From relief to recovery: The WHO tsunami operations

T h e W H O T s u n a m i O p e r a t i o n s FROM RELIEF TO RECOVERY WHO Library Cataloguing-in-Publication data World Health Organization, Regional Office for South-East Asia From relief to recovery: the WHO tsunami operations 1. Natural Disasters. 2. Emergency Medical Services—organization and administration. 3. Relief Work. 4. International Agencies. 5. International Cooperation. 6. India. 7. Indonesia. 8. Maldives. 9. Myanmar. 10. Sri Lanka. 11. Thailand. ISBN 978–92–9022–243–9 (NLM classification: HC 79.D45) © World Health Organization 2007 All rights reserved. Requests for publications, or for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – can be obtained from Publishing and Sales, World Health Organization, Regional Office for South-East Asia, Indraprastha Estate, Mahatma Gandhi Marg, New Delhi 110 002, India (fax: +91 11 23370197; e-mail: publications@searo.who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed by , New Delhi, India Design and layout: Ms Netra Shyam Printed in India Acknowledgements Foreword Abbreviations A cataclysmic event Gearing up to respond Country reports Indonesia Sri Lanka The Maldives India Thailand Myanmar Looking to the future Sources of information iv v v i i 1 5 27 83 113 143 169 187 193 206 C O N T E N T S ii iii A C K N O W L E D G E M E N T S For millions of people, Sunday 26 December 2004 brought an unimaginable change in their lives. The beautiful and tranquil beaches were transformed to a personal nightmare across the Region when wall-high waves swept across the shores and washed away lives, livelihoods, homes and the certainty of life as it had been. Without the courage, determination, compassion and humanity of the affected communities themselves, of the local health workers and volunteers and of the many organizations that worked tirelessly in the days following the tsunami, little could have been achieved. The leadership demonstrated by national governments and district administrations together with the hard work of dedicated people not only enabled immediate assistance to reach the people in need, but also ensured that rehabilitation and reconstruction commenced as soon as possible. The tsunami also brought about an unprecedented reaction from people and their governments across the world; who expressed their shock and sympathy and whose generous support enabled a quick and extensive humanitarian response. The work of World Health Organization (WHO) during the crisis was greatly facilitated by the financial assistance received from donor agencies. Two years have passed and, on the surface, life has returned to normal for many of the people who suffered. Houses have been rebuilt, hospitals and schools have been reconstructed and improved, and life goes on. But the images of the day the world changed will remain etched in all our minds. Our heartfelt gratitude goes to all those who worked with WHO and allowed us to make a difference. WHO also thanks all the photographers whose work appears in this book. This book is a tribute to all of them. The effect of the tsunami on the countries of the Regions is described according to the magnitude of their burden. Special tanks to Dr Bandana Malhotra and Ms Netra Shyam for putting together this report in such a short time. Time stood still on 26 December 2004. The waves that lashed the shores of many countries, including six from the South-East Asia Region, changed the lives of millions and set back the development clock by quite a few years. The initial reaction was awe and horror. The scale of devastation and destruction was overwhelming. This sinking feeling was immediately accompanied by the realization of the enormity of the task at hand to respond immediately to assist Member countries in saving lives, preventing outbreaks, and rebuilding health systems and the broken psyche of the people who had faced, braved and lost. There was no time to waste and the spirit was imbued by a missionary zeal to help out in a constructive way. To care and to make a difference. We put together a team of dedicated soldiers to man the Operations Room located in our Office in New Delhi from where the entire operation was managed. People from far and near, from HQ and other Regional Offices, each experts in their own right, joined forces to mount, what seemed then, a daunting response. Two years later, I can say, as leader of the Operations, that what my team carried out was not only unprecedented, but by far the biggest and most challenging mission that WHO in the Region has ever had to face. Among the crucial ingredients of the response were: B Health protection and disease prevention—including communicable diseases, early warning, surveillance and response, and the establishment of health information systems B Health services—access to essential health care through assessing and responding to needs. Immunization activities, providing psychosocial support, water and sanitation, health-care waste management, nursing and midwifery were are some of the areas we focused on. B Medical and logistic supply—emergency health kits, surgical kits, vehicles and IT-related components, rehabilitating laboratories, re-establishing supply chains for the distribution of cold- chain vaccines. B Resource mobilization and coordination among partners—coordination of the international health response in formulating country work-plans and sourcing the funds to implement them. The