ESTIMATE COSTS OF DAMAGES AND LOSSES (EXAMPLE) 45 n ANNEX 7: FORM TO CALCULATE LOSS OVER TIME IN THE HEALTH SECTOR (EXAMPLE) 48 n ANNEX 8: SAFE HOSPITAL INTERVENTIONS (EXAMPLES) 49 n ANNEX 9: DISASTER RISK REDUCTION AND PREPAREDNESS INTERVENTIONS (EXAMPLES) 50 n ANNEX 10: WORKSHEET FOR A RESULTS-BASED RECOVERY PLAN (EXAMPLE) 51 n ANNEX 11: GLOSSARY 51 n ANNEX 12: REFERENCES AND FURTHER READING 52 ACRONYMS AIDS Acquired Immune Deficiency Syndrome DRM Disaster Risk Management DRR Disaster Risk Reduction HIV Human Immunodeficiency Virus MDG Millennium Development Goals MOHS Ministry of Health PDNA Post Disaster Needs Assessment SGBV Sexual and gender-based violence 1 | HEALTH INTRODUCTION This document provides guidance to national and international stakeholders involved in the health sector during Post Disaster Needs Assessments (PDNA) processes and recovery planning. The guidance is based on applying an integrated approach when undertaking the PDNA process. An integrated approach involves taking the standard damage and loss assessment methodology and including a recovery strategy that puts special emphasis on the human condition. Updates and additional tools for PDNAs and guidance for recovery planning in the health sector can be found on the websites of the following organisations: • International Recovery Platform; • Pan American Health Organisation (PAHO); • United Nations Economic Commission for Latin America and the Caribbean (ECLAC); • World Bank Global Facility for Disaster Reduction and Recovery (GFDRR); and • World Health Organisation (WHO). This guidance brings together the four components needed for a comprehensive PDNA analysis, which are: 1. 1. health infrastructure and assets; 2. delivery of health services (including access to and changes in demand for services); 3. health governance processes; and 4. vulnerability and health risks of the affected population. These elements will be used consistently when describing the pre-disaster baseline, the effects of the disaster, the estimation of the economic value of damage and loss, the disaster’s impact on the economy and human de- velopment, and what is needed for a recovery and reconstruction strategy, including elements of building back better (referred to as BBB) and related costing. Building back better refers to the concept that recovery and reconstruction should not only aim at restoring the health system to its pre-disaster condition, but also should address underlying vulnerabilities that may have con- tributed to the extent of the disaster’s effects. Building back better aims to strengthen the resilience of the health system and communities so that they can better manage future disasters and their risks to the health sector. 2 | HEALTH ESTABLISHING THE ASSESSMENT PROCESS A MULTISECTORAL PROCESS When a country is affected by a disaster, the analysis of its effects and the formulation of the needs for recovery and reconstruction are done through a multisectoral process. This process helps to acknowledge the differences between sectors, but also their interdependency. Sectors and their accompanying sub-sectors are defined by the National Accounting Framework of a country. Broadly speaking, PDNAs often distinguish between three main groups of sectors: 1) productive, 2) social, and 3) infrastructure, and 4) cross-cutting. Health falls under the social sector, together with education, housing and culture. Nutrition is usually integrated under health. RECOVERY COORDINATION AND CONSULTATION The health sector PDNA process is led by the Ministry of Health (MoH). The first step is for the Minister of Health to designate a focal point to manage the health part of the PDNA and recovery process. The MoH recovery focal point will work together with the other sectoral focal points appointed by the government, which allows synergies with other sectors relevant to health. Depending on the national context, the recovery process may fall under a National Disaster Management Authority. If the MoH has a focal point responsible for health disaster risk management functions connected to the National Disaster Management Authority, this person may also be appointed as the focal point for recovery. The MoH recovery focal point will establish a health sector recovery coordination mechanism that allows mobil- isation of technical resources from relevant departments in the MoH and consultation with subnational health authorities. When a government requests external support for a PDNA process, the MoH recovery focal point will be supported by recovery experts from WHO, the World Bank and the European Union. A small Steering Group can be established with clear roles and responsibilities assigned to the various stakeholders. For examples of practical steps to take in managing the PDNA process, including timelines, see Annex 1. In addition to the United Nations, World Bank and European Union, it is important to involve all relevant health partners in the PDNA process, such as other United Nations agencies, development banks, donors, non-govern- mental organisations, faith and community based organisations, civil society, professional associations and the private sector. 3 | HEALTH LINK TO HEALTH SECTOR DEVELOPMENT COORDINATION If a national health sector development coordination mechanism exists - such as a sector-wide approach or an in- ternational health partnership - the recovery Focal Point should be connected to this group and the development partners need to be consulted to assist in the PDNA process. This ensures optimal harmonisation and alignment of the recovery strategy to national health policy and strategic planning. If such a sector-wide development co- ordination mechanism does not yet exist, the PDNA process can be used as an opportunity to initiate one. LINK TO HUMANITARIAN COORDINATION The PDNA process needs to be linked to national and subnational coordination for humanitarian responses. Since the humanitarian reform of 2005, national emergency coordination mechanisms are supported through the Inter-Agency Standing Committee’s Cluster Approach. It is particularly important to ensure that the PDNA builds on humanitarian assessments, as much as possible. Infor- mation collected to inform humanitarian responses (for example, a Multisectoral Initial Rapid Assessment (MIRA) or a Health Resources Availability Mapping System (HeRAMS) is also essential to inform the PDNA and recovery strategy. THE ASSESSMENT FRAMEWORK While the health sector part of the PDNA is harmonized with the other sectors, it makes use of existing, specific health system frameworks and assessment methods. This section describes how existing frameworks and meth- ods can be used to identify relevant issues that need be assessed to inform the various elements of the PDNA. THE HEALTH SYSTEM FRAMEWORK WHO, in the World Health Report 2000 and their 2007 framework for action Everybody’s Business: Strength- ening Health Systems to Improve Health Outcomes, defines the health sector as a system which “consists of all organisations, people and actions whose primary intent is to promote, restore or maintain health.” This includes efforts to influence determinants of health as well as more direct health-improving activities. According to WHO, a health system framework is made up of six building blocks, with a strong interdependence between the building blocks. These are: • service delivery: packages; delivery models; infrastructure; management; safety and quality; demand for care; • health workforce: national workforce policies and investment plans; advocacy; norms, standards and data; • information: facility and population based information and surveillance systems; global standards, tools; • medical products, vaccines and technologies: norms, standards, policies; reliable procure- ment; equitable access; quality; • financing: national health financing policies; tools and data on health expenditures; costing; and • leadership and governance: health sector policies; harmonisation and alignment; oversight and regulation. 4 | HEALTH THE WHO HEALTH SYSTEM NETWORK System Building Blocks Overall Goals/Outcomes Service Delivery Health Workforce Acess Imporved Health (Level and Equity) coverage Information Responsiveness Medical Products, Vaccines & Technologies Social and Financial Risk Protection Quality Financing Safety Improved Efficiency Leadership/Governance HEALTH SECTOR ASSESSMENT AND ANALYSIS FRAMEWORK Health sector analyses are based on the above health system framework. The health system framework is used in an assessment and analysis matrix that guides the health recovery team to establish: 1. a baseline; a systematic assessment of changes in the epidemiology of the burden of disease; the per- formance of the main health programmes; and 2. the six health system building blocks. It takes into consideration the assets, stakeholders and processes that are typically included in the sector and how these may be affected by a disaster. This enables analysis of how pre-existing performance and constraints may affect the requirements needed to restore access to essential services, meet new health needs and identify priorities for Building Back Better. Using the existing health system framework as a starting point allows linking recovery planning with longer-term national health development plans. HEALTH SECTOR RESPONSE DOMAINS Linked to service delivery, WHO lists a number of health sector response domains. These domains are: 1. general clinical services and essential trauma care; 2. child health (including treatment of malnutrition); 3. communicable diseases; 4. sexual and reproductive health (including STI and HIV/AIDS, maternal and newborn health and sexual violence); and 5. non-communicable diseases and mental health; and 6. environmental health. 5 | HEALTH The domains represent the main health programmes that should be taken into account when undertaking a PDNA to determine the pre-existing burden of disease related to each domain and how the disaster affected this. Also required is an assessment of the performance of health programmes that had been addressing the morbidity and how this capacity has been affected by the disaster. RISKS TO HEALTH AND SOCIAL DETERMINANTS OF HEALTH The health sector response domains can also be used to describe pre-existing risks that contribute to the related burden of disease. To determine the effect of the disaster on health risks, the analysis needs to include how these risks and determinants were affected by the disaster and if the disaster created new health risks. LINKING THE HEALTH SYSTEM FRAMEWORK WITH THE FOUR PDNA RECOVERY ELEMENTS The diagram below demonstrates how the components of the health system framework and the health sector response domains are linked to the four dimensions of a PDNA: 1) infrastructure; 2) Service Delivery; 3) gover- nance; and 4) risks. 1a Service Delivery; health programmes • General clinical services & trauma care • Child Health • Communicable diseases • Sexual & reproductive health Infrastructure and Assets • Non communicable diseases • Environmental health Service Delivery availability, access and demand 1b Service Delivery; Organisation and manage- Governance ment of services, incl. health network 2. Leadership governance Risks 3. Health information system 4. Human resources for health 5. Health financing 6. Medical products, vaccines & technology 6 | HEALTH HEALTH SECTOR ASSESSMENT AND ANALYSIS MATRIX The analytical matrix (see Table 1) provides a standardised and systematic protocol for collection and analysis of assessment data. Table 1: Analytical matrix for the health sector contribution to the recovery strategy Response Effect of for recovery, the including Baseline disaster, Key building Health programmes and health indicators, key Humanitarian indicators back better system functions pre-crisis chal- response for approaches, challenges lenges monitoring for the short, for early medium and recovery long term 1. (a) Service delivery - health programmes: • general clinical services and trauma care • child Health • communicable diseases • sexual and reproductive health • noncommunicable diseases and mental health • environmental health 1. (b) Service delivery - organisation and management of services, including the health network 2. Leadership and governance 3. Health information system 4. Human resources for health 5. Health financing 6. Medical products, vaccines and technology The matrix assists the assessment team to collect information that is aligned with key chapters of PDNA sectoral reports, such as the sector overview and baseline and disaster effect and recovery needs, including building back better approaches. The health sector team collects and provides information based on the best available data, evidence and/or professional judgements. Annex 2 provides examples of baseline data and indicators, common disaster effects, constraints and responses in relation to the immediate relief and early to medium recovery responses. WHO fact sheets on the health ef- fects of hazards are also a good resource (www.who.int/hac/techguidance/tools/WHO_strategy_hazards.pdf). 7 | HEALTH ASSESSMENTS EXISTING DATA AND INFORMATION A data collection strategy and gathering information for health sector recovery should be seen as a process and placed within a cycle of disaster management. Assessments and information gathering required for recovery should build on data collected even before the disaster happened - data available from the normal health information management systems and other re- ports, such as disaster preparedness reports. This available data can be used as pre-disaster baselines and to inform rapid assessments in the early humanitarian phase. The data should then become part of a monitoring system of health system performance that can also measure the progress of the humanitarian response and recovery activities. The scope and depth of the health sector assessment is constrained by the limited time in which it needs to be accomplished. Whenever possible evidence should be used; but it may also involve using the expert judgements of the team on the validity and accuracy of estimates. In particular for the estimates of costs, both for damage and loss, but also for the recovery plan, underlying assumptions and unit costs used in calculations need to be explained in a separate assumption sheet (see Annexes 3 and 4). SECONDARY AND PRIMARY DATA The assessment teams should make use of existing secondary data whenever possible, such as data that has al- ready been collected through humanitarian interventions, and decide which critical additional information needs to be collected specifically for the PDNA. Primary data collection is usually limited to purposefully selected field visits, to verify assumptions based on the secondary data review and to seek the perspective of health authorities and communities in the affected areas. SOURCES FOR ASSESSMENTS PDNAs are based on mixed assessment methods, as there is no single source or single method that can pro- vide all the necessary information. The main sources for the PDNA are key informants, for example, from the MoH and development partners, focus group discussions with stakeholders and relevant experts, health facili- ty-based information systems, observations, complemented by surveys of health facility performance and pop- ulation-based surveys. When surveys are appropriate, sampling will be purposive in the initial