Bangladesh - PreventionWeb

A Priority Implementation Partnership (PIP) between the Disaster Management Bureau (DMB), Ministry of Food and Disaster Management and the Ministry of Health and Family Welfare, Government of Bangladesh

Safer Health FacilitiesBa

nglad

esh Towards Mainstreaming

Disaster Risk Reduction into planning, design and construction of Health Facilities in Bangladesh

Under the Regional Consultative Committee on Disaster Management (RCC) Program on Mainstreaming Disaster Risk Reduction into Development in Asia.

Implemented by Supported byFacilitated by

Technical Group Members from

Disaster Management BureauMinistry of Health and Family WelfareMinistry of Food and Disaster ManagementMinistry of Housing and Public WorksMinistry of Planning

health_BangladeshD.indd 1 11/26/2009 12:46:00 PM

Health Sector a priority for Mainstreaming Disaster Risk Reduction

BACKGROUND

Protecting health facilities from impacts of disasters is essential for social and economic development. Thus the Regional Consultative Committee (RCC) on Disaster Management under its program on Mainstreaming Disaster Risk Reduction into Development (MDRD) has identified Health along with Infrastructure, Agriculture, Housing and Education as priority sectors to initiate mainstreaming disaster risk reduction (DRR).

In the RCC which comprises of heads of the National Disaster Management Offices of 26 Asian Countries, members had submitted expressions of interest to initiate mainstreaming DRR into particular sectors depending on the development priorities of their country.

Disaster Management Bureau (DMB) under the Ministry of Food and Disaster Management, Government of Bangladesh which is a member of the RCC, had expressed interest in initiating mainstreaming DRR into Health sector in partnership with Ministry of Health and Family Welfare (MoHFW). Accordingly in the second half of 2008, the Priority Implementation Partnership (PIP) was initiated by DMB with technical support from Asian Disaster Preparedness Centre (ADPC) and with financial support from Australian agency for International Development (AusAID).

HEALTH SECTOR IN BANGLADESH

Bangladesh is committed to achieving the Millennium Development Goals (MDGs) by 2015 and has been pursuing various programs to translate the MDGs into reality. This is reflected in the Draft National Health Policy (August, 2008) which emphasizes the need for further expansion and utilization of health services especially for the poor and the disadvantaged.

In Bangladesh, the largest service provider in the health sector is the Government. The MoHFW is the public authority responsible

for providing health care to the entire population. Over the past two decades, MoHFW has established a country–wide network of physical and organizational infrastructure to plan, manage, and deliver health services.

The organizational structure of the MoHFW follows the administrative set up of the country which is divided into six divisions, 64 districts, 481 upazila and 4,498 unions. Each union has nine wards and two to three villages constitute a ward. At the national level, the MoHFW is responsible for macro level policy, planning and decision making. Under MoHFW, there are two major implementation wings; the Directorate General of Health Services (DGHS) and the Directorate of Family Planning. The DGHS is responsible for implementation of all health programmes and providing technical guidance to the Ministry. There are also specific units/departments which are directly under the administration of MoHFW such as the Construction, Maintenance and Management Unit (CMMU).

The function of health facilities; hospitals and healthcare units is to provide specialized services, and accordingly the planning, design and construction process of these facilities should cater to such services. In the post-colonial period in Bangladesh, the buildings that served as health facilities and clinics were no different from other buildings in terms of space, meeting functional requirements or architectural expression. But with the sixties and the seventies, the trend of constructing specially designed healthcare facilities slowly initiated and the government’s


target was to upgrade and modernize the existing hospitals and establish new ones. However, as indicated above the old buildings which were being used as hospitals still continue to function but with deteriorated conditions. For example, the Dhaka Medical College caters to 1,500 beds whereas its original capacity was only 800. The condition of other divisional and specialized hospitals is similar.