close proximity and collaboration of WHO Country Offices with the ministries of health in Member countries helped mount an effective response. Conformity with governance structures embedded in all countries has eased the process of providing relief. The opening of field offices in three places in Sri Lanka, four locations in Indonesia and one in Tamil Nadu, India ensured that interventions reached those who needed them most. We could not have done it alone. The funding we received from donors worldwide enabled us to undertake this massive operation. Contributions were received both in kind and in cash from governments of donor countries as well as the private sector. Many partners gave WHO the flexibility F O R E W O R D iv v A C K N O W L E D G E M E N T S For millions of people, Sunday 26 December 2004 brought an unimaginable change in their lives. The beautiful and tranquil beaches were transformed to a personal nightmare across the Region when wall-high waves swept across the shores and washed away lives, livelihoods, homes and the certainty of life as it had been. Without the courage, determination, compassion and humanity of the affected communities themselves, of the local health workers and volunteers and of the many organizations that worked tirelessly in the days following the tsunami, little could have been achieved. The leadership demonstrated by national governments and district administrations together with the hard work of dedicated people not only enabled immediate assistance to reach the people in need, but also ensured that rehabilitation and reconstruction commenced as soon as possible. The tsunami also brought about an unprecedented reaction from people and their governments across the world; who expressed their shock and sympathy and whose generous support enabled a quick and extensive humanitarian response. The work of World Health Organization (WHO) during the crisis was greatly facilitated by the financial assistance received from donor agencies. Two years have passed and, on the surface, life has returned to normal for many of the people who suffered. Houses have been rebuilt, hospitals and schools have been reconstructed and improved, and life goes on. But the images of the day the world changed will remain etched in all our minds. Our heartfelt gratitude goes to all those who worked with WHO and allowed us to make a difference. WHO also thanks all the photographers whose work appears in this book. This book is a tribute to all of them. The effect of the tsunami on the countries of the Regions is described according to the magnitude of their burden. Special tanks to Dr Bandana Malhotra and Ms Netra Shyam for putting together this report in such a short time. Time stood still on 26 December 2004. The waves that lashed the shores of many countries, including six from the South-East Asia Region, changed the lives of millions and set back the development clock by quite a few years. The initial reaction was awe and horror. The scale of devastation and destruction was overwhelming. This sinking feeling was immediately accompanied by the realization of the enormity of the task at hand to respond immediately to assist Member countries in saving lives, preventing outbreaks, and rebuilding health systems and the broken psyche of the people who had faced, braved and lost. There was no time to waste and the spirit was imbued by a missionary zeal to help out in a constructive way. To care and to make a difference. We put together a team of dedicated soldiers to man the Operations Room located in our Office in New Delhi from where the entire operation was managed. People from far and near, from HQ and other Regional Offices, each experts in their own right, joined forces to mount, what seemed then, a daunting response. Two years later, I can say, as leader of the Operations, that what my team carried out was not only unprecedented, but by far the biggest and most challenging mission that WHO in the Region has ever had to face. Among the crucial ingredients of the response were: B Health protection and disease prevention—including communicable diseases, early warning, surveillance and response, and the establishment of health information systems B Health services—access to essential health care through assessing and responding to needs. Immunization activities, providing psychosocial support, water and sanitation, health-care waste management, nursing and midwifery were are some of the areas we focused on. B Medical and logistic supply—emergency health kits, surgical kits, vehicles and IT-related components, rehabilitating laboratories, re-establishing supply chains for the distribution of cold- chain vaccines. B Resource mobilization and coordination among partners—coordination of the international health response in formulating country work-plans and sourcing the funds to implement them. The close proximity and collaboration of WHO Country Offices with the ministries of health in Member countries helped mount an effective response. Conformity with governance structures embedded in all countries has eased the process of providing relief. The opening of field offices in three places in Sri Lanka, four locations in Indonesia and one in Tamil Nadu, India ensured that interventions reached those who needed them most. We could not have done it alone. The funding we received from donors worldwide enabled us to undertake this massive operation. Contributions were received both in kind