phases towards representative sampling in later phases (see: Operational Guidance for Coordinated Assessments in Humanitarian Crises. Inter-Agency Standing Committee, Needs Assessment Task Force, 2010). Annex 5 provides an example of data to be collect- ed from district health authorities on the effects of the disaster that is required to estimate damage and loss. Care must be taken to ensure that both women and men from the affected community can participate in assess- ments. There needs to be a gender balance of the assessment team conducting the interviews, as well as of the informants and participants in focus group discussions. If appropriate, separate, private interviews can be held with men and women and attention should be paid to the time and venue of the assessment, etc., to ensure that both genders can participate equally. The needs, priorities and interests of women and men of all ages as 8 | HEALTH well as sub-groups of the population should be identified through a gender and age analysis based on the rou- tine collection of qualitative sex and age disaggregated data and indicators, qualitative information sources and consultations and interviews with women and men in communities and among key stakeholders. RESOURCES AND DOCUMENTS TO CONSULT FOR ASSESSMENTS Key resources and documents for the baseline, as well as identification of pre-existing constraints, and to guide recovery priorities include: • the WHO statistics information system (see: www.who.int/whosis/en/); • national statistics and health information management system reports (including morbidity rates of the common diseases in the country and in the affected area for the past five years); • national health policy documents and annual health sector reviews; • national disaster preparedness plans; • available data from the MoH on location and capacity (such as numbers of beds, consultation rates, etc.) of both the public and private health infrastructure network, standards for health facili- ties, equipment and services, and their related unit costs; • a description of the health management system, including its financing sources (whether free med- ical attention is given and paid for by the government or whether individuals must pay themselves and/or with the help of medical insurance schemes) and annual government budget appropria- tions;the unit cost of the services supplied (including differences in unit costs between the private and public sector), such as the cost of an outpatient consultation, daily hospital admission, etc. • demographic health surveys and multi indicator cluster surveys; • vulnerability and risk assessment and mapping; • World Bank and UNDP Millennium Development Goal websites; • humanitarian assessments and surveillance reports (MIRA, Public Health Risk Assessments, Disease Early Warning Systems); • health strategies in the Inter-Agency Standing Committee Flash Appeal and/or the humanitarian strategic response plan; and • humanitarian general and health sector situation reports (humanitarian dashboard). For more on common indicators, see: • www.who.int/healthmetrics/tools/GFGuidanceOnRecommendedIndicators09.pdf • www.who.int/hac/global_health_cluster/guide/tools/en/index.html • www.who.int/hac/techguidance/tools/disrupted_sectors/en/index.html For more on humanitarian assessment methods for the health sector, refer to the WHO Health Cluster Guide: www.who.int/hac/network/global_health_cluster/guide/en/index.html. 9 | HEALTH HEALTH SECTOR OUTPUTS FOR INCLUSION IN THE PDNA The health sector assessment should have two outputs that are included in the larger PDNA document. The first is a summary of the health sector situation, requirements and proposed recovery startegy, which is usu- ally no more than three to four pages. The second output is a 15-20 page more detailed report from the as- sessment and a more detailed strategy for recovery. These reports typically include a set of tables or annexes (see Annexes 6 and 7). The time horizon for the recovery strategy is determined by the government, but usu- ally ranges from two to five years. The more extensive health sector recovery strategy and plan can be used as a basis for reviewing and revising, as required, provincial and district health plans in the areas affected. Examples of post-disaster health sector assessments and recovery plans can be found on the websites of the World Bank (www.gfdrr.org/node/118) and the International Recovery Platform (www.recoveryplatform.org/ resources/tools_and_guidelines). THE ASSESSMENT TEAM The health sector assessment team normally is headed by a designated leader from the MoH, and includes ex- perts from different professional disciplines as required for the assessment, and should be supported by experts from international organisations. In general, the team needs to have experts on public health and health systems, including medical doctors and epidemiologists, together with architects or civil engineers (that can estimate the value of damage to health infrastructure), and health economists that can estimate the value of production losses. Depending on the areas affected by the disaster, the subnational health authorities need to be involved in the assessment to ensure full access to information at all levels and to all locations in the affected areas, as well as to seek their views for the recovery strategy. An adequate gender balance of the assessment team needs to be ensured. One team member should be ap- pointed as the gender focal point and be responsible for coordinating findings with other teams and the gender advisor. This person should have prior experience with gender mainstreaming in the health sector. Health devel- opment partners will be offering assistance to support the health recovery assessment. A Steering Committee can be formed, inclusive of the most relevant stakeholders, to oversee the health recovery assessment process and ensure consultation with partners. Provisions for engagement with representatives of private health facilities should also be made, since in many countries the private sector share contributes significantly to the health in- frastructure and subsequent service delivery capacity. Transport for the assessment team is required to conduct site visits for direct observation and consultation with local health authorities and managers of affected health facilities. Transportation for the PDNA assessment should be supported by the development partners, so the national authorities can dedicate their transport ca- pacity to the emergency response. 10 | HEALTH PRE-DISASTER BASELINE This section describes how to create a health sector overview and a pre-disaster baseline and which key issues should be addressed under the four PDNA components. To estimate the effect of a disaster on the health sector, it is necessary to know what the health sector’s charac- teristics were prior to the event. Average unit costs for the various components of the PDNA need to be estab- lished in the baselines. Most of this information should be available before the disaster happens and be part of the disaster risk management and preparedness process. In this section the most important pre-disaster challenges and constraints for service delivery are highlighted. Further details can be found in Annex 2, under the column ‘pre-disaster baseline and challenges’. CONTEXT The baseline starts with a context analysis. This should include: • a description of the development status of the country (for example, the country’s ranking in the Human Development Index and health sections in Poverty Reduction Strategies); • the country’s progress in achieving health-related Millennium Development Goals; and the political context. INFRASTRUCTURE AND ASSETS The baseline describes health system-related infrastructures and assets, as listed below. The baseline should include data for the public, private not-for-profit and private for-profit sectors. • Description of the health network, including the locations and the levels of the health system (community, primary, secondary and tertiary levels) and referral mechanisms. • Data on numbers of the various levels of the health infrastructure (for example, based on Service Availability and Readiness Assessments). • Description of the physical infrastructures, including facilities for vertical health programmes, public health institutes, labouratories, pharmaceutical factories and warehouses. • Logistics of the health system, such as transport of patients and pharmaceuticals. • Administrative infrastructure for the health authorities. • Infrastructure for schools and universities for training health workers is usually included under tertiary education under the education sector. SERVICE DELIVERY, AVAILABILITY, ACCESS AND CHANGES IN DEMAND As part of the baseline, information related to service delivery should be described and can be broken down as follows: • Key health status and coverage indicators linked to the health sector response domains. 11 | HEALTH • The socio-demographic situation and the status of the main epidemiological indicators, including the morbidity incidence of diseases that are relevant to the type of disaster in question. • Availability and coverage of services can be described for the various health programmes and relat- ed to health status indicators, disaggregated by age and sex when relevant. • Focus on top five mortality and morbidity patterns. • Status and progress of health-related MDG indicators. • Key indicators linked to human resources for health, health financing and medical products and technology. Describe main constraints when these factors affect coverage and access to services. • Access, as defined by coverage and utilisation, as determined by affordability, financial and geo- graphical barriers, cultural barriers and quality of care. (Utilisation can be described by average consultation rates.) • Availability and coverage of essential packages of health services. GOVERNANCE To describe how the health system is governed, the baseline should describe the items below. • Organisation, management and regulatory functions of the health authorities for general service delivery. • Funding sources and mechanisms for the health sector. • Vision and mission statements from national health strategic plans and priorities for health sector reform. • Participatory governance mechanisms for health service provision and processes at all levels (nation- al to community level), including existence of complaint mechanisms for patients. • (Disaster) Laws and regulations affecting the access of segments or sub-groups of the population to certain health services, e.g. reproductive health services. • Coordination mechanisms for health development and humanitarian and disaster risk management. • Health sector preparedness plans. • Capacity to manage disaster response and recovery processes. • Functionality of health information management and early warning systems. RISKS AND VULNERABILITIES A pre-disaster baseline analyses the potential risks and vulnerabilities of the country’s health system. These include: • social determinants of health that could lead to increased marginalisation and discrimination in access to health services, including but not limited to poverty, ethnicity, religion and gender; pre- existing health risks, and types of disasters and presence of diseases with epidemic potential epi- demics that have occurred in the country, including sexual- and gender-based violence (SGBV); and • marginalised and/or disadvantaged sub-groups of the population with a special risk profile. 12 | HEALTH ASSESSMENT OF THE DISASTER’S EFFECT ON THE HEALTH SECTOR The section provides key considerations that will help analyse the effects on health and health sector perfor- mance linked to the four dimensions of PDNA, in both the public and private sectors, as well as the direct responses to mitigate these effects. In Annex 2, the column on ‘disaster effects’ provides further examples of effects of disasters on the health system building blocks and the health sector response domains, followed by typical humanitarian responses. GENERAL DESCRIPTION OF THE DISASTER The assessment begins with a general introduction describing the disaster, including the following information: • geographical scope, population affected, number of people dead and injured, the evolution till date, etc.; and • priorities for the immediate humanitarian response. EFFECTS ON INFRASTRUCTURE AND PHYSICAL ASSETS The disaster’s effects on the infrastructure and physical assets of the health system are then described, including: • physical damage to health system infrastructure (both total numbers and percentage against baselines of the various levels of health facilities, whether partially or fully damaged, disaggregated by administrative units, and including private and public facilities); physical damage to furniture, equipment and medical supplies; and • types and numbers of temporary health facilities established to replace damaged health facilities or in settlements of displaced populations. EFFECTS ON SERVICE DELIVERY, ACCESS AND DEMAND Answering the questions below will help to assess the effects of the disaster on service delivery, access and demand. • To what extent did the damage to infrastructure affect the functionality of the facilities and de- crease availability of health service delivery? • What is the effect of the disaster on morbidity patterns, in particular injuries, mental health (www. who.int/mental_health/emergencies/en/) and incidences and nature of SGBV? • How are health facilities in unaffected areas able to deal with trauma, SGBV and injuries, including capacity for transport and medical evacuations? • How do population movements influence the caseload for health facilities in unaffected areas that host displaced populations? • What are the direct effects on health workers (including displacement, deaths and disabilities) and indirect effects on the capacity to train health workers to address new and/or increased morbidity? 13 | HEALTH • What are the effects on the availability of pharmaceutical products? • How does the disaster affect the access to health services of women and men of all ages and sub- groups of the affected population? • How did the disaster affect the ‘ability to pay’ for access to health services for affected households and those that lost their livelihoods? • Are there new geographic barriers to access functional health facilities? • As a result of death, injury, displacement and migration caused by the disaster, household com- position may change. As women and men may have different mobility and levels of access to and control over income, specific attention must be paid to access to services of households newly headed by women, older people or children. EFFECTS ON GOVERNANCE AND SOCIAL PROCESSES Analyse how the disaster affected health sector governance and social processes by considering the questions below. • How did the disaster affect the capacity of the health authorities to manage health services? • How did the disaster affect the capacity of the health authorities to coordinate the humanitarian response and recovery process? • What capacities are brought to the disaster response through international aid agencies and how can this capacity be used to support the recovery process? • Are health information management systems affected by the disaster and are the health authori- ties able to establish early warning systems? EFFECTS ON RISKS AND VULNERABILITIES • When examining the disaster’s effects on health risks and vulnerabilities, be careful to consider the status of children, pregnant and lactating women, older persons, persons with disabilities and persons living with long-term or chronic illnesses. • What was the impact of the disaster on the health of women and men of all ages and sub-groups of the affected population? • Did the disaster affect the pre-existing health risks? • What are the new disaster-induced health risks that women and men of all ages, households and communities may face? • What are the increased risks for the transmission of communicable diseases (e.g., cholera, malar- ia, influenza, measles, TB), but also health risks due to the interruption of emergency and routine services, such as emergency obstetric care services and care for chronic and noncommunicable diseases (e.g., heart disease, diabetes, cancer, etc.). • Has the disaster exposed populations to SGBV? (SGBV can increase after disasters and during crises). 