The race for safer hospitals in quake-hit Nepal

A nurse at the Tribhuvan University Teaching Hospital in Kathmandu, Nepal. The hospital was still able to operate after a 7.8-magnitude earthquake struck the country because of disaster preparedness efforts initiated by the U.S. Agency for International Development, a member of the Nepal Risk Reduction Consortium. Photo by: Kashish Das Shrestha / USAID / CC BY-NC

This week, the World Health Organization and other partner U.N. agencies are expected to deploy the first set of medical camp kits in the districts hardest hit by Nepal’s recent earthquake.

The kits comprise temporary structures that will reinstate the provision of primary health care services in areas where they are most needed, but where they are disrupted due to the limited number of currently functioning health facilities.

The demand for health care services in Nepal has shot up dramatically following April’s quake. Upwards of 23,000 thousand people were injured and remain in need of emergency to long-term care. The risk of communicable disease outbreaks is also high, compounded by the current lack of basic structures and the onset of the rainy season. But with more than 1,000 health facilities partially damaged or rendered completely unusable by the temblor, the health sector’s capacity to cope has been significantly reduced.

The sheer devastation caused by the quake — measuring 7.8 on the Richter scale — is largely blamed on the weak infrastructure, prevalent across many of Nepal’s districts.

Some of Nepal’s major hospitals, such as the Grande and Norvic International Hospitals, Bir Hospital’s new intensive care unit and the old building of Paropakar Maternity and Women’s Hospital in Thapathali, have also suffered structural damage, although it’s unclear whether to the point of being inoperable.

But several hospitals were spared: Patan Hospital located in Lalitpur, and the Tribhuvan University Teaching Hospital in Kathmandu, for example, remain fully operational, as well as the Civil Hospital for government employees, and the new trauma center at Bir Hospital — the oldest and one of the busiest public hospitals in Kathmandu, which was inaugurated just last year.

The result of preparedness

The first two hospitals have been subject to retrofitting measures and nonstructural interventions like cabinets and operating theater lights screwed down, wires put in place to keep glassware and medicines from falling in case of a quake, among others. The latter two, meanwhile, have been designed and built seismic proof from the outset.

These actions largely stem from heightened awareness by government and stakeholders from different sectors of the need to keep Nepal’s health facilities functional during a disaster. In 2011, the Nepal Risk Reduction Consortium was formed, bringing humanitarian and development actors, donors and the government of Nepal together with the aim of reducing the country’s vulnerability to natural disasters.

Among its flagship priorities was making Nepal’s schools and hospitals earthquake resilient.

The consortium’s formation was a big “turning point” in the campaign for safer hospitals by WHO and its partners, according to Dr. Roderico Ofrin, the health aid agency’s overall head of response in the ongoing relief operations in the country. A decade after learning of Nepalese hospitals’ vulnerability to seismic shifts and recommending a number of interventions, the campaign was finally receiving political attention from the highest levels of government, financial support from donors, and a common understanding that “this is everyone’s business.”

A decade of advocacy

But it was a painfully slow recognition process.

In 2002, a structural vulnerability assessment jointly conducted by Nepal’s Ministry of Health and Population, the WHO and local NGO National Society for Earthquake Technology warned that most if not all hospitals in Kathmandu were far below the recommended performance capacity by the Pan American Health Organization — namely, that they can withstand a “rare and big earthquake that has a 10 percent probability of being exceeded within 50 years of a building’s occupancy.”

A few of the hospitals assessed — 30 buildings in 14 public, nongovernmental and private health facilities in the Nepalese capital — were predicted to go out of service for weeks or even months if hit by earthquakes with moderate to high intensity. But most, it was assumed, could go out of service for years — or may never recover.

The team recommended several actions to prepare the Kathmandu Valley hospitals for future seismic hazards and guide the construction of future health facilities. For instance, in the preparation of cement for sturdier structures, they emphasize the need for a mix ratio of 1 part cement to 3 parts sand instead of 6 parts sand, which the report claims is common practice in Nepal. Other recommendations included broader columns on the lower levels of buildings; and limiting the height of buildings to four storeys.

The team also recommended the health sector to prioritize work on emergency planning for an earthquake with mid-to-high intensity. Although the country’s major hospitals may be prepared, it warned that it was still inadequate to handle huge numbers of casualties numbering in the thousands.

Despite the warning, however, the assessment yielded no immediate substantial actions, according to Ofrin.

“Pretty much, at that time, it ended with assessment,” he told Devex. “Some donors were not interested.”

With not much funding to push forward with, the organization and its partners focused instead on disaster preparedness training, such as mass casualty management and triage. Ofrin noted that this proved to be highly useful following the recent earthquake.

Continued delays

The recognition for hospital intervention eventually arrived in 2012. The U.K. Department for International Development, which became a member of the NRRC, announced support for a hospital vulnerability assessment that built on the 2002 study, but that was “far more comprehensive,” according to then deputy head of DfID Nepal Philip Smith in a U.N. interview.

The assessment was expected to be carried out on 60 hospitals across Nepal, including those already identified as priorities by the Ministry of Health and Population and WHO in 2010, and with the aim of building local expertise in construction and retrofitting, monitoring and ensuring quality work and materials. From that number, 10 were scheduled to be selected for detailed retrofitting designs and budget.

DfID expected to complete the initial assessments by mid-2013, in time for a donor conference set for that year.

But Dr. Gunaraj Lohani, head of the curative service division of Nepal’s Ministry of Health and Population, told Devex the conference didn’t push through, as the assessment has yet to be finalized.

Without the full report, they could not present a full picture of their needs to donors.

The government official could only presume that it was a difficult process that took a longer time to complete. But in a 2013 review, DfID claimed late issuance of permission letters by the MoHP to access the buildings, the increased number of buildings in need of assessments — rising from 60 to some 200 — and other changes in the original plan led to delays and increased project costs.

While the rapid vulnerability assessments were completed in May 2013, the second part — the structural surveys — remains in progress for 21 hospitals, according to Lohani.

It’s unclear how far the assessment gone, or whether the advisory committee formed by the MoHP has identified the 10 priority hospitals to be subject for retrofitting, or in some cases reconstruction. But it is urgent to have that report ready in a couple of weeks, as Nepal prepares for a donor conference and pledges to finance its reconstruction efforts.

Minister of Finance Ram Mahat announced the conference will take place on June 25, in Kathmandu. The government and several donors are currently working on a post-disaster needs assessment, which is expected to influence the conference outcome. Debt relief is also expected to be a key item for discussion.

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About the author

  • Jenny Lei Ravelo

    Jenny Lei Ravelo is a Devex Senior Reporter based in Manila. She covers global health, with a particular focus on the World Health Organization, and other development and humanitarian aid trends in Asia Pacific. Prior to Devex, she wrote for ABS-CBN, one of the largest broadcasting networks in the Philippines, and was a copy editor for various international scientific journals. She received her journalism degree from the University of Santo Tomas.