and in cash from governments of donor countries as well as the private sector. Many partners gave WHO the flexibility F O R E W O R D iv v to deploy resources in areas and across countries that needed priority attention and to utilize contributions better as needs evolved. We thank all donors not only for their generous contribution and timely response but also for the trust and confidence they invested in WHO. I have always maintained that this is our biggest strength. The tsunami of December 2004 changed a lot of things. It woke up Member countries to the threat natural disasters can pose to development in general and public health in particular. It has also been a watershed as to how we, within the UN, have looked at security issues pertaining to such emergencies. While globally, this has set in motion a tide of humanitarian reforms, within the South- East Asia Region, this has accelerated attention to the crucial issues of preparedness and risk mitigation. The focus now shifts to the larger issues of capacity at the country level, building better and more resilient health systems, reducing vulnerability of communities to external shocks through better preparedness, response strategies and plans, and providing the developmental link between disaster management and overall poverty reduction strategies. We have drawn our lessons from the tsunami crisis and are in the process of translating them into action. Together with Member countries and partners, we have developed benchmarks for emergency preparedness and response. On the recommendation of Member countries, we are also setting up a South-East Asia Regional Health Emergency Fund which will allow us to respond faster and more effectively in the future. Within our own house, we have strengthened our presence in countries and built capacity in the Emergency and Humanitarian Action Unit by putting together a multi-skilled team to support country offices. Our mission remains to reach the unreached, to serve the underserved, and to protect and promote public health in emergencies. The tsunami has brought partners together; they have closed ranks, developed a better understanding and fostered closer cooperation than at any other time in recent history. Today, WHO and its partners are more aware of mutual complementarities and are perhaps better coordinated as a result of this disaster. This will surely facilitate the implementation of the cluster approach for future emergencies. We invite all partners to join us in carrying this process forward to strive for even greater harmonization and to redouble efforts towards achieving more progressive health outcomes. It is indeed time to move beyond the tragedy that was the tsunami into the opportunity of forging effective partnerships for health for the people of the South-East Asia Region. A B B R E V I A T I O N S AD auto-disable ADB Asian Development Bank ADRA Adventist Development and Relief Agency AFP acute flaccid paralysis AFRIMS Armed Forces Research Institute of Medical Sciences (Pune) AIIMS All India Institute of Medical Sciences (New Delhi) AmRC American Red Cross ANC antenatal care APN Advanced Practice Nurse ARC Australian Red Cross ARI acute respiratory infection AusAID Australian Government's Overseas Aid Programme AWW anganwadi worker BRR Bureau for Reconstruction and Rehabilitation (Badan Rehabilitasi Dan Rekonstruksi) CAH Child and Adolescent Health CBO community-based organization CDC Centers for Disease Control, Atlanta, USA CEmONC Comprehensive Emergency Obstetric and Newborn Care CLW community-level worker CMC Christian Medical College (Vellore) CMHN clinical mental health nurse CNO Centre for National Operations COC Central Operation Centre CPS Community Placement Survey CPDMS Clinical Performance Development and Management System CRC Canadian Red Cross CSB corn–soya blend CTF crisis task force DAD development assistance database DDPM Department of Disaster Prevention and Mitigation DFID Department for International Development, UK DF dengue fever DH district hospital DHF dengue hemorrhagic fever DHO district health office DMC Disaster Management Centre DMH Department of Mental Health (Thailand) DMT Disaster Management Team DoH Department of Health DoMS Department of Medical Science DPDHS Deputy Provincial Director of Health Services DPH Department of Public Health DRC Data Resource Centre DTF Disaster Task Force DTPS District Team Problem Solving DVI Dead Victims Identification ECHO European Community's Humanitarian Aid Office EHA Emergency and Humanitarian Action (UN Department) EHAP Emergency Health Action Programme EIU Emergency Information Unit EMR emergency medical relief EMU Emergency Management Unit EPI Expanded Programme on Immunization EPR Emergency Preparedness and Response ETS expenditure tracking system EURO WHO Regional Office for Europe EWARN Early Warning Alert and Response Network EWORS Early Warning Outbreak Response System EWS early warning system FAO Food and Agriculture Organization FETP Field Epidemiology Training Programme FRU first referral unit GDP gross domestic product GH Government Hospital GHQ 12 General Health Questionnaire 12 GIS geographical information system GOARN Global Outbreak Alert and Response Network GoI Government of India GoM Government of Maldives GRI Gandhigram Rural Institute (Tamil Nadu, India) HAC Health Action in Crises HCWM health-care waste management HIC Humanitarian Information Centre HIRU Housing and Infrastructure Redevelopment