14 | HEALTH DAMAGE AND LOSS DUE TO THE DISASTER This section gives guidance on how to estimate the value of damages and losses to the health sector due to the disaster. Damage and loss valuation extracts from the section on effects of the disaster as a starting point. Iden- tify those elements that have financial implications, including damages to infrastructure and assets and losses due to changes in financial flows as linked to infrastructure, service delivery, governance and risks. Damage and loss should be disaggregated for public and private facilities. DAMAGE The damage analysis looks at health infrastructure including hospitals, health centres and other health sector-re- lated facilities, including health authority administration buildings, equipment and furniture and medical supplies. Damage is defined as the value of destroyed durable physical assets (buildings, equipment and machinery), replaced with the same characteristics and standards as prior to the disaster. In principle, assessment of infra- structure damage is done on a facility by facility basis, usually based on detailed estimates of numbers of square metres of the infrastructure damaged (disaggregated for roofing, floors, walls, etc.) with average unit costs per square meter for repair. When large numbers of health facilities are damaged in the disaster-affected area and it is not feasible to assess all damaged facilities separately, estimates of the numbers of partially and fully damaged health facilities are made. The estimate is based, for example, on reports from subnational health authorities and initial humanitar- ian assessments. The estimation uses the average estimated value based on standards for each type of health infrastructure and average costs for repair and rehabilitation of partially damaged facilities by type. The same applies for the value of damaged equipment, furniture and medical supplies. In principle, this should be based on a detailed assessment for each health facility against pre-disaster inventories. But in case of large numbers of affected health facilities, average estimates need to be made, for example as a percentage of full replacement costs against national standards. LOSS Loss refers to changes in the financial flows of the sector due to the temporary absence of infrastructure and assets and to increased or new demands for medical interventions for the affected population. Losses are mea- sured as the change in operational costs for the provision of post-disaster medical care. Operational costs post di- saster normally include higher expenditures over and above the normal budgetary appropriations for the health sector and lower revenues. Most interventions that involve increased expenditures are those that are managed as humanitarian response interventions to address the immediate consequences on health and health risks of the affected population. It is important to determine the time needed for rehabilitation and reconstruction of health facilities, not only for planning the reconstruction, but also as losses occur until reconstruction has been completed, and/or prevention or control of epidemics have been accomplished and health risks are back to pre-disaster levels. Annex 7 pro- vides a table to plan recovery interventions over time. 15 | HEALTH As mentioned earlier, an assumption sheet must be produced, explaining how unit costs were estimated and what other assumptions were made to calculate damage and loss. More details on the method to calculate the costs of damage and loss can be found in Damage, Loss and Needs Assessment: Guidance Notes, Volume 2, The World Bank, Global Facility for Disaster Reduction and Recovery. 2010. EXAMPLES Typical examples for damage and loss are found in table 2 below. Annexes 3 and 4 provide examples of tables for baseline unit costs and assumptions on damage and loss for the health sector as included in PDNA sector reports. Table 2: Typical elements included in an assessment of damage and loss Damage Changes in flows Infrastructure and assets 1. Increased expenditures for: • Buildings disaggregated by community, tertiary, infrastructure secondary and primary levels (hospitals, health cen- • remove debris, mud and other bio-hazardous materials from tres, clinics, dispensaries, pharmacies, health posts, the destroyed or damaged facilities blood banks, labouratories, etc.) • establish temporary health facilities or mobile clinics for • Equipment and furniture displacement settlements or in the vicinity of damaged • Medical supplies facilities until facilities are reconstructed • Transport and logistics, ambulances, etc. service delivery and access • Infrastructure of the Ministry of Health at national • treating increased number of patients due to new and/or and subnational levels increased health risks Notes: • additional cost per patient treated in alternative, temporary Ambulances are included under the secondary and medical facilities tertiary facilities. • long term medical treatment for disabilities and psychologi- Pharmaceutical factories are included under the indus- cal care of affected people try sector. governance Schools and universities for training health workers • costs for increased coordination needs, support manage- are usually included under tertiary education infra- ment capacity for service delivery structure in the education sector. The reduced ability • costs for establishing early warning systems to scale up health workers capacity may be a con- straint to service delivery. risk reduction • additional expenditures for surveillance and control of possible epidemics • health prevention campaigns, vaccinations, vector control, etc. • health promotion campaigns 2. Loss of revenue, due to: • interrupted service delivery in damaged facilities during the period of rehabilitation and/or reconstruction; and • temporary suspension of user fees for affected population. 16 | HEALTH ASSESSMENT OF DISASTER IMPACT MACRO-ECONOMIC IMPACT The macro-economic impact analysis includes an estimation of the disaster likely effects on economic per- formance and the temporary macro-economic imbalances that may arise, as well as the temporary decline in employment, income and well-being of affected individuals and households. To measure the impact on mac- ro-economic variables, analyses are usually made of the post disaster performance on gross domestic product, the balance of payments and the fiscal sector. For the health sector, an additional analysis can be done on the impact of the cost of damage and loss in relation to total health expenditures. The health sector assessment team should deliver the following estimates of values to the PDNA team members handling the economic impact analysis: • The higher number of medical attention provided to patients and the lower number of surgeries undertaken as a result of the disaster. This data will be used for the estimation of the disaster’s impact on the value and growth of gross domestic product. • The higher costs of monitoring morbidity rate increases and of preventive measures arising as a result of the disaster. This data will be used for the estimation of the disaster’s impact on the value and growth of gross domestic product. • The estimated recovery items (including items related to prevention and mitigation for the health sector) that must be imported from other countries in the absence of local production. This infor- mation will be used for the analysis on the balance of payments. • The estimated portion of the health sector reconstruction costs that will have to be imported from abroad due to not being produced locally, expressed in a percentage of the total estimated recon- struction needs. This information will be used for the impact analysis on the balance of payments. • The total value of higher government expenditures and lower revenues, over and above regular budget appropriations. This information will be used for the analysis of the fiscal sector impact. • Estimates of the higher-than-normal costs of obtaining medical or health care. This will be used for the analysis of personal or household impacts. THE HUMAN DEVELOPMENT IMPACT The human development impact is the difference between pre-disaster and post disaster levels of human de- velopment directly resulting from the disaster. The impact on human development is the disaster impact on the quality of human life in the medium and long term as measured through indexes, such as the Human Develop- ment Index, Gender Inequality Index, Multidimensional Poverty Index, the Millennium Development Goals and/ or the new Sustainable Development Goals. To estimate the human development impact of the disaster, it is useful to analyse: • the performance on human development components before the disaster utilizing a pre-crisis base- line (pre-disaster human development trends, including key challenges, and the salient features of the policies implemented pre-crisis that influenced the condition of human development for affected populations); and 17 | HEALTH • the consequences of the disaster effects indicating short, medium and long term implications through business as usual scenarios, worse case scenarios and/or best case scenarios, based on past performance had the disaster not occurred, utilizing clearly stated assumptions. When using the health-related MDGs, several indicators are difficult to measure over short periods of time, as the indicators were not designed as dynamic measures and are not sensitive to shocks, such as disasters. Health information systems may not provide required data at disaggregated level for the districts affected, such as maternal mortality ratios. However, data on other indicators, such as measles immunization coverage, antenatal care coverage, or HIV, TB and malaria patients with access to treatment, are part of a standard PDNA health assessment. Using this data to estimate impact on MDGs remains complicated. (Refer to Table 3 below). Service availability and access to health programmes are often interrupted during and after disasters, but usually not for long. Services may be quickly restored by the health authorities. When collection of user fees is suspend- ed for the affected population and when service delivery is supported by international aid agencies, access to services may actually be higher compared to pre-disaster levels. Table 3: Health-related MDGs, targets and indicators Goal 4: Reduce child mortality Target 4.A: 4.1 Under-five mortality rate Reduce by two-thirds, between 1990 4.2 Infant mortality rate and 2015, the under-five mortality rate 4.3 Proportion of one-year-old children immunized against measles Goal 5: Improve maternal health Target 5.A: 5.1 Maternal mortality ratio Reduce by three quarters, between 1990 5.2 Proportion of births attended by skilled health personnel and 2015, the maternal mortality ratio Target 5.B: 5.3 Contraceptive prevalence rate Achieve, by 2015, universal access to 5.4 Adolescent birth rate reproductive health 5.5 Antenatal care coverage (at least one visit and at least four visits) 5.6 Unmet need for family planning Goal 6: Combat HIV/AIDS, malaria and other diseases Target 6.A: 6.1 HIV prevalence among population aged 15-24 years Have halted by 2015 and begun to 6.2 Condom use at last high-risk sex reverse the spread of HIV/AIDS 6.3 Proportion of population aged 15-24 years with comprehensive correct knowledge of HIV/AIDS 6.4 Ratio of school attendance of orphans to school attendance of non-orphans aged 10-14 years Target 6.B: 6.5 Proportion of population with advanced HIV infection with access Achieve, by 2010, universal access to to antiretroviral drugs treatment for HIV/AIDS Target 6.C: 6.6 Incidence and death rates associated with malaria Have halted by 2015 and begun to 6.7 Proportion of children under 5 sleeping under insecticide-treated reverse the incidence of malaria and bed nets other major diseases 6.8 Proportion of children under 5 with fever who are treated with appropriate anti-malarial drugs 6.9 Incidence, prevalence and death rates associated with tuberculosis 6.10 Proportion of tuberculosis cases detected and cured under directly observed treatment short course 18 | HEALTH CROSS-SECTORAL LINKAGES, INCLUDING CROSSCUTTING ISSUES Intersectoral discussions should take place during all phases of the PDNA. Standards should be agreed upon, particularly on key dimensions such as administrative boundaries, place names and some of their key attributes such as demographics, which will provide a solid basis for data comparability and cross-sectoral analysis. Health sector specialists need to work closely with environmental health (water and sanitation), nutrition and food security, housing and education, and age and gender specialists. These sectors are relevant to health; and conversely health considerations need to be integrated into these sectors. Furthermore, clarification of which sector aspects are addressed in other sectors helps to avoid double counting. For example, damage to health training facilities is usually included under the education sector. Crosscutting issues relevant for health include the status of children, pregnant and lactating women, the elderly, persons with disabilities and persons living with long-term or chronic illnesses such as HIV/AIDS. In addi- tion, there are also social determinants to be considered that could lead to increased vulnerability. These include the conditions in which people are born, grow, live, work and age. These usually include poverty, ethnicity and religion. Crosscutting issues and gender and age analysis are integrated as relevant in the four components un- der the pre-disaster baseline, disaster effects and recovery strategy. In disaster situations, people are affected differently based on gender and age, and each category may have different resources available and different coping strategies. Available data suggests that there is a pattern of gender differentiation at all levels of the disaster process: exposure to risk, risk perception, preparedness, re- sponse, physical impact, psychological impact, recovery and reconstruction. Women, older persons and children - particularly girls - may face increased risks to adverse health effects and vi- olence due to their possible dependence on others, limited mobility, etc. They may be unable to access assistance safely and, therefore, often require different relief and recovery efforts and approaches. Additionally, females are often insufficiently included in community consultation and decision-making processes, resulting in their needs not being identified and met. Different age groups will also be affected differently and will have varying needs. Older people can be particu- larly vulnerable. For example, of those who died in the wake of Hurricane Katrina in 2005, 71 percent were 60 years and older. Advanced age can result in decreases in mobility, sight, hearing and muscle strength, as well as greater vulnerability to heat and cold. Chronic diseases common to older age, such as coronary heart disease, hypertension, diabetes and respiratory disease, can worsen when treatment is interrupted. 