Moreover, Bangladesh has a peculiar geomorphology, largely a delta, which is prone to cyclone, flood and rampant land erosion. Thus in many areas these health facilities are affected by natural hazards and cannot provide healthcare services during the hour of emergency. The Joint Damage,

Loss, and Needs Assessment undertaken by the Government of Bangladesh in the wake of Cyclone SIDR, estimated the total damage and losses caused by the cyclone to be of amount US$ 1.7 billion. Particularly in the Health & Nutrition sector both the damages and losses were estimated to be US$ 17.5 million. Source; SIDR, Damage, Loss, Need Assessment; March, 2008

Thus unless planning, design and construction standards take hazard resilient factors into consideration, the chances of impact of disasters on health facilities would continue. Thus DRR needs to be integrated in the planning, design and construction process of health facilities at all levels in the country.

Priority Implementation Partnership (PIP) a Process towards Mainstreaming Disaster

Risk Reduction

A MULTI – AGENCY TECHNICAL WORKING GROUP TAKES THE LEAD

The construction of public health facilities in Bangladesh involves a close collaboration of various agencies such as MoHFW and its DGHS and departments such as CMMU. If the size of the facility is above 100 beds, it requires the involvement of Ministry of Housing and Public Works. The Health Wing of the Socio-Economic and Infrastructure Division of Planning Commission of Ministry of Planning plays an important role in the approval process of health facilities.

Thus the PIP under the leadership of DMB brought together the relevant agencies to form the Technical Working Group (TWG). The membership of the TWG is shown in the adjacent Box 1.

Box 1 Technical Working GroupChairDirector General, Disaster Management Bureau, Ministry of Food and Disaster Management

MembersMinistry of Planning:• Social and Infrastructure Division, Planning

Commission

Ministry of Health and Family Welfare• Joint Secretary and Line Director,

Construction, Repair and Maintenance, Director, Planning and Research

• Directorate General of Health Services• Director, Hospital• Director, CDC• Program Manager, EPR• Deputy Director, CDC, • Chief Engineer, Construction Maintenance

and Management Unit• Director Planning, DMB• CMS, DMB• Deputy Chief, MoFDM

Ministry of Housing and Public Works• Head, Design Division• Deputy Chief Architect, Department of

Architecture

Technical Partners• ADPC• WHO


Box 2 Development Project Proposal

Part –A

Project Summary

• Project Title• Sponsoring Ministry and Division and

Executing agency• Objectives of the project• Location of the project• Estimated cost of the project (In lakh Taka)

and Exchange rate with date• Location wise cost breakdown to be

attached as per Annexure• Mode of financing with source• Project implementation period• Component and estimated cost summary• Log Frame• Proposed management setup and

procurement plan• Financial and physical target plan

Part-B

Project Detail

• Background objectives, priority, rationale, linkage, target and outputs / outcomes of the project including finding of feasibility study / survey if any

• Pre-appraisal / pre-investment study was done before formulation of this project

• Lessons learnt from similar nature of the project

• Indicate the basis of total and item-wise cost estimate and the date of preparation of rate of schedule

• Detail annual phasing of cost• Specification / design of major components• Amortization schedule for the projects

having involvement of loan from Government

• Describe the effect/impact and specific mitigation measures

• Specific linkage with PRS and MDGs• Involvement of private sector / local govt. or

NGO’s participation • Magnitude and cost of rehabilitation /

resettlement• Indicate risks during implementation and

operation and mitigation measures• Any other important details, technical or

otherwise (e.g sustainability, governance, Steering committee, project implementation committee etc.)

PIP LOOKED INTO

Construction of each health facility starts as a project and typically follows the traditional project management cycle of planning, design, implementation and monitoring. Thus the primary scope of the PIP in this phase was to look at the health facility construction phases and existing entry points for integrating DRR.

PLANNING STAGE OF HEALTH FACILITIES

Approval process of health facilitiesThe construction of health facilities are approved by MoHFW if the project size is less than 250m Bangladesh Taka. If the project size is more it needs to be approved by the Executive Committee of the National Economic Council (ECNEC) and by the Project Evaluation Committee (PEC), Health Wing of the Socio-Economic and Infrastructure Division of Planning Commission.