Unit HIS health information system HQ Headquarters (Geneva) HR human resource HRC Health Rehabilitation Centre IAP Indian Academy of Pediatrics ICDS Integrated Child Development Scheme ICRC International Committee of the Red Cross vi vii Dr Poonam Khetrapal Singh Deputy Regional Director Nature unleashed its fury with unprecedented violence on the morning of 26 December 2004. At 7.58 a.m., an earthquake that measured 8.9 on the Richter scale occurred under the sea off the western coast of North Sumatra. The epicentre was about 30 km under the seabed and 250 km south-southwest of Banda Aceh in Indonesia. This massive earthquake was followed by several aftershocks ranging from 6.0 to 7.3 on the Richter scale. These aftershocks were in themselves large and powerful enough to destroy thousands of lives. The quake triggered powerful tsunamis, about ten metres in height, which moved through the Indian Ocean at astounding speeds of over 500 km an hour, wrecking coastal areas in India, Indonesia, Sri Lanka, Thailand and the Maldives, as well as in Myanmar, Seychelles, Malaysia, Tanzania, Kenya and Somalia. What promised to be a pleasant, post-Christmas Sunday turned into one of the biggest disasters humankind had ever known. The affected countries had no experience of a tsunami and, on the beaches, the receding waterline initially drew many Sunday revellers further out to sea. The enormous walls of water that followed caught them unawares, and thousands of lives were snuffed out within the blink of an eye. Asia, particularly South and South-East Asia, is the most densely populated area in the world. Coastal areas have a disproportionately high population density (450 persons/sq.km versus 175 persons/sq.km elsewhere in the world). In the affected countries, coastal areas were flooded and homes and buildings, roads and bridges, water and electricity supplies, crops, irrigation and fishery infrastructure, food and fuel networks, telecommunication networks were washed away. The trauma caused by this unprecedented catastrophe affected every facet of life and livelihood. Six countries in the WHO South-East Asia Region simultaneously bore the brunt of the tsunami. Indonesia, the country closest to the epicentre, was the worst affected, particularly the provinces of Aceh and North Sumatra. The water pushed its way 12–14 km inland, sweeping away everything in its path. The disaster affected the lives of every single family in the region. A catac lysmic event Nature unleashed its fury with unprecedented violence on the morning of 26 December 2004. At 7.58 a.m., an earthquake that measured 8.9 on the Richter scale occurred under the sea off the western coast of North Sumatra. The epicentre was about 30 km under the seabed and 250 km south-southwest of Banda Aceh in Indonesia. This massive earthquake was followed by several aftershocks ranging from 6.0 to 7.3 on the Richter scale. These aftershocks were in themselves large and powerful enough to destroy thousands of lives. The quake triggered powerful tsunamis, about ten metres in height, which moved through the Indian Ocean at astounding speeds of over 500 km an hour, wrecking coastal areas in India, Indonesia, Sri Lanka, Thailand and the Maldives, as well as in Myanmar, Seychelles, Malaysia, Tanzania, Kenya and Somalia. What promised to be a pleasant, post-Christmas Sunday turned into one of the biggest disasters humankind had ever known. The affected countries had no experience of a tsunami and, on the beaches, the receding waterline initially drew many Sunday revellers further out to sea. The enormous walls of water that followed caught them unawares, and thousands of lives were snuffed out within the blink of an eye. Asia, particularly South and South-East Asia, is the most densely populated area in the world. Coastal areas have a disproportionately high population density (450 persons/sq.km versus 175 persons/sq.km elsewhere in the world). In the affected countries, coastal areas were flooded and homes and buildings, roads and bridges, water and electricity supplies, crops, irrigation and fishery infrastructure, food and fuel networks, telecommunication networks were washed away. The trauma caused by this unprecedented catastrophe affected every facet of life and livelihood. Six countries in the WHO South-East Asia Region simultaneously bore the brunt of the tsunami. Indonesia, the country closest to the epicentre, was the worst affected, particularly the provinces of Aceh and North Sumatra. The water pushed its way 12–14 km inland, sweeping away everything in its path. The disaster affected the lives of every single family in the region. A catac lysmic event In India, the Andaman and Nicobar Islands were severely damaged, and subjected to more than 215 aftershocks. On the mainland, the southern states of Tamil Nadu, Andhra Pradesh and Kerala, and the union territory of Pondicherry experienced the onslaught. The impact on the island nation of the Maldives was enormous. By the time the tsunami reached the country, the waves were only about 3–4 metres in height, but as this archipelago comprising several islands is only 1.5 metres above sea level, the damage was extensive. All the 200 widely dispersed inhabited islands were affected, and some were destroyed forever. This was the worst disaster the country had ever known, though, compared with the other affected countries, the death toll of 82 was low. In Thailand, six provinces suffered immense damage. A