Assessing Health and Education Services in the Aftermath of a Disaster

Elizabeth Frankenberg, Jed Friedman, Bondan Sikoki, Wayan Suriastini, Cecep Sumantri, Duncan Thomas, Fadia Saadah

RESULTS ARE EXTREMELY PRELIMINARY, DO NOT QUOTE OR CITE

The Earthquake and Tsunami December 26, 2004

• earthquake 9.3 (Richter scale)• epicenter 150 km from Aceh (Sumatra)• Displaced a trillion tons of water• Generated a tsunami surge that slammed into

Aceh (and coastlines in ten other countries)

GOAL: measure the immediate and longer-term impacts of the 2004 tsunami on mortality, health and economic status of the population in Sumatra, Indonesia, and on physical infrastructure and services

HOW: • Follow up respondents interviewed prior to the tsunami for five

years afterwards.• Respondents are from communities directly affected by the

tsunami and from “comparison” areas.• Satellite imagery provides a means of objectively assessing the

degree of destruction to the built and natural environment.• Interviews with community leaders and at health facilities,

schools, and markets provide data on the availability, price, and quality of services

Study of the Tsunami Aftermath and Recovery (STAR)

Gleebruk Village, before ……………and after the tsunami

Baseline Data

• National Socioeconomic Survey (SUSENAS) 2004, collected by Statistics Indonesia

• ~800,000 households throughout Indonesia

• Multi-topic, covers all household members

• Our target: 42,000 people in 600 communities

• Companion community and facility survey to characterize the infrastructure and services in respondents’ communities

Impact not the same everywhere!!

Damage Zones and STAR EAs

Some enumeration areas fall within the pink zone of damage, others are located very nearby but were not directly in harm’s way.

Local Area Affected or Unaffected?

None/Light: neither satellite measures nor STAR supervisors indicate tsunami affects

(344 communities, 25,000 people)

Moderate: no damage as measured by satellite, but early assessments by Indonesian government reported damage

(145 communities, 10,000 people)

Heavy: satellite data suggests inundation

(87 communities, 6,000 people)

Proportion Dead by Age, Sex, and Degree of Damage

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0-9 10-19 20-29 30-39 40-49 50-59 60+

Age Group

Pro

po

rtio

n D

ead

Heavily damaged

Moderately damaged

Baseline

---- Females

Males

Studying Service Delivery in the aftermath of a Disaster

• 2004 SUSENAS: households representative of the pre-tsunami population, in directly, indirectly, and unaffected areas

• Households are clustered in communities • We’d like to describe the environment before

and after the tsunami – The population’s access to services before the

tsunami– Changes in access after the tsunami– Characteristics of the services after the tsunami – Changes in facility quality and receipt of assistance

How do we build a picture of population access to services?

Construct community level lists based on HH respondents’ answers to questions about use/knowledge

Health facilities:

where respondents most recently sought outpatient care (or where they would go if no visit has been made)

Schools:

current/last school attended since November 2004

How do we build a picture of population access to services?

• Transfer each facility on that list to a “service availability roster”

• Ask the community leader whether each facility was – In use before the tsunami– Damaged or lost staff because of the tsunami– Temporarily closed (and reopened)– Travel time and cost to reach the facility

• Ask the community leader to add any other facilities that were in use before or after the tsunami, including any that have closed

Illustrative Results

• Only about 20% of the Community Facility data are in

• Results will change as more data become available

• What follows is based on information from 115 communities, 26 with significant tsunami damage

• And on information from 32 government health facilities and 69 schools in the directly affected sub-districts, 99 and 204 in the indirectly and unaffected sub-districts

Changes in community-level access to government health centers

% of communities in which facilities:

Directly affected

Indirectly/Unaffected

were damaged or destroyed 46% 29%

had staff killed 17% 0%

closed after the tsunami 50% 17%

that were closed all reopened 79% 97%

are “newly” in use 8% 10%

Changes in community-level access to elementary schools

% of communities in which facilities:

Directly affected

Indirectly/Unaffected

were damaged or destroyed 52% 30%

had staff killed 16% 0%

closed after the tsunami 72% 26%

that were closed all reopened 68% 99%

are “newly” in use 8% 0%

Service disruptions and provision of emergency services

% of communities with poorer access to:

Directly affected

Indirectly/Unaffected

primary health care 54% 15%

elementary schools 63% 22%

% of communities in which emergency services were put in place:

primary health care 42% 5%

elementary schools 17% 3%

GPS, GIS, and Location Information

• Once facilities are listed, they are visited and GPS data are collected so that their exact location can be pinpointed

• This information in combination with information on community locations (or locations of HH respondents) can be used to derive measures of distance

• All the spatial data can be organized using GIS, and additional features (roads, waterways, environmental parameters, etc) can be added

Drawing a Facility Sample and Conducting a Survey

• Household respondents’ answers to questions about the facilities they know about and use can serve as a sampling frame

• The fraction of listed facilities that are visited depends on resources

• Sample can cover multiple types of facilities (i.e. public and private)

STAR Facility Survey

• Separate sampling lists for government health centers, private health practices, community health posts, elementary schools, junior secondary schools, and senior secondary schools

• 2-3 of each per enumeration area• In Sumatra, facilities are sparse enough so that

for most facility types we will have a census

Government Health Centers Report on Worsening Facility Quality after the Tsunami

Conditions immediately after tsunami Directly affected

subdistricts Indirectly/ unaffected

subdistricts Staff shortages 22% 2% Condition of buildings 50% 9% Inadequate water 41% 8% Inadequate toilets 29% 5% Sterile conditions inadequate 26% 3% Drug supply 22% 7% Equipment supply 28% 7% Current infrastructure conditions Facility has electricity? 56% 78% Has piped water? 39% 63% Has interior water source? 56% 60% Has private toilet w/ septic tank? 69% 71% Has running waste water system? 75% 71%

Schools Report on Worsening Facility Quality after the Tsunami

Directly affected

subdistricts Indirectly/ unaffected

subdistricts Reduced # of teachers and staff 32% 7% Reduced training of teachers 25% 4% Impaired condition of building 59% 14% Books unavailable 46% 10% Other supplies unavailable 46% 9% Inadequate extracurricular infrastructure 36% 5% Inadequate water and hygiene 35% 9% Inadequate scholarship funds 15% 2%

Changes in Numbers of Students, Teachers, and StaffAll School Types

Before After Diff Directly affected subdistricts Number of students 381 343 -38 Student/teacher ratio 16 12 -4 Student/teacher and staff ratio 14 11 -3 Indirectly/unaffected subdistricts Number of students 367 411 44 Student/teacher ratio 13 17 4 Student/teacher and staff ratio 12 16 4