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 Table of Contents  
Year : 2020  |  Volume : 9  |  Issue : 1  |  Page : 66-72

Assessment of drought resilience of hospitals in Sri Lanka: a cross-sectional survey

1 Ministry of Health, Nutrition and Indigenous Medicine, Colombo, Sri Lanka
2 World Health Organization Health Emergencies Programme, World Health Organization Regional Office for South-East Asia, New Delhi, India

Date of Web Publication26-Apr-2020

Correspondence Address:
Dr Novil W A N Y Wijesekara
Ministry of Health, Nutrition and Indigenous Medicine, Colombo
Sri Lanka
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DOI: 10.4103/2224-3151.283000

PMID: 32341225

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Background Drought is an extreme weather event. Drought-related health effects can increase demands on hospitals while restricting their functional capacity. In July 2017, Sri Lanka had been experiencing prolonged drought for around a year and data on the resilience of hospitals were required.
Methods A cross-sectional survey was done in five of the most drought-affected and vulnerable districts using two specially developed questionnaires. Ninety hospitals were assessed using the Baseline Hospital Drought Resilience Assessment (BHDRA) tool, of which 24 purposefully selected hospitals were also assessed using the more detailed Comprehensive Hospital Drought Resilience Assessment (CHDRA) tool and observation visits.
Results Of the hospitals assessed, 73 and 77 reported having adequate supplies of drinking and non-drinking water, respectively. Of the 24 hospitals studied using the CHDRA tool, bacteriological water quality testing was done in 8, with samples from only 4 hospitals being satisfactory. Adequate electricity supply was reported by 77 hospitals, of which 72 had at least one generator. None of the hospitals used rainwater or storm water harvesting, water recycling, or solar or wind power. Of the 24 hospitals selected for detailed analysis, awareness materials on safeguarding water or electricity and avoiding wasting water or electricity were displayed in only 6 hospitals; disaster preparedness plans were available in 9; and drought was considered as a hazard only in 6.
Conclusion The findings indicate that drought needs to be considered as an important hazard in hospital risk assessments. Drought preparedness, response and recovery should be embedded in hospital disaster preparedness plans to ensure the continuity of essential health services during emergencies.

Keywords: climate resilience, drought resilience, hospital preparedness, safe hospitals initiative, Sri Lanka

How to cite this article:
Wijesekara NW, Wedamulla A, Perera S, Pesigan A, Ofrin RH. Assessment of drought resilience of hospitals in Sri Lanka: a cross-sectional survey. WHO South-East Asia J Public Health 2020;9:66-72

How to cite this URL:
Wijesekara NW, Wedamulla A, Perera S, Pesigan A, Ofrin RH. Assessment of drought resilience of hospitals in Sri Lanka: a cross-sectional survey. WHO South-East Asia J Public Health [serial online] 2020 [cited 2022 Jan 22];9:66-72. Available from: http://www.who-seajph.org/text.asp?2020/9/1/66/283000

  Background Top

Drought can be defined as a period of time, generally lasting months or years, when the water supply at a particular location is consistently at a lower level than would be expected given climatic and hydrological norms.[1] Unlike sudden onset disasters such as floods or landslides, which become the subject of headlines in the media, slow onset disasters such as drought often go unnoticed until their later stages.[1] Furthermore, the lack of a universally accepted definition of “drought” makes drought management more difficult.

The effects of a drought on the community are severe, yet they can go unnoticed for long periods of time.[2] However, the opportunity provided by the slow onset nature of drought for preparedness, early warning and early response could be used to reduce the effects on communities.[3]

It is widely recognized that climate change is contributing to the vulnerability of countries to drought. The El Niño–Southern Oscillation (ENSO) is a recurring climate pattern involving changes in the temperature of waters in the central and eastern tropical Pacific Ocean. Unusually warm ocean temperatures in the equatorial Pacific characterize El Niño, while unusually cold ocean temperatures in the equatorial Pacific characterize La Niña. There is an ENSO-neutral state between the extremes of El Niño and La Niña.[4] In addition to causing floods in certain parts of the globe, El Niño and La Niña events also cause droughts in certain areas.[5]