Further, if the project size is in value above 500m Bangladesh Taka, then in addition to ECNEC, it also requires the clearance of the Government Purchase Committee established by the Ministry of Establishment. The Prime Minister acts as the Adviser to the Committee and is represented by other Ministers and chaired by the Minister of Finance.

Some of the development related to Health Facilities fall under the longterm ongoing program such as the Health, Nutrition and Population Sector Programme (HNPSP). However, for projects which are not included in the above, a Scheme Summary or Development Project Proposal (DPP) is developed which describes the project, proposed along with the design of the proposed building and budget (see Box 2). The Director General of DGHS and Director,


Planning and Research of DGHS are the signatories of the Scheme Summary. During the course of the PIP, several DPP and Scheme Summary were reviewed to understand the areas of possible improvement in the approval process of the health facilities to make sure the planned facility is hazard resilient. Some of these areas of improvement identified include undertaking risk assessment in the context of suitability of the proposed land and site selection.

Site selection of health facilitiesSite selection is carried out by the site selection committee at the field level which is led by the Deputy Commissioner and includes local representatives of PWD, CMMU, Department of Architecture (if required) and MoHFW. The client agency seeks land through the Deputy Commissioner. Because of scarcity of land, often cooperation is sought from the local social elite and leaders.

The responsibilities of the members of the site selection committee comprise of:• Deputy Commissioner: administrative

issues• Civil surgeon / Divisional Director:

health aspects• Executive Engineer: technical aspects• Local leader/s: mobilising community to

provide land where necessary

The decisions regarding the land; acquisition, size etc. is carried out following standard procedure and the final site is provided to the respective department for undertaking the construction. There is no checklist / guideline available for site selection of health facilities. However, the following aspects are broadly considered:• Geographical location• Physical orientation• Topography• Catchment area• Soil condition• Protection against land slide / soil

erosion• Environment friendly (Reactive) / site

and building• Vegetation / landscape• Land and sea breeze.• Law and order• Transportation and communication• Availability of support services (gas,

water supply, electricity, sewerage, postal/telephone, others)

• Flood level• Land value

Though the above mentioned aspects includes concerns related to reducing the risk from natural hazards, in the absence of a standard checklist / guideline it is difficult to certify to what extent all of the aspects are taken into consideration during the process of site selection. In this regard, there is a need to have a standard checklist / guideline which would guide the process and particularly the local engineers who play a vital role in the process.

Design Stage of Health Facilities The Department of Architecture of the Ministry of Works is responsible for architectural design and the Department of Public Works for structural design, construction, supervision and maintenance of health facilities of a size of more than 100 beds. Both the departments have the technical manpower to execute the projects.

As explained earlier, the CMMU, which is the engineering unit of MoHFW is responsible for planning, design, construction and maintenance of health facilities of a size and fewer than 100 beds. Most of the times, engineering consultancy firms are hired through a competitive bidding process to undertake the task.

In both cases, after developing the preliminary designs, it is sent to the Ministry for approval. The final designs are signed by the concerned practicing architect, Chief Architect of the Ministry and attached with the DPP / Scheme Summary and submitted for PEC approval.

No standard guideline is available for designing health facilities; the Bangladesh National Building Code (BNBC, 2006) is followed for the design of health facilities in the country. The code does not have a specific chapter for health facilities; however, specific requirements for the design of heath facilities are mentioned in various places. These details largely cater to the requirements for occupancy, water supply etc. Specific design requirements for seismic and wind load are provided in the section on General Design in Chapter 2, which specifies the minimum design forces including dead load, live load, wind and earthquake load, miscellaneous loads and their various combinations (Page Number 10,586). However, these specifications are for all kinds of buildings and not specifically for health facilities.

