## Friday, December 28, 2018

### An incomplete guideline: Enabling India's health facilities to cope with disasters

by Supriya Krishnan.

Health facilities offer the first line of response in any disaster. Damage to hospitals impedes long-term recovery of victims. The recent floods in Kerala highlighted the frailty of health systems. The flood damaged a 125-year-old hospital that serves 3.5 lakh people. This was similar to the Chennai floods (2015) where 18 patients died due to a hospital power failure. The Gujarat earthquake (2001) collapsed a 281-bed civil hospital leading to 172 deaths. Such losses and lapses in health infrastructure are not a recent problem in India. Then, how are Indian states formulating plans to make their hospitals resilient?

### Resilient hospitals

The governance response to manage natural disasters in India is the Disaster Management Act 2005. The Act requires state governments to formulate state disaster management plans (SDMPs) to detail how to prepare, mitigate, respond and recover from disasters (Section 23). A component of these plans is medical preparedness and mass casualty management. When both time and resources are constrained, these SDMPs are essential for knowledge transmission to enable faster decision making. We review SDMPs of Indian states to study the inclusion of guidelines for disaster management of health facilities.

We utilized two recognised guidelines for resilient hospitals to review the SDMPs: 1) WHO indicators; and 2) India's national guidelines for hospital safety. In 2010, the World Health Organization (WHO) laid down indicators for "Safe Hospitals in Emergencies and Disasters". The indicators are made for countries to assess the vulnerabilities of existing health facilities and upgrade them to ensure continuous operations. WHO organises the indicators into three assessment checklists: Structural, Non-Structural and Functional. Countries are required to adapt actions in these checklists to suit their local context and protocol.

In 2016, the National Disaster Management Authority (NDMA) India laid down guidelines for Hospital Safety. These guidelines are in line with the WHO guidelines and build upon further requirements suitable for Indian frameworks for hospitals. To ensure a fair comparison of Indian SDMPs, the global indicators that were not addressed by any Indian SDMP have been excluded from the evaluation altogether. Based on the two documents (WHO, NDMA), the following list of indicators was chosen for assessment:

1. Structural: Indicators that enable the facility itself to withstand the shock from disasters such as design and engineering standards, location, compliance with fire codes and building materials.
2. Chosen indicators (2): Design codes; location/ land use.

3. Non-structural: Indicators for the smooth functioning of the facility following a crisis such as a lifeline equipment, architectural elements, service installations, handling of hazardous substances and general security of the facility.
4. Chosen indicators (1): Safety checklists.

5. Functional: Indicators that enable the facility to be fully operational to respond during disasters such as emergency procedures, site accessibility, communication and monitoring systems.
6. Chosen indicators (8): Equipment and supplies; Plans for emergency and disaster: Contingency Plan, Medical Preparedness Plan, Psycho-social care and mental health, Hospital networking, Mass casualty management; Human Resources: Emergency teams, training, and drills.

7. Others: Indicators not part of the WHO guidelines but present in most SDMPs to enable better management of health resources during a disaster.
8. Chosen indicators (8): Mobile hospitals; Media; District level data; Capacity of facilities; Standard Operating Procedures (SOPs) of departments in charge; GIS; list of hospitals; Use of National and State Disaster Resource Network (SDRN).

We studied SDMPs of 24 states that were available in the public domain on websites of State Disaster Management Authorities or allied departments (such as the Revenue Department).  The plans were text mined for keywords related to health like "hospitals", "health", "medical" and "casualty". Each paragraph containing any of the keywords was then evaluated against the above indicators to check for actions/guidelines for compliance. For each indicator addressed, one point was assigned to that plan document. The resulting scores are tabulated in this SDMP scoreboard spreadsheet. A map of India with state scores is presented below in Figure 1.

Figure 1: State-wise scores for the inclusion of health in State Disaster Management Plans (SDMPs)

### The current state of plans

A broad overview of SDMPs indicates the lack of a comprehensive framework to ensure the inclusion of relevant aspects. There are significant gaps in the style and comprehensiveness in drafting the plans. Hospitals are identified as critical lifelines but requirements for health are scattered throughout different sections for different SDMPs. Plans were also out of date. Even though the law requires states to update their plans annually, only 12 states had updated their plans till 2016. Plans dedicate the majority of their sections towards response to a disaster, rather than preparedness in their Standard Operating Procedures (SOPs). Jammu and Kashmir, Himachal Pradesh, Punjab and Meghalaya address the most indicators while Haryana, Jharkhand and Andhra Pradesh address less than half the chosen indicators. The following is a detailed evaluation per indicator:

Structural indicators: Structural indicators are the most communicated and find mention in 75% of the documents. E.g. Himachal Pradesh mentions that 48% of its medical institutions are located in highly vulnerable districts and must comply with codes of the Bureau of Indian Standards (BIS). Punjab recommends assigning a quality auditor agency to monitor construction in seismic zones 3,4 and 5 (medium to very high earthquake risk).

Non-structural indicators: Non-structural indicators are the least addressed in all documents. Less than 50% refer to even one of the indicators from the WHO Safe Hospitals indicators. Points on the safety of medical equipment, furniture, backup supplies are mentioned as part of larger checklists for response but most do not provide actionable points. The plans do not refer to any other universal guidelines that hospitals may follow for the safety of non-structural aspects.

Functional indicators: Functional indicators find a mention in 75% of the documents. All states recommend the preparation of a medical preparedness plan, mass casualty management plan and checklists to train health workers for emergencies. An essential requirement to enable functional continuity of hospitals during emergencies is a list of all available health facilities and supporting services (such as power station, police station, ambulances). A mere 45% of documents provide any information on health facilities in the state. Odisha highlights provisioning of a dedicated high tension power line to the district headquarters hospitals for uninterrupted communication with the health control room.