19 | HEALTH THE HEALTH SECTOR RECOVERY STRATEGY This section provides guidance on how to develop and present the health sector recovery strategy. When pos- sible, the health sector recovery strategy should be harmonized with the country’s existing health sector de- velopment plan, while taking into account pre-disaster vulnerabilities, post disaster conditions and stakeholder consultations. SECTOR RECOVERY VISION AND GUIDING PRINCIPLES The recovery vision is developed jointly during the consultative process, which ensures the support of key stakeholders for the recovery strategy. The recovery vision serves as a guide for the recovery process and provides the overall direction and ‘end state’ that the stakeholders desire to achieve. The overall goal of health system recovery is to build the health system back and even make it better so as to contribute to a reduction in morbidity and mortality and improve the health status of the disaster-affected pop- ulation. Health system recovery aims to strengthen and build upon humanitarian activities, while also correcting those aspects of the system that allowed for the negative impacts of the disaster on the health system in the first place. This means the system will have safer infrastructure, be better prepared for key public health hazards and future disasters and provide equitable and affordable services to all. The key reference that should inform the recovery vision is the national health strategic plan. Significant pre-di- saster constraints in the performance of the health system need to be taken into account, and planning for re- covery should include further analysis to address these constraints. If there are ambitions for health sector reform formulated in the national health strategic plan, they need to be reflected in the recovery process. At times, the recovery process is used to accelerate the introduction of health sector reforms. The enthusiasm for reconstruction may be high, the generosity of donors may be considerable and resistance to change reduced. However, stakeholders involved in PDNAs should be cautious with using this ‘window of opportunity’ to in- troduce institutional and regulatory reforms or to aim for significant improvements in a short recovery period. Reform goals must be balanced with what can be practically achieved in the context of the disaster recovery period. While expectations may run high, there is limited evidence that major reforms in such contexts works. Furthermore, there are risks of being encouraged to introduce new policy approaches by international consul- tants or influential donors that may not be appropriate or realistic. The below guiding principles apply to the recovery process in the health sector.Government commitment, leadership and ownership at all levels are critical for successful health system recovery. • Governments can use the recovery process to strengthen their capacity. • Planning health system recovery should start early, in parallel with the humanitarian response. • Health system recovery plans should reflect the priorities and concerns of affected communities and focus on the most vulnerable and most affected. • Adopt a health system approach using the six health system building blocks. 20 | HEALTH • Ensure that the recovery plans stay connected to development coordination processes and that the recovery plans take into account national strategies on health development and poverty reduction. • Ensure continual coordination with other sectors. • Throughout the process, maintain synergies with humanitarian actions. • Work in partnership with civil society, donors, non-governmental organisations, the World Bank, other United Nations agencies and the private sector. • Use the disaster as an opportunity to reinforce national capacities for disaster risk management and disaster risk reduction. RECONSTRUCTION AND RECOVERY NEEDS, INCLUDING BUILDING BACK BETTER This section provides guidance on how to define needs for reconstruction and recovery. R During the PDNA, it is important to conduct inter-sectoral consultations to avoid double counting in the identification of recovery needs and costs (see the World Bank’s GFDRR Damage, Loss and Needs Assessment Guidance Notes, Volume 3). The analysis of recovery and reconstruction needs aims at restoring the situation at least to pre-disaster levels, and also identifies needs and opportunities for building back better approaches. Building back better implies enhancing the health infrastructure’s resilience to disasters, improving access to services and goods, catalyzing the economy, supporting livelihoods, strengthening disaster risk management capacities of government and communities, and reducing risks and vulnerabilities to future disasters. While the recovery plan should be harmonized with existing national health development plans and any pro- posed sector reform reflected in these, the recovery plan cannot aim to include measures that address the full development objectives. Table 4 (below) summarizes the main effects of a disaster on the health system and recovery and reconstruction needs, including suggestions for ways to build back better. 21 | HEALTH Table 4: Disaster effects, recovery and reconstruction needs, including building back better Health Recovery and reconstruction needs Disaster effect Restore pre-disaster conditions Building back better Partial or full destruction of Establish temporary health structures Ensure all infrastructures are Infrastruc- health infrastructure and and possible mobile health units. hazard resilient. ture and assets. Reconstruct and repair destroyed Modernize and rationalize the assets and/or damaged heath infrastruc- health network. ture, replace assets lost. • Reduced availability of • Restore capacity to deliver • Address possible pre-existing health services and health services and procure constraints in capacity and disrupted procurement pharmaceuticals. performance of service delivery. of pharmaceuticals. • Provide additional capacity in • Adapt the health workforce and • Reduced access to and availability of services to meet availability of pharmaceuticals Service possible increased increased and possible new de- • Reduce pre-existing and new delivery, demand for health mands for services. access and inequities in access to health services delivery. • Ensure equitable access to health services. Improve utilisation demand service delivery and ensure utili- and reduce barriers for access, sation of services, in particular for taking into account reduced pre-existing and new vulnerable ability to pay. groups by reducing old and new barriers for access and utilisation. • Effects on capacity of • Restore governance role for service • Strengthen governance role of the health authorities delivery of health authorities at national health authorities to to manage service national and subnational level, better manage equitable delivery, including including community participation. service delivery and disaster community participation, • Manage the response and recovery risks, based on a disaster Governance and capacity to manage process and coordination mecha- risk management capacity the response and nisms, within the health sector and assessment, including health recovery process. between different sectors. information management and early warning systems. • Support health information management and early warning systems • Effects on pre-existing • Conduct targeted health pro- • Reduce vulnerabilities and risks risks to health, new motion and disease prevention to health, and support com- health risks caused by interventions to control and mit- munity resilience. the disaster, and effect igate impact of pre-existing and • Introduce longer term disaster Risks on the health status of new risks to health, reduce excess/ risk reduction interventions, the affected population. avoidable morbidity and mortality based on more detailed caused by the disaster. vulnerability and risk assessment and mapping. RECONSTRUCTION NEEDS FOR INFRASTRUCTURE AND ASSETS Infrastructure needs include the requirement to repair and/or reconstruct damaged infrastructure and repair or replace assets. Credit schemes can be considered for reconstruction and repair of private hospitals and other private health service-related facilities. For reconstruction needs related to building back better approaches, several elements can be taken into consideration, as seen below. 22 | HEALTH • Ensure that buildings are able to withstand future hazards and remain functional if or when the next disaster happens. A first step is ensuring adherence to building codes and retrofitting. The safe hospital approach, for example, proposes making hospital infrastructure more resilient to common hazards and conducting training of health staff in managing disaster responses, including mass casualty management (for examples of the interventions used in safe hospital programmes, see Annex 8). A more detailed assessment of the safety of health infrastructure is often not feasi- ble during the first three months after a disaster occurs, but such an assessment can be included in the recovery plan. • When standards for health infrastructure have changed, the reconstruction can be used as an opportunity for the ‘modernization’ of the health facilities. • The existing health network in the affected areas may need to be rationalized and streamlined to meet the changed needs because of population movements and changes in disease patterns. RECOVERY NEEDS FOR INFRASTRUCTURE, ASSETS AND SERVICES RESTORE TEMPORARY HEALTH INFRASTRUCTURE While waiting for more permanent reconstruction of health infrastructures, which can take up to several years, it is necessary to establish temporary structures. This can be done, for instance, by renting a building and/or ini- tiating mobile health units in the vicinity of damaged health facilities that are not functional and in displacement settlements or areas hosting large numbers of displaced persons where the capacity of the existing facilities is no longer sufficient. RESTORE SERVICE DELIVERY CAPACITY AND ENSURE ACCESS TO SERVICES The immediate need in the affected areas is to restore the capacity to deliver health services at community, primary and secondary care levels, to ensure that health workers can resume their duties, and to procure phar- maceuticals. Additional capacity may be needed to meet increased and possible new demands for services based on changes in disease patterns, such as trauma and mental health. Ensure that appropriate triage and referral systems exist for emergency medical, surgical, trauma and obstetric care. Primary health care services should be easily accessible to populations remaining in the affected areas and at temporary settlement sites, while secondary care services can be provided at appropriate sites. Health facilities in areas that receive significant numbers of internally displaced populations need to be strengthened to cope with the increased number of patients. The availability of essential packages of health services needs to be reviewed, as well as how these packages may need to be adapted to changes in disease profiles and an increased burden of disease, as is often seen after disasters. If infrastructure related to the production of pharmaceuticals has been destroyed, their production capacity will need to be restored as well as the functionality of the cold chain. For service delivery needs related to building back better approaches, several elements can be taken into consideration, as seen below. The availability and performance of service delivery may need to be improved to address possible increases or changes in morbidity. If capacity was insufficient before the disaster, and access had been limited for vulnerable groups, these constraints need to be addressed. 23 | HEALTH • The health workforce capacity can be adapted to meet priority gaps and new health demands, and packages can be offered that encourage staff to return to or be (re)deployed to the affected areas. • Efforts can be made not only to restore, but also to increase the national production capacity for pharmaceuticals. Also, regulations can be improved and better quality assurance mecha- nisms initiated. • Address the pre-existing constraints related to performance of and access to health services. As examples: -- reduce financial barriers to access services by, for example, suspending user fees for displaced persons and oth- er populations that have reduced ability to pay for health services as many may have lost assets and livelihoods due to the disaster. Identify planned initiatives to reduce financial barriers, such as programmes for free Mother and Child Health services, that may already have been introduced as part of the health sector reforms; -- reduce pre-existing and new inequities related to access by taking into account new and old differentiated vulnerabilities, needs and interests of women and men of all ages and sub-groups of the population, as well as findings from gender analyses; and -- repair roads and bridges that can allow access to still functioning health facilities, as this may make it unneces- sary to establish temporary facilities in affected areas. RESTORE AND STRENGTHENING GOVERNANCE CAPACITY, INCLUDING DISASTER RISK MANAGEMENT If it has been interrupted, the governance role for service delivery of the health authorities at national and sub- national level needs to be restored, including community participation as it existed prior to the disaster. This capacity is required to coordinate and manage the response and recovery processes. When large numbers of international health agencies enter the country to assist, these need to be registered nationally to ensure they meet national quality criteria. Furthermore, systems need to be put in place to ensure adequate and regular re- porting by national and international partners, adapted to the emergency conditions (for example, more regular reporting, using simplified reporting formats). This includes the activation of early warning systems. For governance related building back better needs, the recovery phase poses opportunities to strategy inte- grate or strengthen the existing national disaster risk management programme for the health sector, in coordina- tion with the national disaster management authorities. The recovery phase can be used to scale-up existing health systems to manage emergencies and to protect and increase the resilience of the health systems and communities. While the PDNA itself cannot do an in-depth assessment of disaster preparedness capacity and plans for disaster risk reduction, the recoverycan plan for such further analysis and include a budget to address obvious gaps. Other