The Imarat Nirman Bhidhimala; (Rules for building construction) in urban areas,


specifies requirements for health facilities too, largely on issues related to site planning.

Presently four types of layout are used in the design of low rise hospital / healthcare facilities in Bangladesh (see Box 3).

Some of the specific issues related to the design of health facilities include:• Most existing health facilities were not

planned and designed to cope with the present demand. Hence any alteration in design should consider this limitation. This requires carrying out assessments of existing structures from structural, non-structural and functional points of view.

• The topography of the country (especially the deltaic region prone to cyclone, flood and land erosion) should be considered in while designing the building.

CONSTRUCTION AND MAINTENANCE OF HEALTH FACILITIES

In the construction stage, the usual activities include; contractor selection, public works, evaluation, project handover and maintenance. For each project a Project Steering Committee headed by the Secretary, MoHFW, is formed to guide the implementation process. In addition, a Project Implementation Committee is responsible for managing the implementation. With members from DGHS and MoHFW, Department of Architecture, Public Works Department, Planning Commission and Ministry of Finance. The Project Implementation Committee has defined Terms of Reference (TOR) which include the monitoring of physical and financial progress of the project. In this regard, guidance needs to be given to the Committee on identifying risk to the health facility from natural hazards and vice versa and possible measures to reduce the risk. This would require including issues regarding DRR in the TOR of the Project Implementation Committee.

The PWD engineers at the Division level supervise the construction activities. The capacity of these engineers on assessing risk faced by health facilities and necessary tools and guidelines need to be provided which will help them in guiding construction which is resilient to natural hazards. Training masons is equally important in this aspect.

Box 3 Design of Low Rise Hospital

Type ASeparate block type; Individual building housing one or a group of inter-related functions arranged in a single premise.

Type BPavilion corridor type; Individual building are inter-connected with corridors or covered walkways.

Type CCourtyard type; Functions are arranged in one or more building set around a courtyard.

Type DSingle building type; All functions are in one building, on the other hand is a multistoried hospital building layout.


• Dhaka Medical College, Dhaka• NITOR, Medical College, Dhaka• Chittagong Medical College, Chittagong• Bongo Bandhu Memorial Hospital,

Chittagong

Detailed checklists (see Box 4) were developed by the sub-committee for undertaking the assessments, based on past and ongoing experience of various partners in Bangladesh on carrying out vulnerability assessment of buildings as well as looking into the Global Hospital Safety Index of WHO.

Considering the importance for carrying out the assessment of existing structures of the Health system, in the immediate phase of the PIP, the TWG prioritised the following tasks:• Finalization of methodology of

Assessments of Health Facilities in Bangladesh

• Develop a criteria for selection of Health Facilities for undertaking assessments in the future

Both PWD and CMMU have engineers at the divisional and districts level who are involved in carrying out routine maintenance activities. Based on the requisition sent by the hospital authority the PWD develops an index of all requisition and estimates for maintenance through the field engineers of PWD / CMMU. After obtaining approval from the MoHFW and Ministry of Finance the maintenance and renovation work are taken up by the PWD. The existing system of maintenance provides an entry point for setting up a system for postdisaster assessment of health facilities.

DEVELOPING A SYSTEM FOR THE ASSESSMENT OF HEALTH FACILITIES

Since a large amount of construction of health facilities in Bangladesh is related to upgrading the existing structures, it is of utmost importance to carry out a detailed assessment (structural, non structural and functional) of the structures before any upgradation is carried out. It is realized that such assessment needs to be carried out at a large scale and cannot be completed in one go, hence there is a requirement to establish a system for carrying out such assessment of health facilities in the country.

Thus the TWG under this PIP recognized the need to form a sub-committee with members from relevant agencies from the TWG, which detailed out the steps necessary for developing a national approach for the assessment of health facilities related to hazard resilience. This approach could be the base for developing the national methodology / guideline for carrying out assessments (structural, non-structural, functional) of health facilities in the future by various interested stakeholders.

