Nepal: Awareness triggers action at a major public hospital

Nepal is highly prone to earthquakes and a large-scale, devastating earthquake is likely in its future. This good practice example discusses an earthquake mass casualty scenario used to predict how Nepal's health services would cope with such a disaster.

The event that prompted action

Nepal is highly prone to disasters, particularly to earthquakes, which claimed more than 11,000 lives in the 20th century alone. Data suggest that earthquakes of the magnitude of the Great Bihar Earthquake in 1934 occur approximately every 75 years and although this is only a statistical estimate, a devastating earthquake is inevitable in the long run and likely in the near future. This is particularly troublesome because the Kathmandu Valley Earthquake Risk Management Action Plan suggests that as many as 60% of buildings in the area are likely to be heavily damaged if the ground motion of the 1934 earthquake is repeated today.

How would Nepal’s health services cope with such an event? To find out, an earthquake mass casualty scenario was used for Kathmandu Valley to estimate the number of people that would require hospital services, based on:

  1. Expected damage to buildings;

  2. A 1-to-5 ratio of deaths to injuries; and

  3. The 2002 Kathmandu Valley’s population of 1.5 million.

The estimates ranged as high as 22,500 dead (up to 1.5 per cent of the population), with up to 112,500 injured.

Even the best of health systems would be hard pressed to deal with this scale of injury. And in the most severe intensity earthquakes, chances are that even the combined capacity of all emergency departments in Kathmandu Valley would only be able to serve a fraction of those requiring care. The limited number of patient beds and the fact that hospitals would be damaged, unable to function or even collapsed are aggravating factors that would put thousands of patients and health workers at risk.

Action taken

Recognizing the gap between current hospital capacity and predicted medical needs in a post-earthquake scenario, a seismic assessment of 14 hospitals was conducted in 2001 in Kathmandu Valley, including Patan Hospital. Subsequently, Patan was one of four priority hospitals to undergo a more rigorous study. Unlike most other hospitals in Nepal, Patan Hospital’s earthquake resilience was considered relatively good. Nonetheless, it was almost a foregone conclusion that a major earthquake would leave the hospital unable to function due to structural and non-structural damage . Therefore, the study recommended a detailed structural analysis to assess how the hospital would fare during high-intensity earthquakes. It also called for backup generators with an adequate fuel supply to provide an uninterrupted supply of electricity if external power is interrupted, response scenarios that simulate handling at least 200 casualties (the potential consequences of mid-scale earthquakes) and plans and procedures that contemplate a hospital that has been out of service.

Hospitals are more than concrete blocks and steel beams. They are made up of people and services and systems, all of which go into making a safe hospital. Patan Hospital was one of the first hospitals in Nepal to develop a hospital emergency plan, and so it is not surprising that it became one of the first health facilities to take part in a mass casualty mock drill. Civil society organizations and health officials worked together in a simulated rescue chain, from incident site to emergency ward, thus strengthening the links between community and hospital, including the critical pre-hospital response. Equally important, the mock drill created awareness of the need for mass casualty management in host communities and among community-based organizations. Since that first drill in 2002, Patan Hospital has conducted annual drills to test and refine its emergency plan.

Patan Hospital has also taken measures to reduce seismic risk. The hospital abandoned its original plan to expand the maternity wing by adding an extra floor to existing buildings when the roof was deemed structurally too weak to carry the extra load during earthquake ground motion. Instead, a new maternity wing is being built as a separate structure, in compliance with earthquake-resistant standards. The new maternity wing will be completed next year and will add 120 beds to the present 320 beds.

Snapshot of Patan Hospital

Type and Size: A General Public Hospital that annually treats 300,000 patients
Staff: 60 doctors and 250 nurses
Critical and essential facilities: Emergency department (5 beds, 100 % occupied), operating theatre (4 beds, 30 surgeries daily)
Other facilities: ICU, maternity unit, gynaecological unit, radiology, pathology
Total number of beds: 320
Bed occupancy rate: 90–100 %
Ambulances: none
Annual patients seen in Emergency Department: 33,000

The 2001 assessment included rough cost estimates and plans for priority retrofitting. Subsequently, Patan Hospital submitted to donors a detailed funding proposal for a comprehensive structural assessment and design drawings needed to accurately estimate the cost of retrofitting existing structures so they would be functional after moderate to severe earthquakes. While the hospital itself made some of the required modifications, they were less successful in securing the needed financial support, pointing to the need to increase awareness of investing in safety measures before disaster events occur rather than undertaking costly rebuilding projects afterwards.

The WHO has worked with the National Society for Earthquake Technology-Nepal (NSET) to raise awareness of the need to incorporate seismic mitigation measures in hospitals in Kathmandu Valley, conducting ongoing assessments since 2001, disseminating their results and developing hospital vulnerability assessment guidelines. In 2006-2007, assessments were made of six Red Cross blood banks, the National Public Health Laboratory and the Epidemiology and Disease Control Division of the Department of Health Services. High-level meetings between senior health policy makers, the donor community and international banks have helped to keep the issue of disaster-resilient hospitals and health facilities on the agenda.

Lessons learned

  1. Studies have shown the economic and social returns of improving the structural and non-structural behaviour of vulnerable hospital buildings. Structural retrofitting and non-structural measures can save lives and significantly increase the reliability of health services when they are most needed. Even when there is a strong evidence base and a high level of earthquake risk, health planners and policy makers do not put seismic assessments and risk reduction measures at the top of their list of concerns. Often, buildings are viewed as “completed projects” that should not be modified; reconstruction is considered to expand space. Convincing health professionals of the need for seismic assessments and retrofitting is a long-term process, unless it is directly linked to disaster rehabilitation, as was the case following the 2001 Gujarat earthquake or the 2006 Kashmir earthquake.

  2. In Nepal, concerns about disaster risk reduction in the health sector had their origins in local institutions, and this may be one of the key factors in the subsequent success achieved. Support from WHO helped to consolidate many initiatives taken over the previous 15 years. Health officials came on board when it was clear that risk reduction in health was a mutual concern of WHO, external development partners and civil society.

  3. One of the key reasons that Patan Hospital was so receptive to the recommendations stemming from assessments and other initiatives (mass casualty drill, triage, etc.) was that it was – and still is - a well-functioning facility with close links to the surrounding community, which helped to create the necessary support base and sustainability for pursuing seismic safety.

Although there is still a long way to go, the hospital has taken steps and proved that awareness can trigger assessments, assessments result in planning and planning in mitigation; a cycle that ultimately helps minimize the consequences of living with earthquake risks in Nepal.

More information is available from:

Dr Rajesh N. Gongal
Patan Hospital, Medical Director
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Amod Dixit
National Society for Earthquake Engineering-Nepal
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Erik Kjaergaard
World Health Organization, Nepal Office
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