The vulnerability of the World Health Organization (WHO) South-East Asia Region to drought as a result of ENSO has been clearly demonstrated.[6] In a national assessment in 2009, the Sri Lankan Ministry of Disaster Management found that, in the preceding three decades, the types of disaster that had affected the largest proportions of people were flood (48% of those affected by a disaster) and drought (43%).[3] Sri Lanka experienced a severe drought in 2016–2017, which affected an estimated 1.2 million people at its peak in March 2017.[7] This was followed by a long spell of dry weather in 2019, with more than 780 000 people affected in late September, mainly in the northern and eastern areas.[8] The Intergovernmental Panel on Climate Change (IPCC) states that extreme El Niño and La Niña events are likely to occur more frequently as a result of global warming. The IPCC further states (with a medium level of confidence) that existing impacts will intensify, with drier or wetter responses in several regions across the globe, even at relatively low levels of future global warming.[9]

The health effects caused by drought are well known. A systematic review has classified the effects of drought as nutrition-related effects, water-related effects, airborne and dust-related diseases, vector-borne diseases, mental health effects and other health effects.[10] Meanwhile, hospitals have been identified as heavy users of water. The vulnerability of hospitals to drought has been observed in various instances. In 2019 in Chennai, India, almost all private hospitals had to purchase water from privately owned water tankers as a result of drought.[11] In the same year in Manila, the Philippines, some hospitals had to buy additional water from tankers, while others had to postpone admissions because of drought-induced water scarcity.[12]

Several tools are available to assess and increase the climate resilience of hospitals, including their drought resilience. These include the WHO comprehensive Safe Hospital Framework[13] and the Hospital Safety Index: guide for evaluators,[14] the Pan American Health Organization (PAHO) Smart Hospitals Toolkit,[15] the Canadian Health Care Facility Climate Change Resiliency Toolkit[16],[17] and the Sustainable and Climate-Resilient Health Care Facilities Toolkit used in the United States of America.[18]

A conceptual framework was developed to enable a better understanding of the complex effects on hospitals of drought (see [Figure 1]). Drought creates water scarcity, which impinges on water quality. Water scarcity and reduced water quality are reflected in the health effects in the community.[10],[19] The community members use hospitals for outpatient, inpatient and clinic services, creating increased service demand. Meanwhile, both water scarcity and reduced water quality reduce the business continuity of hospitals. Furthermore, water scarcity may lead to reduced electricity supply, as 23% of Sri Lanka’s electricity generation capacity is provided by hydropower and other renewables.[20] Electricity cuts put further strain on hospital business continuity. The critical area that could mitigate the effects of the interaction between reduced hospital business continuity and increased service demand is the hospital’s capacity to prepare for, respond to and recover from drought. When such capacity is poor, the service delivery of the hospital will not only be reduced but also be of poor quality, at a time when demand from the community has increased. Services of reduced quantity and quality will function as a vicious positive feedback loop, further aggravating health problems in the community.
Figure 1. Conceptual framework – the effects on hospitals of drought

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As is evident from the conceptual framework presented in [Figure 1], hospitals are important components of the community as well as the health system when it comes to responding to drought. Their functioning throughout disasters, emergencies and crises is essential to ensure that health services are continued. With the increased risk of drought in the future, the preparedness of hospitals for drought becomes of paramount importance, both in the South-East Asia Region as a whole and in Sri Lanka as a country. This paper reports on an assessment of the drought resilience of hospitals in Sri Lanka, conducted by the Ministry of Health, Nutrition and Indigenous Medicine in collaboration with WHO. The lessons learnt from this study could be beneficial for other Member States of the WHO South-East Asia Region, and Member States in other regions, in making hospitals more resilient to drought.

  Methods Top

This assessment was done during May to July 2017, when Sri Lanka had been experiencing prolonged drought for around a year. A survey of hospitals was carried out in five of the most drought-affected and vulnerable districts of Sri Lanka, namely Anuradhapura, Mannar, Monaragala, Polonnaruwa and Vavuniya. The assessment focused on hospitals with inpatient facilities (teaching hospitals, district general hospitals, base hospitals type 1 and type 2, and divisional hospitals type A, type B and type C, excluding those without inpatient facilities, a preventive health unit or a maternal and child health clinic).

The survey was done using two questionnaires (available from the authors on request): the Baseline Hospital Drought Resilience Assessment (BHDRA) tool and the Comprehensive Hospital Drought Resilience Assessment (CHDRA) tool. The BHDRA questionnaire asked about the main sources of drinking/non-drinking water; the adequacy of water supplies over the past month; water storage capacity and type; and electricity supply and generator availability. All questions in the BHDRA were included in the CHDRA, which also gathered more detailed information on the volume of clinical and non-clinical activities; water quality monitoring and maintenance; water conservation methods used; alternative energy sources; and disaster preparedness and communications.