large number of foreign nationals visiting the popular tourist resorts of the country caused grave concern to their governments. Myanmar was affected to a lesser extent compared with the other countries; however, at least 61 people died and twelve townships were damaged. In Sri Lanka, the immediate loss of life was around 31 000. The districts most affected were Jaffna in the north; Kilinocchchi, Mullaitivu, Trincomalee, Batticaloa and Ampara districts along the east coast; Hambantota, Matara and Galle districts in the south and Kalutera, Colombo, Gampaha and Puttalam districts in the west. A phone call from the Maldives provided the call to action. “We're being flooded! Malé is being flooded,” was all the panic-stricken voice could say before the telephone line went dead. The call was made to the WHO Regional Office for South-East Asia, and galvanized a chain of events that would result in one of the best organized emergency relief operations n history. The Regional Director, Dr Samlee Plianbangchang delegated to the Deputy Regional Director, Dr Poonam Khetrapal Singh the responsibility for all aspects of the operations. WHO SEARO responded immediately to the emergency by establishing a 24- hour operations room and a senior-level task force to support the emergency needs of the five most affected countries in the Region. SEARO was made the nodal point for coordination of WHO's efforts in all the affected countries of the Region. Constant support was provided by WHO Headquarters, particularly Health Action in Crises (HAC) in Geneva. At a meeting on 27 December 2004, response plans were set into motion. WHO worked hand-in-hand with national authorities so that international assistance would result in prompt and appropriate reactivation of local health systems working with UN Systems such as the UNDAC and UN Disaster Management Teams. WHO collaborated with the Ministries of Health and international partners in the affected countries to help determine the damage, needs and capacities. A c a t a c l y s m i c e v e n tF r o m r e l i e f t o r e c o v e r y In India, the Andaman and Nicobar Islands were severely damaged, and subjected to more than 215 aftershocks. On the mainland, the southern states of Tamil Nadu, Andhra Pradesh and Kerala, and the union territory of Pondicherry experienced the onslaught. The impact on the island nation of the Maldives was enormous. By the time the tsunami reached the country, the waves were only about 3–4 metres in height, but as this archipelago comprising several islands is only 1.5 metres above sea level, the damage was extensive. All the 200 widely dispersed inhabited islands were affected, and some were destroyed forever. This was the worst disaster the country had ever known, though, compared with the other affected countries, the death toll of 82 was low. In Thailand, six provinces suffered immense damage. A large number of foreign nationals visiting the popular tourist resorts of the country caused grave concern to their governments. Myanmar was affected to a lesser extent compared with the other countries; however, at least 61 people died and twelve townships were damaged. In Sri Lanka, the immediate loss of life was around 31 000. The districts most affected were Jaffna in the north; Kilinocchchi, Mullaitivu, Trincomalee, Batticaloa and Ampara districts along the east coast; Hambantota, Matara and Galle districts in the south and Kalutera, Colombo, Gampaha and Puttalam districts in the west. A phone call from the Maldives provided the call to action. “We're being flooded! Malé is being flooded,” was all the panic-stricken voice could say before the telephone line went dead. The call was made to the WHO Regional Office for South-East Asia, and galvanized a chain of events that would result in one of the best organized emergency relief operations n history. The Regional Director, Dr Samlee Plianbangchang delegated to the Deputy Regional Director, Dr Poonam Khetrapal Singh the responsibility for all aspects of the operations. WHO SEARO responded immediately to the emergency by establishing a 24- hour operations room and a senior-level task force to support the emergency needs of the five most affected countries in the Region. SEARO was made the nodal point for coordination of WHO's efforts in all the affected countries of the Region. Constant support was provided by WHO Headquarters, particularly Health Action in Crises (HAC) in Geneva. At a meeting on 27 December 2004, response plans were set into motion. WHO worked hand-in-hand with national authorities so that international assistance would result in prompt and appropriate reactivation of local health systems working with UN Systems such as the UNDAC and UN Disaster Management Teams. WHO collaborated with the Ministries of Health and international partners in the affected countries to help determine the damage, needs and capacities. A c a t a c l y s m i c e v e n tF r o m r e l i e f t o r e c o v e r y Nature unleashed its fury with unprecedented violence on the morning of 26 December 2004. At 7.58 a.m., an earthquake that measured 8.9 on the Richter scale occurred under the sea off the western coast of North Sumatra. The epicentre was about 30 km under the seabed and 250 km south-southwest of Banda Aceh in Indonesia. This massive earthquake was followed by several aftershocks ranging from 6.0 to 7.3 on the Richter scale. These aftershocks were in themselves large and powerful enough to destroy