building back better initiatives may include the following: • Strengthen governance role of national health authorities to better manage equitable service delivery, including health information management and early warning systems. • Strengthen the role of communities in the management and planning of health services and support to community resilience. • Strengthen governance for disaster risk management, including updating of national disaster manage- ment laws. Depending on what is already known about the disaster risk management capacity of the MoH, a capacity assessment may need to be planned. This is often not feasible during the first three months after a disaster happened, but such an assessment can be included in the recovery plan. 24 | HEALTH • Revise and/or update preparedness plans and consolidate early warning systems. • If not already specifically mentioned in the national health strategic plan, ensure that disaster risk capaci- ty is included in the next Joint annual review and in the revision of the national health strategic plan. • Promote participatory processes and systems inclusive of women, girls, boys and men with national stakeholders. ADDRESSING HEALTH RISKS AND DISASTER RISK REDUCTION INTERVENTIONS FOR FUTURE RISKS The immediate need following a disaster is to control and mitigate the effects of pre-existing and new risks to health and to support community resilience. Risks need to be broken down in prevention and disaster risk reduc- tion programmes, into the following parts: 1. the probability of the risk occurring; 2. the severity of its consequences when it occurs; and 3. who is exposed to the risks and how. The PDNA analysis should examine the root causes of disaster, including the vulnerability of assets, sectors and communities to the related hazards. This should be based on in-depth vulnerability and risk assessment and mapping, when such analysis is available. To mitigate the most common risks, the below interventions should be undertaken: • Prevent disease outbreaks and ensure capacity for early detection and rapid response to public health emergencies by strengthening early warning systems and ensuring outbreak preparedness and prepositioning of supplies; • Resume vaccination services as soon as possible and consider mass vaccination in crowded settings, such as camps, or for other populations at increased risk; • Conduct vector control exercises and implement preventive measures to reduce the risk of vector-borne diseases; • Intensify community social mobilisation, including health risk communication, to promote safe water, sanitation and hygiene practices and key information messages. (For examples, see: www.cdacnet- work.org/i/20140728102420-genh0). Support adequate maternal and newborn health services, ensuring privacy and cultural sensitivity, with registration in camps, early detection of and referral for complications of pregnancy and childbirth, safe delivery and provision of relevant commodities; • Support appropriate infant and young child feeding, supplementation for pregnant and lactating mothers and management of malnutrition, including building health worker capacity and support- ing referral and hospital care for management of severe malnutrition in communities; • Ensure continuity of treatment for chronic diseases (communicable and noncommunicable); • Implement programmes that prevent and respond to sexual and gender-based violence. For further examples of disaster risk reduction and preparedness interventions, see Annex 9. 25 | HEALTH THE SECTOR RECOVERY PLAN PRIORITIZATION AND SEQUENCING OF RECOVERY NEEDS Following the rational of the recovery strategy, it is necessary to identify key outcomes, outputs and interven- tions based on the needs identified, then prioritise and sequence them over time (short, medium and long term) and distinguish those interventions that are related to restoring the situation as it was before the disaster from building back better interventions. This prioritisation and sequencing exercise should be based on a consultative process and should include, and The following considerations should be taken into account when conducting the prioritisation: • Be informed by and aligned with the national health development objectives, as reflected in, for example, national health development policies, poverty reduction strategies, etc. • Address and prioritise the key risks and vulnerabilities that contributed to the extent of disaster’s impact on communities, systems and infrastructure. Note those that can be avoided (an obvious example is that damaged infrastructure that is rebuilt according to proper building codes and disas- ter retrofitting is more likely to ensure continued services and protect investments in infrastructure reconstruction during future hazards). • When possible, building back better interventions should also have a positive contribution to the recovery from the current disaster. Post disaster health recovery needs often outweigh available resources and cannot aim to take on the entire na- tional health development agenda, hence the need to prioritise. The first group of priority interventions include those that will reconstruct damaged infrastructure, ensure access to services, restore governance and address health risks. Then priorities need to be established for interventions to building back better, as linked to these prior areas. Mostly prioritisation is done based on expert opinion consensus, but should not be driven by international ex- perts and development partners. Often in late stages of prioritisation, lobby groups or political interests may divert evidence-informed priorities. While discussions and arguments for prioritisation should be informed by available evidence, time usually does not allow in-depth ranking based on various methods of prioritisation, such as single criteria and multi-criteria decision analysis. The criteria for these prioritisation methods are listed below: Single criteria analysis 1. Burden of disease analysis (e.g., top ten morbidity and mortality) 2. Cost-effectiveness analysis 3. Equity and gender analysis Multi-criteria decision analysis (MCDA - ranking) 1. Population affected 2. Severity of the problem 26 | HEALTH 3. Ease of implementation of required interventions 4. Emergency situation 5. Burden of disease 6. Population vulnerability 7. Cost effectiveness With regards to sequencing, PDNAs usually have three timeframes: short, medium and long term. The short term or early recovery interventions overlap with the humanitarian response. For example, for the reconstruction of infrastructure, the period required for staged reconstruction of facilities and services needs to be estimated, taking into account existing construction sector capacity and replacement availability of specialised equipment. The humanitarian and recovery phase should ensure access to an essential health care package and public health programmes that reduce vulnerabilities and save lives. The reconstruction phase needs to restore and further develop service packages, ensure that the medium- to longer-term health consequences of the disaster are ad- dressed and build the health system back better. COSTING This section explains the logic of how costs for reconstruction and recovery are calculated based on the projected needs and offers realistic approaches to estimating the costs for building back better. All assumptions, possible formulas and references used for unit costs for each budget line item need to be made explicit, including for building back better, and attached as an annex to the sector chapter. The following considerations should be taken into account for costing:The total required budget should be real- istic and take into account the existing total health expenditures and absorption capacity of the health sector as to what is feasible to achieve over a period of three to five years. • The costs for building back better should be proportionate to the costs of recovery and reconstruc- tion needs, as well as the type of disaster (for instance, a slow onset drought may have very low reconstruction needs, but have high needs to invest in resilience and building back better). • The costs for building back better should be realistic compared to the government’s recovery bud- get and the financial envelope pledged by the government and international development part- ners. Building back better plans must take into account that a large percentage of the funds will be needed for physical reconstruction and compensation for losses, even though partially. • The costs for building back better should also be realistic in terms of the absorption capacity of the country. The difference between the cost of the proposed recovery and reconstruction needs and the value of the dam- age and loss should not become too large. (It is important to note that the value of recovery and reconstruction needs is not equal to the sum of damage and losses, it may be more or less.) For post-disaster donor pledging conferences, the development partners are accustomed to looking at the size of the damage and loss and pledging accordingly. There is usually little funding remaining for investments in improved access, improvement of governance performance and risk reduction measures. 27 | HEALTH Costing of infrastructure reconstruction is guided by the estimated value of damage, augmented by additional costs involved in the introduction of quality improvements, technological innovations and risk reduction measures. Reconstruction needs = value of damage + cost of (quality improvement + technological modernization + relocation, when needed + disaster risk reduction features + multi-annual inflation) To plan for the incremental costs to make the health infrastructure ‘all hazard’ resilient depends on the original structural design criteria for the buildings and on the degree of improvement in construction standards and norms, as defined in the reconstruction strategy adopted after the disaster. The additional costs have been found to range from 10 to 35 percent of the replacement cost. Structural and civil engineers who are familiar with disaster-resilient construction standards would be able to define the percentages. When relocation of a hospital or clinic to a safer area is required to reduce disaster risk, the additional cost of land acquisition and provision of water, sanitation, electricity and other utilities need to be taken into account. Furthermore, the reconstruction strategy may include a rationalization of the health network, taking into account possible population movements and opportunities for increased efficiency. This may make the costs for reconstruction either higher or lower. A scheme of structural retrofitting of hospitals and health facilities may also be required, to ensure that undam- aged or lightly-damaged units are able to withstand the impact of future disasters and to continue functioning uninterruptedly. The financial needs are estimated by specialised structural or civil engineers after defining the standards for retrofitting and the degree of disaster resilience to be achieved, particularly in the case of earth- quakes. Health facility safety is not limited to disaster resilient buildings. Not only must the buildings remain standing after a disaster, but the facility must remain fully functional and even be able to cope with increased numbers of patients. A comprehensive recovery plan for the health facility will encompass not only disaster resilience of buildings, but also focus on emergency preparedness at the level of the health facility, including response plan- ning and mobilisation of emergency medical response teams, training of health facility staff and conducting of simulation exercises. The action of individual hospitals should be integrated into a national programme to make hospitals safer and prepared for disasters. An indicative range of the required budget for the development of a national programme on safe and prepared hospitals (not including implementation of extensive structural or non-structural measures) is as follows: Risk assessment, including social economic assessment $50,000 - $200,000 Rapid assessment of safety of health facilities $50,000 - $200,000 per annum Implementation of a national safe hospitals programme $100,000 - $500,000 per annum Training and capacity development $30,000 - $100,000 per annum TOTAL $230,000 - $1million COSTING FOR HEALTH SECTOR RECOVERY The costs of providing health services under temporary conditions while damaged infrastructures are being repaired or rebuilt (in some cases taking several years) – whether it be the introduction of tent hospitals and clinics, rented premises or mobile services – must be carefully estimated. Additionally, funding is required for 28 | HEALTH re-establishing essential services, addressing crucial issues such as access and quality in the context of possibly increased morbidity and lower purchasing power, and support to governance and management capacity and to management of health risks. The costs for the basic recovery needs are guided by the value of estimated changes in flows, which cannot be covered by the regular budget of the government without negatively impacting the sector’s normal develop- ment activities. Recovery needs = estimated value of changes in flows over the total period until reconstruction is achieved - the amount of funds available in the government budget for this purpose The costing for investments related to building back better for the health system is more complicated and needs to take into account the building back better considerations mentioned earlier. For the purpose of the recovery plan, it is often not necessary or possible to do a detailed bottom up costing or to use formulas. Examples of recovery interventions and subsequent building back better approaches can be found in Table 4 and Annex 2. An assumption sheet is used to explain how cost estimates are made, including those for building back better (see Annexes 3 and 4). STRUCTURE OF THE RECOVERY PLAN In line with the PDNA guidance on a recovery strategy (in Volume A), the sector recovery plan should be for- mulated following a results-based model, and therefore include: 1) priority needs; 2) interventions required; 3) expected outputs; 4) recovery costs; and 5) intended outcomes. See Annex 10 for a table that may be used for a recovery plan. There is no blueprint for recovery planning. The depth of response analysis will be limited, largely due to time constraints. The PDNA can identify issues that need to be assessed and analysed in further detail at a later stage, before making more explicit policy and planning choices for which implications cannot yet be overseen. This includes, for example, the rationalizing of the health network when there have been major population move- ments, policy issues as human resource production and distribution, or health financing to address reduced capacity to pay. Possible policy responses need to be based on an analysis of the main constraints in the health system (see: WHO’s manual on Analysing Disrupted Health Sectors, Module 12: Formulating strategies for the recovery of a disrupted health sector and Annex 13, pages 382-385). Table 4 and Annex 2 include examples of typical early to longer term responses, based on previous PDNAs. The reconstruction and recovery plan for the health sector of the PDNA should follow the same main headings used to describe the effects of the disaster, and the interventions of the plan should be based on the priorities of the identified needs. Furthermore, expected outputs and outcome indicators need to be added. IMPLEMENTATION ARRANGEMENTS PARTNERSHIPS, COORDINATION AND MANAGEMENT The mechanisms that need to be in place for implementation of a health recovery strategy follow the same prin- cipals as discussed in section 1.2. Management of the health recovery strategy should be led by the MoH and be part of the multisectoral implementation by the government entity that has that mandate. 