The primary task of the sub-committee was to detail out the steps for developing the proposed approach for carrying out the assessment of health facilities in Bangladesh. The approach would have to be finalised through an extensive process of consultation and consideration of existing methodology prevalent in Bangladesh for structural assessment of buildings as well as availability of global guidelines such as the Hospital Safety Index of WHO.

In order to have a better understanding of the scope, methodology and limitations of the assessment, the sub-committee undertook assessments of four selected \health facilities in Bangladesh;

Box 4 Checklist on Assessment of Healthcare Facilities

Checklist 1

General Information about the Hospital; location, facility type, occupancy rate, capacity etc.

Checklist 2

Hazards related to the location of the Hospital

Checklist 3

Visual inspection and qualitative assessment; number of floors, existence of a soft story, presence of heavy overhangs, building quality, short columns, pounding effect, topographic effects, local soil condition etc.

Checklist 3a

Detailed survey for both RCC and masonry buildings; column and beam dimension, infill wall, floor height etc. For masonry structures additional factor such as maximum unsupported wall length, bracing of roof, horizontal band, vertical reinforcement etc.

Checklist 4

Non structural vulnerability assessment


Linking with the Global Safe Hospitals Campaign: Save Lives, Make Hospitals Safe in Emergencies

In 2005, 168 nations endorsed the Hyogo Framework for Action 2005-2015 (HFA), which included commitment to and success of disaster risk reduction: Integrate disaster risk reduction planning into the health sector; promote the goal of “hospitals safe from disasters” by ensuring that all new hospitals are built with a level of resilience that strengthens their capacity to remain functional in disaster situations, implement mitigation measures to reinforce existing health facilities, particularly those providing primary healthcare. Hospitals and health facilities need to remain functional during disasters. The human cost of hospital failure is made very clear in the aftermath of disasters, as the immediate focus is on fatalities, search and rescue, and the need to tend to the injured. When hospitals are unable to fulfill their emergency function at the time when most needed, critical care is compromised and lives are lost needlessly.

The World Disaster Reduction Campaign is an initiative of the UN International Strategy for Disaster Reduction (ISDR), in collaboration with the World Health Organization (WHO) and World Bank (WB).

The Campaign’s objectives are to effect change that helps to1 Protect the lives of patients and health

workers by ensuring the structural resilience of health facilities

2 Make sure health facilities and health services are able to function in the aftermath of emergencies and disasters – when they are most needed

3 Improve the risk reduction capacity of health workers and institutions, including emergency management

FINDINGS AND RECOMMENDATIONS

The National Workshop of the PIP, organized by DMB in July, 2009, Dhaka with the participation of various agencies involved in the construction of health facilities, recognized the importance of the initiative and the need to continue work in order to achieve the objective of mainstreaming DRR. Based on the discussions held with the TWG members over the course of the PIP and at the workshop, the following specific initiatives were identified as future activities:

1. Integrating DRR concerns in the planning process of health facilities in the DPP format of Project Development

2. Development of a national system for assessment of existing health facilities before disasters

3. Developing an National Action Plan on undertaking vulnerability assessment of health facilities

4. Based on the National Action Plan (developed in activity 3), undertake assessment of existing health facilities at all levels

5. Integrating DRR in the design process of health facilities by reviewing the Bangladesh National Building Code and Rajuk Building Construction Acts in terms of integrating DRR into clauses related to health facilities

6. Development of National Guidelines for construction of Safe Health Facilities

7. Development of a system for post disaster assessment of health facilities

8. Capacity building of officials involved in planning, design and construction of health facilities at all levels

9. Awareness raising and orientation of officials involved in the Health sector on integrating DRR in the construction of health facilities


Box 5 Global Safe Hospital Campaign Activities in Bangladesh

Before the World Health day 2009

Celebration of WHD(07 April 09)

After the World Health day 2009

Press briefing Essay Competition Art Competition Talk Show in Electronic Media

Documentary Film show

Distribution of IEC Materials at district level: Poster, Leaflet, Sticker & Souvenir