Existing tools were reviewed prior to the tool development.[13],[14],[15],[16],[17],[18] Some of these tools were designed to cover multiple hazards among which drought was only one, and therefore the emphasis on drought was not marked; in addition, some were too complex to be used in an assessment to be conducted in a short time.[13],[14],[15] Furthermore, tools developed for use in other regions and countries were not fully relevant in the Sri Lankan context.[16],[17],[18] Therefore, using the concepts included in the existing tools to assess climate resilience, we developed the BHDRA and CHDRA to focus specifically on the drought resilience of hospitals in the local context.

Both the BHDRA and CHDRA tools were verified for suitability in two hospitals each from a drought-affected and a non-drought-affected district prior to use in the assessment. Pilot testing of the tools was done in a moderately drought-affected district. Minor adjustments to the wording and order of the questions were made based on the results of the verification and pilot testing.

The BHDRA tool was used to collect data from all hospitals in the five districts covered by the study. Of these, a purposeful sample of hospitals was selected to be assessed using the CHDRA tool in order to collect more detailed information on drought resilience. The CHDRA tool was administered to up to 6 hospitals from each district to give a maximum of 30 hospitals from 5 districts. Facilities were selected for more detailed analysis based on two criteria: (i) at least one hospital from each of six categories (one tertiary care hospital, one base hospital type 1, one base hospital type 2, one divisional hospital type A, one divisional hospital type B and one divisional hospital type C) was to be included in the sample, if at least one hospital in each category existed in the district in question; (ii) when selecting a hospital from a category, the one with the highest utilization rate was given priority.

The BHDRA and CHDRA tools were sent to the hospitals by email, fax and post. The head of the institution (hospital director or medical superintendent) was the key point of contact for data collection; however, other sources within the hospital were contacted after permission had been obtained to do so. Each institute was given 2 weeks to complete the questionnaires and return its responses. Some selected institutions were visited by the research team for field observations. Hospitals were selected for field visits based on the results of the preliminary analysis and in consultation with the district health authorities to ensure that the whole range of hospitals was covered.

Data from the BHDRA and CHDRA tools were entered into SPSS (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.). The minimum water supply needed for each hospital was calculated using the standards shown in [Table 1].[21],[22] The ratio of minimum need to water storage capacity was then calculated for each of the facilities, which were then ranked accordingly.
Table 1. Minimum water quantities required by hospitals

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  Results Top

All of the 90 hospitals in the 5 districts studied participated; assessments using the CHDRA tool were conducted in 24 hospitals, while the BHDRA tool alone was used in 66 hospitals (see [Table 2]). The main source of drinking water was the National Water Supply and Drainage Board (NWSDB) (41 hospitals; 45.6%) Dug wells (38 hospitals; 42.2.%) followed by tube wells within hospital premises were the next most commonly used sources of drinking water. The NWSDB was used by 27 hospitals (30.0%) to supply water for purposes other than drinking.
Table 2. Basic characteristics of the 90 hospitals surveyed

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Mixing of water from two sources sometimes took place, with, for example, water supplied by the NWSDB and water from a community-based supply stored in the same tank in certain hospitals, while some hospitals had separate tanks for storing water from different sources. The number of water storage tanks in use in a hospital ranged from a single tank to 40 tanks, while storage capacity ranged from 500 litres to 100 000 litres. Plastic overhead water storage tanks have become more popular, while concrete overhead tanks are being abandoned by most small to medium-sized hospitals, on account of maintenance difficulties.

To supplement supplies during times of drought, the Regional Director of Health Services has a water bowser (mobile tank). Staff take the bowser to the NWSDB, fill it with safe, certified water and distribute it to hospitals in need. On request, the bowser can also be used to serve some non-health government institutions.

Larger hospitals were, unsurprisingly, ranked as the highest water users with the largest water storage capacities. However, when the ratios of minimum recommended water quantities needed to water storage capacities were calculated, the largest hospitals were ranked much lower (see [Table 3]).
Table 3. Hospital rankings for water use, water storage capacity and water requirement to storage capacity ratio

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Of the hospitals in the study population, 73 (81.1%) stated that the supply of water for drinking purposes was adequate, while 77 (85.6%) indicated that the supply of water for purposes other than drinking was adequate.