29 | HEALTH Depending on funding mechanisms, additional management structures may need to be established, for exam- ple, when multi-partner recovery funds are created (as was the case after the earthquake in Haiti in 2010). Implementation mechanisms should involve regional and district health authorities and ensure links with devel- opment partners, who can use the recovery strategy for updating and revising their national and subnational annual operational plans in areas significantly affected by the disaster. When revising district health plans, the recovery needs can be integrated to provide more detailed implementation plans that will link recovery to devel- opment, with bottom up budgets. During this process, it is realistic to expand consultations and involve subna- tional health authorities and communities. Many humanitarian health organisations offer assistance to a country after a major disaster. In addition to sup- porting life saving interventions, some humanitarian agencies will also support early recovery approaches and/or support recovery programmes of the MoH. Humanitarian health partners need to be informed about the PDNA, which they can use as guidance to integrate early recovery approaches into their humanitarian programmes to support the recovery process. MONITORING AND EVALUATION Establishing a monitoring system - if possible based on the existing health information management system - will allow assessing progress and effectiveness of the recovery interventions. The Monitoring and Evaluation (M&E) plan should: • focus on a few critical indicators; • have a clearly defined frequency and timeline; and • preferably be implemented by a multisectoral team comprised of surveyors and evaluators. For an example of such a monitoring system, see the Tsunami Recovery Impact Assessment and Monitoring System (http://whqlibdoc.who.int/hq/2006/a91183.pdf). A budget, usually 5-10 percent of the recovery and reconstruction budget, should be set aside for this purpose. RESOURCE MOBILISATION AND FUNDING MECHANISMS Reaching consensus on funding mechanisms often poses a major challenge during the recovery phase. Decid- ing which funding mechanisms to use should be based on the local context and aim at achieving the greatest efficiency. Such decisions begin with dialogue between the national government and international partners and consider the pros and cons of each proposed arrangement to arrive at a mechanism that is agreeable to all parties. Financial modalities are often influenced by a Financial Management Assessment done by the World Bank and the funding preferences of specific donors. The result is often a mix of on and off budget funding mechanisms, and may include pooled funding arrangements, such as Multi-Partner Recovery Trust Funds. The modalities chosen should support the governance role of the MoH in financial management. Adequate financial tracking mechanisms for pledges, disbursements and actual expenditures need to be established. 30 | HEALTH CHALLENGES TO SECTOR RECOVERY PLANNING AND IMPLEMENTATION • Some challenges to be aware of when planning the recovery and its implementation are below. • Focusing only on infrastructure and service delivery and neglecting the support components that enable access to services. • Embarking on ambitious investment plans, without a comprehensive analysis of absorption capacity and available resources. • Reproducing the same political and social systems that were at the root of the crisis, or not ad- dressing the underlying vulnerabilities and inequalities that may have contributed to the impact of the disaster. • Particularly when national policy making capacity is weak, international stakeholders pushing politically-oriented policy options or applying standard solutions that may have worked elsewhere but may not be appropriate for the country. • Working within a limited and often unrealistic timeframe, which leads to inadequate consultation with all stakeholders. • Unreliable and incomplete information is always a major challenge in countries in fragile situations. • The risk that the assessments and recovery planning are done in isolation, not sufficiently embedded in either the humanitarian coordination or linked to longer term development cooperation mechanisms. ANNEX 1: STEPS FOR THE PDNA PROCESS FOR THE HEALTH SECTOR When a disaster occurs: • Start collecting baseline information: this can be done in country, as well as remotely (off site); start filling in the analytical matrix with relevant information. • Establish a database of pre-existing health facilities. • Start collecting information on functionality/damage of health facilities. • Start collecting information on disease trends, pre-existing and possible new risks to health, previ- ous and new vulnerable groups, and response interventions done to mitigate health consequences of the disaster. • Collect relevant reports that describe the health system and its pre-disaster performance. • Prepare to send health recovery expert(s) to assist the country. When a PDNA is requested by government: • Government to appoint focal points in the ministries whose sectors will be included in the PDNA, this should include a recovery focal point in the MoH. 31 | HEALTH • World Bank, European Union and World Health Organisation health experts liaise with the MoH focal point.Establish a Steering Committee to oversee the PDNA process and divide tasks. • Prepare for training on the health component of the PDNA as part of the usual one-two day work- shop that formally initiates the PDNA, and train relevant stakeholders. • Call for a meeting with health development partners, identify key stakeholders that can assist in the assessment, and agree on how this group will be linked to recovery planning. • Present the PDNA process and objectives to the humanitarian health coordination body, identify humanitarian partners, including donors, with an interest and capacity to support the (early) recovery process. • Develop a time schedule, according to the overall deadlines of the PDNA, including: -- site visits to verify reports of damages; -- national and subnational workshops or focus group discussions with health authorities to discuss needs and constraints in health system functions and recovery needs and priorities; -- regular meetings of the Steering Committee; -- periodical engagement with other relevant sectors and crosscutting topics; -- periodical meetings with the humanitarian coordination mechanism; -- periodical reporting to the national health sector development coordination body; and -- validation workshop of first draft. • Assist the MoH to prepare for the donor conference, when this is organised. • Hold meetings with donors and government to advocate for the importance of health in the recovery strategy. • Include the MoH in the governing structures to manage the allocation of funds to and/or within the health sector. • Agree on financing and implementation modalities and establish an M&E system for health system recovery based on the recovery strategy. 32 | HEALTH 33 | ANNEX 2: ANALYTICAL MATRIX BASED ON HEALTH SECTOR RESPONSE DOMAINS HEALTH AND BUILDING BLOCKS Pre-disaster baselines and challenges - key Possible humanitarian Possible (early) recovery Disaster impact - key issues indicators responses response Crude mortality rate; Under 5mortality rate; Increased number of deaths due to Top five causes of mortality and Rehabilitation of disabled disability the immediate impact of the disaster morbidity to prioritise the health persons interventions and adjust these as Proportional mortality New health risks (e.g., potential morbidity patterns evolve over time Health outbreaks or interruption of services Life expectancy (by sex) outcomes for chronic diseases) Appropriate management of dead Morbidity patterns bodies (See Management of dead Effects on the health related MDGs bodies after disasters. A field man- ual for first responders. PAHO, WHO, ICRC and IFRC. 2006) Database of health facilities (e.g., SARA) Availability of health resources and (Re) establish provision of essen- Support to the decentralisation services: tial service package services: process when this is part of the Availability of functioning 24/7 referral system national health policy between levels of care Health facilities damaged/ de- cost per case/per capita per year stroyed, including equipment and Support to management of Average population covered by functioning health When necessary set up tempo- furniture and records health facilities facility by type of health facility and by administra- rary health facilities, and deploy tive unit Assess damage and loss medical brigades, supported by Repair of health facilities Service international assistance delivery 1: #of hospital beds per 10,000 population by admin Estimate reconstruction costs Replacement of damaged unit Support health facilities in areas health and medical equipment Organisation by type and extend of destruction that received high numbers of IDPs (based on the safe hospital and # of outpatient consultations per person per year ($) concept) by admin unit Temporary pre-hospital units management Effect on transport, logistics for to treat injuries, and/or medical Replacement of furniture # of consultations per clinician per day by admin unit supplies and referral between levels (including evacuation of care, including communication Relocation of facilities infrastructure, Cost per case (treatment, transportation, etc.) network, accessibility by roads that (Temporary) Increase outreach Re-establish blood banks equipment Costs for campaigns may be blocked, etc. services and transport) Review health network and Average revenue per patient Blood banks destroyed Make buffer emergency medical rationalize numbers, types and Proportional mortality supplies and emergency medical distribution of health facilities, Staff killed, injured or displaced teams available; establishment when appropriate # and % of health facilities that meet basic service Increased demand for health of semi-permanent structures, capacity standards services in unaffected areas due to mobile health units population movements 34 | Pre-disaster baselines and challenges - key Possible humanitarian Possible (early) recovery Disaster impact - key issues indicators responses response HEALTH # health facilities with Basic Emergency Service deliv- Obstetric Care (EmOC)/ ery 1: 500,000 population by administrative unit Organisation # health facilities with Comprehensive and EmOC/500,000 population by administrative unit management % of health facilities with availability of clinical management of rape survivors +EC +PEP (including infrastructure, % of births assisted by skilled attendant equipment and transport) (cont) Pre-disaster baselines and challenges - key Possible humanitarian Possible (early) recovery Disaster impact - key issues indicators responses response Service delivery 2: Health sector response domains Under-five mortality rate Increased child mortality/ Under Total cases of respiratory tract infec- Re-establish routine vaccination 5 mortality rate/ neonatal mor- tion + cost per case 2x/year de-worming campaigns Infant mortality rate tality Total cases of Under 5 diarrhoea + in schools Proportion of 1 year-old children immunized Disruption of routine vaccination cost per case Scale up Integrated Manage- against measles (and estimate of coverage 6 services Mass measles vaccination campaigns ment of Childhood Illnesses as months - 15 years) Increase in malnutrition/disease (combined with vitamin A and bed part of an essential package Child health Coverage of DPT3 in under 1 year by admin unit interactions among vulnerable nets, de-worming, etc.) of health services, including children a strengthened community Basic neonatal care for newborns component linked to deliveries in health facil- ities - see Minimum Initial Service Package (MISP) for EmOC 35 | Pre-disaster baselines and challenges - key Possible humanitarian Possible (early) recovery Disaster impact - key issues indicators responses response HEALTH Service delivery 2: Health sector response domains # of admissions to SFT and TFC (age/sex) Food shortage, lack of access to Incorporate vitamin A, zinc, and iron Growth monitoring food by vulnerable populations, foliate in ongoing immunization Nutrition programmes within Proportion/number of U5 with global acute reduced diversity in diets campaigns Integrated Management of malnutrition and severe acute malnutrition cases detected at the outpatient department/inpatient Changes in breastfeeding practic- Screening for malnutrition in health Childhood Illnesses department es as a result of the disaster facilities and population Prevalence of underweight children under- Treatment of malnutrition dis- Supplementary and therapeutic five years rupted by disaster feeding programmes Nutrition Proportion of population below minimum level of Increased risk of malnutrition Treatment of medical complications dietary energy (women, children and older of malnourished children persons) consumption Prevalence of global acute malnutrition + severe acute malnutrition. Level of food security based on IPC # or incidence rates for selected diseases relevant Increased incidence and Case Treatment of increased morbidity Community health education/ to the local context by age/sex. (cholera, measles, Fatality Rate, possible outbreaks promotion Reactive mass vaccination in epidem- acute meningitis, hemorrhagic fever, zoonotic ic settings (yellow fever epidemic, Restore or establish a compre- Treatment disruption for patients diseases, others) on ARV (including for PMTCT) meningitis epidemic, measles) hensive TB, malaria and HIV Case Fatality Rate for most common diseases and TB/DOTS control programme Disease control surveillance Incidence, prevalence and death rates or Case Increased risk of HIV transmission Preventive vaccination cam- Tracing and treatment of known TB Fatality Rates associated with tuberculosis paigns in risk areas (yellow increased risk of malaria patients fever, meningitis) # and proportion of tuberculosis cases detected (increased exposure due to loss Ensure appropriate HIV prevention and cured under directly observed treatment Further integration of verti- Communicable of homes, bed nets, etc. ) measures short course cal programming with other Diseases Total cases of typhoid/ fever + Tracing and provision of ART for services Incidence and Case Fatality Rates associated with cost per case people previously on treatment, malaria including PMTCT Total cases of diarrhoea + cost Proportion of children under 5 sleeping under per case Mass distribution of bed nets insecticide-treated bed nets Total cases of malaria/ dengue Environmental vector control (in Proportion of children under 5 with fever who are + cost per case prevention and crowded places) treated with control of disease