Other indicators: Other indicators such as mobile hospitals, media management and public relations, district-level data and SOPs are well addressed. 19 of the 24 states mention utilizing the India Disaster Resource Network (IDRN). It is an online portal that includes data of health professionals and medical equipment to accelerate decision making during a disaster. Assam and Gujarat have established a functional State Disaster Resource Network (SDRN). Some states elaborate on existing programs to strengthen their health systems to respond to disasters:

1. Assam: Study on the multi-hazard safety aspect of schools, hospital buildings in Guwahati City along with retrofitting solutions.
2. Gujarat: Safety audit of hospitals.
3. Jammu and Kashmir: Vulnerability assessment of hospitals; promote hazard resilient construction; and implement a disaster preparedness plan for hospitals.
4. Uttar Pradesh: Medical database for health facilities; resource management and identification of a medical incident command system.

### Level of detail in plans

The level of detail of a State Disaster Management Plan did not seem proportional to the disaster proneness of the state. Flood and earthquake-prone Uttarakhand, flood-prone Bihar and the recently flood-ravaged Kerala fair below average on the scoreboard.

The collapse of the civil hospital during the Bhuj earthquake triggered the last revision of the Indian Seismic Code for Earthquake Resistant Design of Structures (IS 1893: 2002). This has also improved the inclusion of structural indicators in most SDMPs as there is both legal mandates and evolved guidelines for health facilities to comply to.

Non-structural indicators have few or no guidelines in India. The NDMA guidelines on Hospital Safety (2016) elaborates on this in detail. But as a relatively recent document, it has not seen adoption in SDMPs yet. This needs more attention while formulating plans as non-structural safety includes a spectrum of indicators for equipment safety, power/water supply backups, architectural elements, fixtures, electrical installations etc that are essential to reduce service disruptions.

Functional indicators such as post-disaster psycho-social support and mental health find a mention in more than half the documents but Meghalaya is the only state with a detailed guideline. At least one-third of the survivors of the super-cyclone in the state of Odisha suffered disabling psychiatric symptoms. NDMA has recognised this issue as "a continuum of the interventions in disaster situations" and laid down guidelines on Psycho-social Support and Mental Health Services (PSSMHS) in Disasters (2009) that states may follow.

### Conclusion

While plans alone will not determine the quality of response to a disaster, lack of a well-drafted plan will reflect in poorly implemented practices when both time and resources are limited. In comparison with global frameworks, India's SDMPs need to improve inclusion of non-structural and functional indicators to better guide the resilience of health facilities. Our study pushes for the creation of a systematic methodology to evaluate plans to start filling these gaps. This mainstreaming of resilience is essential to reduce the negative consequences of a disaster and promote overall well-being. This is achievable through a systematic regulatory framework to evaluate and improve state disaster management plans and assign a value to documented processes.

### Data sources and analysis

1. Link to State Disaster Management Plans (SDMP) utilized for this study.
3. Link to the extracted lines relating to health from all State Disaster Management Plans.
Table 1: Compliance scoreboard for the top four and bottom four states (refer spreadsheet for details on each indicator)
State Structural (2) Non-structural (1) Functional (8) Others (8) Total score (20)
Jammu & Kashmir 2 1 6 7 16 (80%)
Himachal Pradesh 2 0 7 6 15 (75%)
Meghalaya 2 0 5 8 15 (75%)
Punjab 2 0 7 6 15 (75%)
Andhra Pradesh 1 0 4 2 7 (38%)
Jharkhand 0 0 2 4 6 (30%)
Haryana 0 0 0 3 3 (15%)

### References

EM-DAT. Emergency Events Database by Centre for Research on the Epidemiology of Disasters (CRED), Accessed on September, 2018.

ADB 2005. India Post Tsunami Recovery Program Preliminary Damage and Needs Assessment by Asian Development Bank, United Nations and World Bank, March 2005.

Hengesh, J.V., Lettis, W.R., Saikia C.K., et al., 2002. Bhuj, India Earthquake of January 26, 2001 Reconnaissance Report, Hengesh, J.V., Lettis, W.R., Saikia, C.K., Thio, H.K., Ichinose, G.A., Bodin, P., Polet, J., Somerville, P.G., Narula, P.L., Chaubey, S.K. and Sinha, S., Earthquake Spectra 2002

BIS 2002. Indian Standard Criteria for Earthquake Resistant Design of Structures IS 1893 (Part 1): 2002 by Bureau of Indian Standards, June 2002.

Gupta 2000. Cyclone and After: Managing Public Health Meena Gupta, Journal Article, Economic and Political Weekly, 2000.

WHO 2010. Safe Hospitals in Emergencies and Disasters, Technical Report, World Health Organization, 2010.

NDMA 2016. Guidelines: Hospital Safety, National Disaster Management Authority, Government of India, 2016.

IPHS 2012. IPHS Guidelines for District Hospitals, Indian Public Health Standards, Guidelines, 2012.

GHI. A disaster safety checklist for hospital administrators by GeoHazards International.

GoI 2005. Disaster Management Act 2005, Government of India, 2005.

NDMA 2007. Guidelines: Preparation of State Disaster Management Plans. National Disaster Management Authority, Government of India, July 2007.

Supriya Krishnan is a consultant with the United Nations Office for Disaster Risk Reduction and was previously a researcher at the National Institute for Public Finance and Policy. The author would like to thank Shubho Roy for valuable feedback and guidance through the writing of this blog.

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