In the 24 hospitals studied using the CHDRA tool, water quality testing was done in 8 hospitals within the past year, which in every case had included a period of drought. Of the 8 hospitals that had done water quality testing, satisfactory results were obtained in only 4. In response to unsatisfactory water quality results, hospitals implemented hyperchlorination and used reverse osmosis filters.

Reverse osmosis plants had been set up in most of the hospitals visited, generally through philanthropic donations; some had been installed in the past 1–2 years, while others had been established for as long as 5 years. However, most of these plants were broken or dysfunctional. Patients who came to hospitals brought water from home or purchased it from water vendors who purify water using the same reverse osmosis method. Boiling was commonly used for water purification in most of the hospitals studied; however, for divisional-level hospitals, only one or two boilers were available for the whole hospital. Simple ceramic filters proved useful in some hospitals.

Electricity supply is a critical service that can be affected by drought. In 77 hospitals (85.6%), electricity supply was reported to be adequate. Eighteen (20%) hospitals had no generators, fifty-nine (65.6%) had one, nine (10%) had two, two (2.2%) had three, one (1.1%) had four, and one (1.1%) had five.

In recent years, efforts have been made to provide generators of adequate capacity to increase the drought resilience of hospitals. Of the 92 generators available in the 90 hospitals assessed, all but 2 had fuel to run them. Of 90 hospitals, 15 (16.7%) had a generator of over 100 kilovolt-amperes. Nevertheless, an operator for the generator was not available for 7 (7.6%) of the 92 generators available. A further 10 (10.9%) of the 92 generators were not ready for use at the time of the survey for reasons other than lack of fuel or no operator. One such reason why an expensive and sophisticated generator could not be used during times of drought was a lack of coordination between the hospital and the electricity authorities, which meant that the generator could not be connected to the main supply.

There was proper record keeping with regard to generator readings and fuel, and backup fuel supplies were observed. It is important that hospitals have trained and dedicated staff, maintenance systems and the necessary equipment to ensure that the power supply is sustained; this last may become critical in drought conditions.

None of the hospitals used rainwater harvesting and/or another type of water harvesting, or water recycling. Similarly, alternative energy sources such as solar power, wind power or mini-hydropower were not used in any of the hospitals. Awareness materials on safeguarding water or electricity and avoiding wasting water or electricity were displayed in only 6 of the 24 hospitals assessed using the CHDRA tool.

Disaster preparedness plans were available in 9 of the 24 hospitals surveyed using the CHDRA tool. Of these 9, 6 hospitals had disaster preparedness and response plans that included drought as a potential disaster. Safe hospital assessments had not been conducted in any of the 24 hospitals assessed using the CHDRA tool.

  Discussion Top

Drought is a chronic stressor, the health effects of which are widely understood.[1],[2],[3],[4],[5],[6] However, how the functioning of a hospital is affected by drought is less well understood. The study used quantitative and qualitative methods to gather information about the functioning of hospitals in a drought scenario in Sri Lanka.

According to the results of the study, 17 hospitals (18.9%) stated that drinking water supply was inadequate, while 13 hospitals (14.4%) signalled that the supply of water for purposes other than drinking was inadequate. Furthermore, electricity supply was found to be inadequate in 13 hospitals (14.4%). These findings were similar to those in water-stressed hospitals during times of drought in other countries.[11],[12] The majority of the hospitals studied (> 82%) were observed to be prepared for drought in terms of having adequate water supplies.

Having enough water storage tanks could be identified as one of the most common strategies adopted by the hospitals to prepare for drought. When the minimum water requirement was calculated based on the hospital utilization rate and analysed in relation to storage capacity, larger hospitals failed to maintain their rankings. This could be due to either storage capacities being low in comparison with minimum water requirements or the standards used to calculate the requirements not being accurate in less technology-based settings such as Sri Lanka.[21] With regard to this point, a systematic review assessed the published literature on data on water supplies for hospitals providing surgical procedures in low- and middle-income countries.[23] A binary score was assigned to water availability for each hospital (i.e. water reliably available or not reliably available). Information on 430 hospitals in 19 low- and middle-income countries, including Sri Lanka, was identified. Of these 430 hospitals, only 283 (66%) had water reliably available. The authors used these data to model estimated reliable water availability by country, which ranged from less than 20% in Liberia, Sierra Leone and Togo to more than 90% in Armenia, Guinea, India, Malaysia and Thailand. Thus, having fixed minimum water use standards to be used during times of drought as well as normal times is of questionable value.