outbreaks Establish standard precautions (dis- appropriate anti-malarial drugs tribution of hygiene kits, Provision of disinfectants; and safety boxes) 36 | Pre-disaster baselines and challenges - key Possible humanitarian Possible (early) recovery Disaster impact - key issues indicators responses response HEALTH Service delivery 2: Health sector response domains HIV prevalence among population aged 15-24 years # of patients on ART Condom use at last high-risk sex Communicable Proportion of population aged 15-24 years with Diseases comprehensive correct (cont) knowledge of HIV/AIDS Ratio of school attendance of orphans to school attendance of non orphans aged 10-14 years Proportion of population with advanced HIV infection with access to antiretroviral drugs % of births assisted by a skilled attendant Increased risk of maternal and Ensure provision of reproductive Ensure sustainable provision of infant mortality and mortality health services guaranteeing avail- MISP and beyond % expected deliveries by CS by admin unit ability of MISP and expanding as establish minimal availability for Increased risk of sexual and other # of cases or incidence of sexual possible forms of gender-based violence MISP, including EmOC violence (by sex and age) Clinical management of rape services Integration of interventions, in- Disruption in access to family Sexual and Maternal mortality ratio; fertility rate and EmOC (basic and comprehen- planning cluding antenatal care , PMTCT, reproductive sive) nutrition and immunization Contraceptive prevalence rate Disruption of PMTCT regimens health Financial protection maternity Adolescent birth rate for HIV+ pregnant women Strengthening of national family services: free access to deliveries, planning programme Antenatal care coverage (at least one visit and at EmOC, and follow up post-partum least four visits) Unmet need for family planning Prevalence of hypertension and diabetes, mental Interruption of treatment Ensure continuity of treatment for Re-establish data system for health, renal dialysis chronic diseases patients on treatment Patients lost for treatment of hypertension and diabetes, renal Tracing of patients cases on hyper- Strengthen home care for Non-communi- dialysis tension, diabetes and/or mental patients with chronic diseases cable diseases health treatment, renal dialysis (communicable and noncom- Worsening of diabetes and municable) hypertension status after disaster due to changes in diet and stress 37 | Pre-disaster baselines and challenges - key Possible humanitarian Possible (early) recovery Disaster impact - key issues indicators responses response HEALTH Service delivery 2: Health sector response domains % of population with severe or extreme difficul- Potentially high number of Treatment of injuries - prevention of Rehabilitation of persons with ties in functioning injuries long-term disability disability Increased # of people with # of total cases of injuries and cost Strengthen capacity for prosthe- disabilities per case ses and rehabilitation Untreated wounds and infec- Field hospitals, surgery and basic Disability care to be taken into tions of wounds are major public EmOC consideration in new health health problem, risks for tetanus system Injuries Set up referral mechanism, including international evacuation of patients Vaccination campaigns to include tetanus Amputations follow up care to be done at primary care level % of population with severe or extreme difficul- Interruption of treatment of Strengthen community self-help and Initiate development of sustain- ties in functioning mental health diseases social support able community mental health system : Severe disorder (e.g., psychosis, severe depression, Decrease in functioning Ensure access to psychological first severely disabling form of anxiety disorder): 2-3% On average prevalence of severe aid to people in acute distress build long-term, basic, sustain- able community mental health Mild or moderate mental disorder (e.g., mild and mental disorder increases 1% Ensure continuity of treatment, services in areas affected by moderate forms of depression and anxiety disor- managing new and pre-existing On average rates of mild or mod- emergencies ders, including mild and moderate Post-Traumatic erate mental disorder increases severe mental disorders in general Stress Disorder): 10% health care In districts without psychiatric Mental health 5-10% inpatient care, plans for new and psychoso- Address the safety, basic needs and Mild or moderate: 15-20% general hospitals as part of cial support rights of people in mental hospitals + health recovery investment cost per case should include considering planning for a staffed acute psychiatric care inpatient unit Include mental health in curricu- lum and of Primary Heath Care staff 38 | Pre-disaster baselines and challenges - key Possible humanitarian Possible (early) recovery Disaster impact - key issues indicators responses response HEALTH Service delivery 2: Health sector response domains Proportion of people with less than 15 litres of Destruction of clean water supply Provision of safe drinking water Drinking water supply resto- water/day ration to prevent the further Health hazards resulting from Provision of wastewater and solid spread of water-borne diseases % population urban/rural, access to improved stagnant waters and deteriorated waste disposal water sources and sanitation by sex water quality Reconstruction of wastewater Environmental vector control (in Environmental and solid waste disposal Distance to nearest water access point, by sex and crowded places) health age Disposal of medical waste Distance to nearest sanitation facility, by sex and age Disaster and emergency risk management capaci- Reduced national capacity to Coordination mechanism in the Link recovery planning to ties in the MoH respond to disaster acute response/leadership (humani- coordination with development tarian health cluster - government) partners (e.g., SWAp, IHP+, Existence of a health sector preparedness and Many stakeholders already UNDAF) response strategy document linked to national present, and new stakeholders Ensure adherence to national policies needs and priorities that includes the role of the entering, further challenging and guidelines by international actors Exit strategy for international lead and partner agencies health coordination humanitarian NGOs, and/or use Ensure/promote national ownership capacity of (I)NGOs to support Existence of a functioning coordination mecha- Governments likely to send recovery process and capacity nism at central level and subnational level within technical assistance/experts to building of district and central the health sector and crosscutting themes (from strengthen MoH functions for health authorities DRM and health sector development) longer term Integrating disaster risk reduc- Health sector policies and guidelines, standard MoH infrastructure and gover- tion and disaster management Leadership and operating procedures for response; oversight and nance capacity compromised in health strategy Governance regulation; governance capacity (loss of human resources, infrastructure and equipment Preparedness strategies and damaged) plans: identification of hazards, vulnerabilities and capacities, PDNA/Recovery Framework as hazard early warning systems, opportunity to guide new invest- established disaster risk man- ments coming 6-18 months agement, risk awareness and educational programmes for disaster and emergency risk, risk prevention and avoidance programmes and preparedness programme 39 | Pre-disaster baselines and challenges - key Possible humanitarian Possible (early) recovery Disaster impact - key issues indicators responses response HEALTH Service delivery 2: Health sector response domains National workforce policies and investment plans; Loss of workforce, health staff Replacing, strengthening, and/or Replacing/strengthening/reacti- human resource norms, standards and data; distri- affected by the disaster - (dis- reactivating workforce vating workforce bution and competencies of health workers placed, family members to care Financial incentives to re-activate the Reconstruction and reopening for, etc.) health workforce of training facilities Infrastructure for training/production of human resources for health and its capacity # of health workforce (doctor, Train and deploy community out- Adapt training programmes on nurse, midwife) per 10,000 reach workers (with a sex and age new relevant issues Supervision mechanisms population by admin unit (by balance) # of health workforce (doctor, nurse, midwife) per sex) remaining; effect of human Task shifting 10,000 population by admin unit (by sex) resources for health displacement Capacity building in first aid, Health Work- # of Community Health Workers per 10,000 by on distribution disaster preparedness, response force admin unit Damages in schools for health and recovery Annual number of graduates of health professions workers, # of training facilities from educational institutions per 100,000 popula- affected tion by level and field of education Damages to institutes of public health and research and effects on and capacities of training institutions National guidelines and formats for facility and Break down of information Strengthen early warning system, Re-establish routine health in- population based information and surveillance system and reduced analysis including disease surveillance formation system and reporting systems capacity for decision making by age and sex (as relevant) Coordinate information collection Information # of health facilities routinely collecting and re- and analysis by all partners Risk assessment, including porting relevant data hazards, vulnerabilities and capacities 40 | Pre-disaster baselines and challenges - key Possible humanitarian Possible (early) recovery Disaster impact - key issues indicators responses response HEALTH Service delivery 2: Health sector response domains National health financing policies Further loss of livelihood and Ensure health services and access Establish capacity to analyse reduced ability to pay for health to essential medicines are free of possible consequences on qual- Existence of user fee protection for those unable services charge at point of delivery in public ity and access when waiving to pay and private not-for-profit facilities: user fees Increased dependence on exter- Tools and data on health expenditures (national initially three months, then review nal funding Establish mechanism to com- health accounts) NB: Consider the effect of provid- pensate for loss of revenue, in Loss of revenue due to health Costing of services; financial barriers to access ing essential medicines free to the particular in private not-for- facilities rendered non functional, services; ability to pay, catastrophic health expen- private sector also, in particular if the profit, that work on the basis of and temporary waiving of user ditures private sector also waives or reduces cost recovery schemes fees External resources for health as a % of private service delivery fees. Creation of social solidarity or Financing Increased expenses for treat- expenditure on health emergency fund to finance ment, including due to increased Per capita total expenditure on health at average purchasing of services demand exchange rate Medium-long term reform of Increased costs for transport, etc. Per capita government expenditure on health at financing system, exploring average exchange rate (US$) different modalities of (mixed) prepayment mechanisms, Out-of-pocket expenditure as a % of private that include adequate social expenditure on health protection for health, and that includes all groups of service providers Access to essential medical products, vaccines Break down of supply chain and Provision of kits, medicines and med- Procurement of medicines, safe and technologies, assured quality, safety, efficacy, medical logistics ical inputs; replacement of drug kits, delivery kits, medical equipment norms, standards vital medicines and generators Damage to pharmaceutical fac- Existence of an essential medicine list that satisfies tories, pharmacies, warehouses, Advocate for application of national Reestablishment of the cold the priority health care needs of the population equipment and stocks essential medicine list by service chain and that is adequate for the competence level of providers Integrate access to essential (Inappropriate) drug donations Medical health workers Free access to medicines during the medicine within the new NB: consider effect on private products and National pharmaceutical infrastructure for produc- pharmacies when donated medi- emergency phase (first three months, financing modalities (including technology tion capacity and pharmacies then review) creation of social solidarity or cines are provided for free; emergency fund to finance pur- Procurement and supply chains; quality assurance; possible increase in sales of coun- Waiving of customs fees for medical chasing of services and essential drug donations guidelines; health transport and supplies for humanitarian partners terfeit medicines; medicines) logistics, warehouses, cold chain increase of traditional medicines; % of health facilities without stock out of a also due to lack of financial selected essential drug in four groups of drugs by resources admin unit 41 | ANNEX 3: WORKSHEET ON BASELINE UNIT COSTS FOR INFRASTRUCTURE HEALTH AND ASSETS TO ESTIMATE DAMAGES (EXAMPLE) Baseline unit costs for infrastructure and assets to estimate cost of damage in the health sector Type of Number Replacement Furniture, Equipment***, Medical supplies, Ownership Health center center* of units cost, US$ US$** US$ US$**** Public Private Full Destruction 1 2 3 Partial Damage 1 2 3 Totals Sources: * Define each type of center ** Define furniture in center, using standard lists and their costs for each type of health facility *** Define equipment, using standard lists and their costs for each type of health facility **** Define medical supplies, using standard lists of medical supplies and stocks for each type of health facility 42 | ANNEX 4: WORKSHEET ON BASELINE UNIT COSTS TO ESTIMATE HEALTH LOSSES (EXAMPLE) Estimated Baseline unit costs for loss estimation in Health Sector Assumptions Ownership Cost, US$ Provide ex- planation for Component Item Public Private each estimate of unit cost Infra- Demolition Average costs for demolition and rubble remval per type of health facility struc- and rubble ture removal Temporary Costs for tent or other temporary infrastructures for emergency hospital and other health facili- health facil- ties (both to replace damaged infrastructure, as well as additional facilities in IDP settlements) ities Average rental costs of temporary premises Ser- Costs for Transport of injured to other centers and average costs per injured patient vice temporary Overtime salary payment to staff de- increased livery health care Above-normal use of medical supplies and provision Costs per patient for medium to long term medical and psychological care access Average costs per patient for increased overall disaster related patient case load Duration of period with increased case load, and additional numbers of patients estimated per month Costs relat- Average costs per patient for which there was a revenue loss in health facilities, or people no ed to loss of longer able to pay health insurance premium