thousands of lives. The quake triggered powerful tsunamis, about ten metres in height, which moved through the Indian Ocean at astounding speeds of over 500 km an hour, wrecking coastal areas in India, Indonesia, Sri Lanka, Thailand and the Maldives, as well as in Myanmar, Seychelles, Malaysia, Tanzania, Kenya and Somalia. What promised to be a pleasant, post-Christmas Sunday turned into one of the biggest disasters humankind had ever known. The affected countries had no experience of a tsunami and, on the beaches, the receding waterline initially drew many Sunday revellers further out to sea. The enormous walls of water that followed caught them unawares, and thousands of lives were snuffed out within the blink of an eye. Asia, particularly South and South-East Asia, is the most densely populated area in the world. Coastal areas have a disproportionately high population density (450 persons/sq.km versus 175 persons/sq.km elsewhere in the world). In the affected countries, coastal areas were flooded and homes and buildings, roads and bridges, water and electricity supplies, crops, irrigation and fishery infrastructure, food and fuel networks, telecommunication networks were washed away. The trauma caused by this unprecedented catastrophe affected every facet of life and livelihood. Six countries in the WHO South-East Asia Region simultaneously bore the brunt of the tsunami. Indonesia, the country closest to the epicentre, was the worst affected, particularly the provinces of Aceh and North Sumatra. The water pushed its way 12–14 km inland, sweeping away everything in its path. The disaster affected the lives of every single family in the region. A catac lysmic event Nature unleashed its fury with unprecedented violence on the morning of 26 December 2004. At 7.58 a.m., an earthquake that measured 8.9 on the Richter scale occurred under the sea off the western coast of North Sumatra. The epicentre was about 30 km under the seabed and 250 km south-southwest of Banda Aceh in Indonesia. This massive earthquake was followed by several aftershocks ranging from 6.0 to 7.3 on the Richter scale. These aftershocks were in themselves large and powerful enough to destroy thousands of lives. The quake triggered powerful tsunamis, about ten metres in height, which moved through the Indian Ocean at astounding speeds of over 500 km an hour, wrecking coastal areas in India, Indonesia, Sri Lanka, Thailand and the Maldives, as well as in Myanmar, Seychelles, Malaysia, Tanzania, Kenya and Somalia. What promised to be a pleasant, post-Christmas Sunday turned into one of the biggest disasters humankind had ever known. The affected countries had no experience of a tsunami and, on the beaches, the receding waterline initially drew many Sunday revellers further out to sea. The enormous walls of water that followed caught them unawares, and thousands of lives were snuffed out within the blink of an eye. Asia, particularly South and South-East Asia, is the most densely populated area in the world. Coastal areas have a disproportionately high population density (450 persons/sq.km versus 175 persons/sq.km elsewhere in the world). In the affected countries, coastal areas were flooded and homes and buildings, roads and bridges, water and electricity supplies, crops, irrigation and fishery infrastructure, food and fuel networks, telecommunication networks were washed away. The trauma caused by this unprecedented catastrophe affected every facet of life and livelihood. Six countries in the WHO South-East Asia Region simultaneously bore the brunt of the tsunami. Indonesia, the country closest to the epicentre, was the worst affected, particularly the provinces of Aceh and North Sumatra. The water pushed its way 12–14 km inland, sweeping away everything in its path. The disaster affected the lives of every single family in the region. A catac lysmic event In India, the Andaman and Nicobar Islands were severely damaged, and subjected to more than 215 aftershocks. On the mainland, the southern states of Tamil Nadu, Andhra Pradesh and Kerala, and the union territory of Pondicherry experienced the onslaught. The impact on the island nation of the Maldives was enormous. By the time the tsunami reached the country, the waves were only about 3–4 metres in height, but as this archipelago comprising several islands is only 1.5 metres above sea level, the damage was extensive. All the 200 widely dispersed inhabited islands were affected, and some were destroyed forever. This was the worst disaster the country had ever known, though, compared with the other affected countries, the death toll of 82 was low. In Thailand, six provinces suffered immense damage. A large number of foreign nationals visiting the popular tourist resorts of the country caused grave concern to their governments. Myanmar was affected to a lesser extent compared with the other countries; however, at least 61 people died and twelve townships were damaged. In Sri Lanka, the immediate loss of life was around 31 000. The districts most affected were Jaffna in the north; Kilinocchchi, Mullaitivu, Trincomalee, Batticaloa and Ampara districts along the east coast; Hambantota, Matara and Galle districts in the south and Kalutera, Colombo, Gampaha and Puttalam districts in the west. A phone call from the Maldives provided the call to action. “We're being flooded! Malé is being flooded,” was all the panic-stricken voice could say before the telephone line went dead. The call