Newer renewable energy alternatives, such as solar or wind power, and techniques such as rainwater or storm water harvesting and water recycling, had not been adopted, mainly because of a lack on-site support for their implementation. The linking of structural and operational safety with green interventions, at a reasonable cost-to-benefit ratio, is a cornerstone of the PAHO/WHO smart hospitals initiative, and it is important that hospitals embrace green technology when planning to increase their resilience.[15]

An innovative intervention by the regional health authority was adding a water bowser to its fleet of vehicles, to provide water in case of an emergency in consultation with the water supply authorities. Another strategy, initiated by the Meteorological Department of Sri Lanka, is the Monsoon Forum, in which the health sector is an active stakeholder.[24] The Monsoon Forum provides opportunities for the health sector to be informed in a timely manner of monsoon forecasts and to request assistance from water supply, electricity and disaster management authorities to better prepare for droughts. However, the need to strengthen such coordination at district and divisional levels cannot be overemphasized.

Close and detailed coordination with the NWSDB, the main water supplier, with a focus on water safety to ensure that water that is delivered to taps in communities and hospitals is safe to drink is essential. Gaps in frequency of sampling, bacteriological quality and action based on water quality surveillance results were evident from the assessment. These gaps in surveillance of drinking water quality in hospitals, especially during droughts, call for improved coordination between public health staff and hospital administrators. There is also a need to improve coordination and synergy among health staff responsible for water-borne disease surveillance and public health lab staff to ensure better monitoring of water quality surveillance.

Even when appropriate interventions are implemented, sustainability becomes a key factor in responding to prolonged emergencies such as drought. Sporadic donation of reverse osmosis plants with no proper maintenance plans, where simple point-of-use water treatment methods such as boiling and ceramic filtration may prove more effective, is a good example of the need to consider sustainability.

Having a backup power supply is critical for drought preparedness in hospitals. The fact that 80% of hospitals (n = 72) had generators was a good sign of preparedness. However, some generators – which had represented major financial investments – were unused at the peak of the drought and not providing the intended services, as a result of coordination issues.

There is also a need for trained and dedicated staff to maintain backup power supplies in hospitals. Active engagement and capacity-building of staff is critical in keeping such equipment functional throughout a long-lasting crisis such as a drought.

This study revealed that written disaster preparedness plans were available in only 9 of the 24 hospitals surveyed (37.5%), and drought was included as a potential disaster in only 6 of these plans. Despite the recommendation that an all-hazards approach should be taken, acute disaster preparedness and response often takes precedence in hospital plans. Therefore, drought must be considered as a hazard and integrated into hospital risk assessment. None of the hospitals in the current study had used the WHO safe hospitals tools[13],[14] to assess risks to business continuity.

Hospitals are not only service providers but also agents for change. Therefore, they could be encourage good practices for drought resilience in their respective communities. For example, safeguarding water and electricity could be promoted through hospitals to the wider community. The need to provide community awareness materials on drought resilience at household level in hospitals should be addressed through public health communications and outreach support staff.

Recommendations based on the findings of this study (see [Box 2]) will be circulated to all hospitals in Sri Lanka. They could also help to increase the drought resilience of hospitals throughout the WHO South-East Asia Region. Similarly, the drought assessment tools used in the study could be used both for research and to plan sustainable interventions to promote drought resilience in hospitals.

  Conclusion Top

Hospitals in Sri Lanka, especially in drought-prone districts, need to incorporate drought preparedness, response and recovery into hospital disaster plans to ensure the continuity of essential health services during emergencies. Drought should be integrated into hospital risk assessments and considered as an important hazard. The findings from this study should inform other countries in the WHO South-East Asia Region and inspire them to strengthen the preparedness of health facilities to cope with protracted emergencies such as drought.

Source of support: Funding for this study was provided by the World Health Organization Country Office for Sri Lanka and the World Health Organization Regional Office for South-East Asia.

Conflict of interest: None declared.

Authorship: NWANYW drafted the article. AW, SP, AP and RHO reviewed and revised subsequent versions of the article. All authors contributed significantly.

  References Top

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  [Figure 1]

  [Table 1], [Table 2], [Table 3]


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