revenue Duration and numbers of patients for revenue loss Gov- Costs for Average costs per admin unit in affected areas of staff and other resources required to man- er- additional age the response and recovery process, including community participation nance coordination Costs for disaster response and recovery management at national level and disaster manage- Cost of Early warning and alert systems to detect morbidity increases, and other temporary emer- ment needs gency related health information systems (per admin unit and/or standard # target population) Risks Interven- Costs for health promotion and public awareness campaigns (per admin unit and/or standard tions above # target population) normal Control of possible outbreaks costs, including for example vaccination campaigns (by each budget disease per admin unit and/or standard # target population) allocations to mitigate Vector control costs (for each intervention per admin unit and/or standard # target population) disaster related risks ANNEX 5: DISTRICT DATA COLLECTION FORM (EXAMPLE) Sector: Health Province: add province name District: add district name Data provided by: add staff name Data provided on: add date Number Medical Ownership Equipment*** Institution Baseline (and %) of supplies (no. or %) Furniture** Type Number Infrastruc- Totally Partially Destroyed Public Private ture Destroyed Damaged Hospital Health centre Health Clinic Blood Bank Dispensary Labouratory Mobile Healthcare Unit etc 3 Totals Estimation of Losses Duration of reconstruction period, months Cost of EWARN and surveillance: Cost of demolition and rubble removal Cost of health promotion campaigns: Higher expenditures for treatment of injured* Cost of vector control: Lower revenues for attending lower number of pa- Cost of prevention (vaccination, etc): tients Higher expenditures for increased case load: Pre-disaster morbidity, # Pre-Disaster number of patients: Post-Disaster morbidity, # Post-disaster number of patients: Increased morbidity, # Difference: Treatment cost per person Average cost of treatment per patient: Total estimated cost Loss of revenue: Duration of increased morbidity and/or outbreaks: 43 | HEALTH 44 | ANNEX 6: WORKSHEET TO ESTIMATE COSTS OF DAMAGES AND LOSSES (EXAMPLE) HEALTH Damage, million US$ Losses, million US$ Ownership Ownership Damage Public Private Losses Losses Public Private Infrastructure Estimation of Damage and assets a) Facilities fully destroyed Hospitals Health Centers Others b) Facilities partially destroyed Hospitals Health Centers Others c) Equipment d) Furniture e) Medications and supplies de- stroyed f) Other assets destroyed g) Summary of estimated damage, million US$ Estimation of Losses Cost of demolition and rubble Hospitals Infrastructure removal Creation of temporary facility Health Centers Renting temporary space for Others health facility Service Duration of reconstruction period, delivery and months access Higher expenditures for treatment of injured* 45 | Damage, million US$ Losses, million US$ Ownership Ownership HEALTH Damage Public Private Losses Losses Public Private Higher expenditures on patients referred to other facilities** Reduction of revenues due to Pre-Disaster number of patients paying temporary closure to patients in damaged/dysfunctional facilities Post-disaster number of patients paying Difference Average cost of treatment per patient, US$/person Loss of revenue Higher expenditures for overall Pre-Disaster total number of patients/ increased case load month Post-disaster total number of patients/ month Difference Average cost of treatment per patient Increased costs Reduced revenues in case of temporary waiving user fees, or reduced ability to pay health insur- ance premium Costs for additional coordination Average costs per admin unit in affected and disaster management needs areas of staff and other resources required Governance to manage the response and recovery pro- cess, including community participation Costs for disaster response and recovery management at national level, million US$ Cost of Early Warning systems to detect morbidity increases, and other temporary emergency related health information systems, million US$ 46 | Damage, million US$ Losses, million US$ Ownership Ownership HEALTH Damage Public Private Losses Losses Public Private Higher expenditures to mitigate Duration of period with increased risks for Risks disaster related risks outbreaks Cost of health promotion campaigns, million US$ Cost of vector control, million US$ Cost of prevention (vaccination, etc), million US$ Mitigation of other health risks as identi- fied Estimated summary of losses, million US$ * Physical and psychological injuries; cost over and above normal budget assignations, including personnel overtime when necessary ** Cost of transport and of treatment of injured sent to undamaged facilities, whether privately or publicly owned Additional Information for Macro-Economic Impact Estimation Per cent value of imported component for hospital reconstruction Per cent value of imported component for equipment and materials ANNEX 7: FORM TO CALCULATE LOSS OVER TIME IN THE HEALTH SECTOR (EXAMPLE) Loss per component Months after the disaster 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Total Duration of recovery period, months A. Loss of revenues 1. Pre-disaster number of patients 2. Post disaster number of patients (in damaged health facilities) 3. Lower number of patients, post disaster (1 - 2) 4. Average revenue per patient, $/ patient 5. Loss of revenue, $ (3 * 4) B. Costs of increased services 6. Increased cost of medical treat- ment of injured during emergency stage, $* 7.Increased costs of treatment due to increased morbidity, $ 8. Increased cost of medical treatment in higher cost, private facilities, $ 9. Increased cost of disease surveil- lance after disaster, $ 10. Increased cost of disease prevention and health promotion campaigns, $ 11. Increased cost of vector control campaigns, $ 12. Cost for long-term disability and psychological treatment, $ 13. Total increase in costs, $ (6 + 7 + 8 + 9 + 10 + 11 + 12) C. Other losses 14. Costs for demolition and clear- ing of debris 15. Costs for reinforcements of infrastructure, temporary facilities Total losses (5 + 13 + 14 + 15 + 16) 47 | HEALTH ANNEX 8: SAFE HOSPITAL INTERVENTIONS (EXAMPLES) • Development of comprehensive national policies as well as specific policies focusing on building safety and emergency preparedness of health facilities and staff. • Coordination of programmes related to the safety of health facilities and emergency preparedness in the ministry of health, other health agencies, emergency services and civil protection organisa- tions and other sectors, such as water, power, transport and communications. • Ensuring development proposals and plans for all new health facilities include hazard and vulnera- bility assessments. • Assessment of existing health facilities to identify the priorities for retrofitting and other action (e.g., by using the Hospital Safety Index). • Implementation of independent mechanisms to control and supervise infrastructure projects, such as by involving qualified professionals to work with a project team. • Development and application of comprehensive and integrated system design, including land-use planning, architectural design, and building codes standards for the development and maintenance of health facilities. • Guidance and promotion of best practices for: -- assessment and maintenance of safety of health facilities before and after disasters, including structural, non-structural and functional safety; -- emergency preparedness programmes in health facilities; -- multi-task training to manage basic life-saving emergency and surgical interventions; -- development of safe and resilient health facilities in safe locations; -- retrofitting and reconstruction of existing vulnerable facilities; -- safe working environments for health workers; and • Safe infrastructure for health facilities, including continuity of essential services for power, water and waste disposal, and of medical and health supplies of during times of emergency. • Development and delivery of training courses in safety and emergency preparedness in undergrad- uate, graduate and continuing professional courses, for construction, health and other sectors. • Case study development and promotion of good practices in safety and emergency preparedness of health facilities. 48 | HEALTH ANNEX 9: DISASTER RISK REDUCTION AND PREPAREDNESS INTERVENTIONS (EXAMPLES) • Integration of emergency and disaster management into legislative frameworks, policies and plans. • A multidisciplinary unit in the MoH with authority, capacity and resources to provide coordination of health emergency management activities at all levels within the health sector and with other sectors. • Risk assessments, including hazard identification and vulnerability (population and health system vulnerabilities) and capacity assessments in collabouration with the multisectoral disaster manage- ment authority. • National capacity development programme for health emergency and disaster risk management with necessary resources. • Health sector capacity to conduct risk awareness campaigns, including health education, health promotion and social mobilisation to reduce risks and prepare to respond to emergencies. • All hazards early warning systems which takes into account risks to public health and to the health sector. • Integration of disaster and emergency risk management into undergraduate, graduate and profes- sional education of health and relevant human resources for health and other sectors. • Programmes to reduce underlying risk factors (such as improving the safety and preparedness of health facilities). • Risk reduction and preparedness programmes for epidemic/pandemic disease prevention and control, reproductive health, mass casualty management systems, nutrition, environmental health, mental health and other noncommunicable diseases, maternal and child health, prevention of and service delivery for SGBV, and management of the dead and missing. • Health sector response and recovery planning and other elements of the preparedness pro- gramme, including pre-positioning of supplies and exercises to test plans, with other sectors. 49 | HEALTH ANNEX 10: WORKSHEET FOR A RESULTS-BASED RECOVERY PLAN (EXAMPLE) Expected Priority Interventions Recovery costs outputs Intended recovery Short- Medium- Long- Short- Medium- Long- outcomes needs term term term term term term By region To repair/rebuild damaged infrastructure and physical assets, and Build Back Better By region To resume service delivery and access to goods and services, and Build Back Better By region To restore governance and social processes, and Build Back Better By region To address immediate new risks, and disaster risk reduction ANNEX 11: GLOSSARY The definitions below are from the United Nations Office for Disaster Risk Reduction (UNISDR) 2009. DISASTER A serious disruption of the functioning of a community or a society involving widespread human, material, economic, or environ- mental losses and impacts which exceeds the ability of the affected community or society to cope using its own resources. DISASTER RISK The potential disaster losses, in lives, health status, livelihoods, assets and services, which could occur to a particular community or a society over some specified future time period. DISASTER RISK REDUCTION The concept and practice of reducing disaster risks through systematic efforts to analyse and manage the causal factors of disas- ters, including through reduced exposure to hazards, lessened vulnerability of people and property, wise management of land and the environment, and improved preparedness for adverse events. 50 | HEALTH RECOVERY The restoration, and improvement where appropriate, of facilities, livelihoods and living conditions of disaster-affected communi- ties, including efforts to reduce disaster risk factors. RESILIENCE The ability of a system, community or society exposed to hazards to resist, absorb, accommodate to and recover from the effects of a hazard in a timely and efficient manner, including through the preservation and restoration of its essential basic structures and functions. RESPONSE The provision of emergency services and public assistance during or immediately after a disaster in order to save lives, reduce health impacts, ensure public safety and meet the basic subsistence needs of the people affected. RETROFITTING Reinforcement or upgrading of existing structures to become more resistant and resilient to the damaging effects of hazards. ANNEX 12: REFERENCES AND FURTHER READING Health Metrics Network. Guidance on recommended Indicators for HIS Strengthening. www.who.int/healthmetrics/tools/ GFGuidanceOnRecommendedIndicators09.pdf Inter-Agency Standing Committee (IASC) (2008). Humanitarian Action and Older Persons: An essential brief for humani- tarian actors. IASC, Needs Assessment Task Force (2010). Operational Guidance for Coordinated Assessments in Humanitarian Crises. IASC Reference Group for Mental Health and Psychosocial Support in Emergency Settings (2010). Mental Health and Psy- chosocial Support in Humanitarian Emergencies: What Should Humanitarian Health Actors Know? Geneva, Pan American Health Organisation (PAHO) (2010). Health Sector Self-Assessment Tool for Disaster Risk Reduction. Wash- ington, D.C. PAHO, WHO, ICRC and IFRC (2006). Management of dead bodies after disasters. A field manual for first responders. United Nations Development Group (2009). Integrating Disaster Risk Reduction into the Common Country Assessment and United Nations Development Assistance Framework. Guidance Note for United Nations Country Teams, World Bank (2008). Data against natural disasters: establishing effective systems for relief, recovery and reconstruction. Editors Samia Amin and Markus Goldstein. World Bank GFDRR (2010). Damage, Loss and Needs Assessment guidance notes, volume 1, 2 and 3., World Bank (July 2008). Good Practice Notes 1 Health. World Health Organisation (WHO) (2009). Analysing Disrupted Health Sectors, Module 12: Formulating strategies for the recovery of a disrupted health sector.www.who.int/hac/techguidance/tools/disrupted_sectors/en/. WHO (2007). Everybody’s Business. Strengthening Health Systems to Improve Health Outcomes. WHO’s Framework for Action. http://whqlibdoc.who.int/publications/2007/9789241596077_eng.pdf. World Health Report (2000). Health Systems: Improving Performance. Guidance Note for Integration of Disaster Risk Reduction in Bank Projects in the Health Sector 16 March 2009. Work in progress. 51 | HEALTH WHO. Health Cluster Guide. A practical guide for country-level implementation of the Health Cluster.www.who.int/hac/ network/global_health_cluster/guide/en/index.html WHO. Global Health Cluster tools.www.who.int/hac/global_health_cluster/guide/tools/en/index.html. Further reading: Early Warning Systems, World Health Organisation www.who.int/csr/labepidemiology/projects/ewarn/en/ Emergency Risk Management for Health, World Health Organisation www.who.int/hac/techguidance/preparedness/en/index.html Hospitals Safe from Disasters, 2008-2009 World Disaster Reduction Campaign www.unisdr.org/2009/campaign/wdrc-2008-2009.html. The Hospital Safety Index, tool developed by the Pan American Health Organisation new.paho.org/disasters/index.php?option=com_content&task=view&id=964&Itemid=911 52 | HEALTH