was made to the WHO Regional Office for South-East Asia, and galvanized a chain of events that would result in one of the best organized emergency relief operations n history. The Regional Director, Dr Samlee Plianbangchang delegated to the Deputy Regional Director, Dr Poonam Khetrapal Singh the responsibility for all aspects of the operations. WHO SEARO responded immediately to the emergency by establishing a 24- hour operations room and a senior-level task force to support the emergency needs of the five most affected countries in the Region. SEARO was made the nodal point for coordination of WHO's efforts in all the affected countries of the Region. Constant support was provided by WHO Headquarters, particularly Health Action in Crises (HAC) in Geneva. At a meeting on 27 December 2004, response plans were set into motion. WHO worked hand-in-hand with national authorities so that international assistance would result in prompt and appropriate reactivation of local health systems working with UN Systems such as the UNDAC and UN Disaster Management Teams. WHO collaborated with the Ministries of Health and international partners in the affected countries to help determine the damage, needs and capacities. A c a t a c l y s m i c e v e n tF r o m r e l i e f t o r e c o v e r y In India, the Andaman and Nicobar Islands were severely damaged, and subjected to more than 215 aftershocks. On the mainland, the southern states of Tamil Nadu, Andhra Pradesh and Kerala, and the union territory of Pondicherry experienced the onslaught. The impact on the island nation of the Maldives was enormous. By the time the tsunami reached the country, the waves were only about 3–4 metres in height, but as this archipelago comprising several islands is only 1.5 metres above sea level, the damage was extensive. All the 200 widely dispersed inhabited islands were affected, and some were destroyed forever. This was the worst disaster the country had ever known, though, compared with the other affected countries, the death toll of 82 was low. In Thailand, six provinces suffered immense damage. A large number of foreign nationals visiting the popular tourist resorts of the country caused grave concern to their governments. Myanmar was affected to a lesser extent compared with the other countries; however, at least 61 people died and twelve townships were damaged. In Sri Lanka, the immediate loss of life was around 31 000. The districts most affected were Jaffna in the north; Kilinocchchi, Mullaitivu, Trincomalee, Batticaloa and Ampara districts along the east coast; Hambantota, Matara and Galle districts in the south and Kalutera, Colombo, Gampaha and Puttalam districts in the west. A phone call from the Maldives provided the call to action. “We're being flooded! Malé is being flooded,” was all the panic-stricken voice could say before the telephone line went dead. The call was made to the WHO Regional Office for South-East Asia, and galvanized a chain of events that would result in one of the best organized emergency relief operations n history. The Regional Director, Dr Samlee Plianbangchang delegated to the Deputy Regional Director, Dr Poonam Khetrapal Singh the responsibility for all aspects of the operations. WHO SEARO responded immediately to the emergency by establishing a 24- hour operations room and a senior-level task force to support the emergency needs of the five most affected countries in the Region. SEARO was made the nodal point for coordination of WHO's efforts in all the affected countries of the Region. Constant support was provided by WHO Headquarters, particularly Health Action in Crises (HAC) in Geneva. At a meeting on 27 December 2004, response plans were set into motion. WHO worked hand-in-hand with national authorities so that international assistance would result in prompt and appropriate reactivation of local health systems working with UN Systems such as the UNDAC and UN Disaster Management Teams. WHO collaborated with the Ministries of Health and international partners in the affected countries to help determine the damage, needs and capacities. A c a t a c l y s m i c e v e n tF r o m r e l i e f t o r e c o v e r y INITIAL DEVASTATION IN THE REGION A considerable number of deaths were reported initially in Indonesia (4000), Sri Lanka (3225), Maldives (10), Thailand (257), India (2000) and Myanmar. These figures rose steeply in the coming days. At the end of 2005, in Indonesia the number of deaths recorded was 130 736, Sri Lanka 35 322, India 12 405, the Maldives 82, Thailand 8212 and Myanmar 61. Malaysia (Langkawi and Penang), Bangladesh, Soma l i a , Tanzan i a , Seyche l l e s , Bangladesh and Kenya were also affected, but to a much lesser degree. The tsunami caused large-scale damage to infrastructure, including many health facilities. Besides organizing help for mass management of injuries and casualties in hospitals, WHO foresaw the urgent need for assessing the health needs of the affected population. In the short term, additional threats to human life were anticipated from contaminated water sources, poor sanitation and overcrowding. Critical gaps in health response needed to be promptly identified and filled for reactivating and boosting the capacities of local systems for health-care delivery. Strong coordination was needed to optimize local and national efforts with enhanced international goodwill. WHO went to work in accordance with its defined strategic functions in crises. These