Media Orientation

Inauguration at national level Health Fair Distribution of IEC Materials City Decoration & Mobile Folk song Show special commemorative stamp release

Prize giving ceremony Observation at the district level Special supplement in the Newspaper

Scientific Seminar on Safe Hospitals at 14 Medical College Hospital

Orientation training on Safe Hospitals at 61 District level hospital

Orientation workshop with Media People at divisional level

Source: Presentation made by WHO PIP National Workshop, July 2009, Dhaka

The Government of Bangladesh is committed to implement the Global Safe Hospital Campaign. In partnership with WHO, it has undertaken various activities as explained in Box 5. The focus of these activities are on the second and third objectives of the Global Campaign. This Project Implementation Partnership (PIP) on Mainstreaming DRR into the health sector in Bangladesh focuses more on the first objective and these complements the ongoing initiatives under the Global Campaign.


For more information, please contact:

Disaster Management Bureau (DMB)Ministry of Food and Disaster Management

Md. Farhad UddinDirector GeneralDisaster Management BureauEmail: [email protected]

Syed AshrafPIP Focal PointCommunication and Media SpecialistDisaster Management BureauEmail: [email protected]

Asian Disaster Preparedness Center (ADPC)

Aloysius RegoDeputy Executive Director, ADPCEmail: [email protected]

Arghya Sinha RoyProgram ManagerEmail: [email protected]

Anisur RahmanProject ManagerEmail: [email protected]

Md. Jabed HossainPIP CoordinatorEmail: [email protected]

Layout by: Lowil Fred E

spada

Regional Consultative Committee on Disaster Management (RCC)

The RCC comprises of members who are working in key government positions in the National Disaster Management offices of countries of the Asian region. To date, 26 countries are represented by 30 RCC members from the Asia and Pacific regions, namely, Afghanistan, Bangladesh, Bhutan, Brunei, Cambodia, China, Georgia, India, Indonesia, Iran, Jordan, Kazakhstan, Korea, Lao PDR, Malaysia, Maldives, Mongolia, Myanmar, Nepal, Pakistan, Papua New Guinea, Philippines, Sri Lanka, Thailand, Timor Leste and Vietnam.

RCC Program on Mainstreaming Disaster Risk Reduction into development Policy, Planning and Implementation in Asia (RCC MDRD)

A key priority identified by the RCC is the integration of DRR into the development process. To initiate action on this agreed direction, the RCC program on Mainstreaming DRR into development policy, planning and implementation (MDRD) was launched at the 4th RCC meeting in Bangladesh in March 2004. The RCC 5 adopted the Hanoi RCC 5 statement on Mainstreaming DRR into Development in Asian countries which prioritizes mainstreaming of DRR to be initiated in national development planning process as well as sectoral development. It identified priority sectors namely Agriculture, Education, Health, Housing and Infrastructure for mainstreaming of DRR. The program has five components for implementation:1. Partnerships for mainstreaming

disaster risk reduction into National Development Planning processes;

2. Priority Implementation Partnerships (PIP) on mainstreaming disaster risk reduction into sector development;

3. Advocacy for Building awareness and political support for mainstreaming disaster risk reduction into development policy and planning;

4. Knowledge management platform for mainstreaming disaster risk reduction: Showcasing good practice and lessons learned; and

5. Capacity development for mainstreaming of disaster risk reduction into development of national and sectoral ministries, technical institutes, private sector and NGOs in RCC member countries.

This case study highlights the experience of undertaking a Priority Implementation Partnership (PIP) on mainstreaming DRR into the planning, design and construction of health facilities in Bangladesh, implemented by the Disaster Management Bureau (DMB) of the Ministry of Food and Disaster Management (MoFDM) with support from the Asian Disaster Preparedness Center (ADPC) and AusAID.

All photos credit: P

resentation made at the

PIP N

ational Workshop, July 2009, D

haka


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