include the following: = Measuring ill health and promptly assessing health needs, identifying priority causes of ill health and death; = Supporting Member States in coordinating action for health; = Ensuring that critical gaps in health response are rapidly identified and filled; = Revitalizing and building capacity of local and national health systems. Gearing up to respond INITIAL DEVASTATION IN THE REGION A considerable number of deaths were reported initially in Indonesia (4000), Sri Lanka (3225), Maldives (10), Thailand (257), India (2000) and Myanmar. These figures rose steeply in the coming days. At the end of 2005, in Indonesia the number of deaths recorded was 130 736, Sri Lanka 35 322, India 12 405, the Maldives 82, Thailand 8212 and Myanmar 61. Malaysia (Langkawi and Penang), Bangladesh, Soma l i a , Tanzan i a , Seyche l l e s , Bangladesh and Kenya were also affected, but to a much lesser degree. The tsunami caused large-scale damage to infrastructure, including many health facilities. Besides organizing help for mass management of injuries and casualties in hospitals, WHO foresaw the urgent need for assessing the health needs of the affected population. In the short term, additional threats to human life were anticipated from contaminated water sources, poor sanitation and overcrowding. Critical gaps in health response needed to be promptly identified and filled for reactivating and boosting the capacities of local systems for health-care delivery. Strong coordination was needed to optimize local and national efforts with enhanced international goodwill. WHO went to work in accordance with its defined strategic functions in crises. These include the following: = Measuring ill health and promptly assessing health needs, identifying priority causes of ill health and death; = Supporting Member States in coordinating action for health; = Ensuring that critical gaps in health response are rapidly identified and filled; = Revitalizing and building capacity of local and national health systems. Gearing up to respond F r o m r e l i e f t o r e c o v e r y ASSESSMENT AND EMERGENCY RELIEF WHO PRIMARY FUNCTIONS Surveillance and response: Access to essential health care: In the first days, WHO aimed to maximize the life-saving and life-preserving impact of all humanitarian action through support to countries (and the international community) for the following actions: 1. Track patterns of life-threatening diseases among those at risk through prompt setting-up of a surveillance and early warning system with daily epidemiological reports. 2. Work with all partners to ensure equitable access G e a r i n g u p t o r e s p o n d Predicting disease following the emergency Days 1–3 Injury/drowning and deaths Safe disposal of corpses Injury management Needs assessment Days 3–5 Diarrhoeal diseases Health promotion Acute respiratory infections –Sanitation, environment –Water purification –Personal hygiene –Immunization (measles) –ORS Emerging disease surveillance (morbidity/mortality) 5–10 days As above plus: dehydration, As above plus: pneumonia, conjunctivitis, skin Antibiotics for pneumonia infections Drugs for skin infections and conjunctivitis >10 days As above plus: vector-borne Ongoing surveillance, health education, measures for diseases (malaria, dengue fever), vector control, antimalarials, supplementary typhoid fever, measles and feeding programme malnutrition Psychosocial support Psychosocial problems Rebuilding health infrastructure to adequate quality of essential health care through key hospitals and health centres. 3. Provide guidance on critical public health issues (response to disease outbreaks, water quality, excreta management, chemical threats, chronic disease management and mental health). The Organization aimed to fill critical gaps till others were able to take on the task. 4. Contribute to ensuring that medical supply chains functioned as efficiently as possible and responded to the needs of those affected. 5. Coordinate health actors at the local, national and international levels, with agreed strategies and joint action. Implementing the above required a marked scaling-up of WHO capacity and had considerable staffing/resource implications. A critical step was the establishment of operational platforms at the country level (both at national levels and in the worst- affected areas, especially in Indonesia and Sri Lanka) and in SEARO. SEARO determined country by country staffing requirements based on the functions listed above. The Health Action in Crises (HAC) division in WHO Headquarters in Geneva assisted with special assets in the areas of logistics, communications and security. Public health: Medical supplies: Joint action: Operational platform / A senior WHO official and the Emergency and Humanitarian Action (EHA) focal point in the Country Office was on the UNDAC evaluation team conducting assessments in the affected areas. / In Indonesia, WHO joined the MoH in a rapid assessment of the situation in North Sumatra; joint UN Missions were also conducted to search for staff and assess the situation within the week. / The WR for Thailand assessed affected areas in that country. / Two staff from WHO office in Nepal were mobilized to assist the regional relief operations. / Two senior staff from Headquarters travelled to Delhi, and additional experts were mobilized from Headquarters, and Regional Offices for Europe and the Western Pacific. Staff was on standby in the WHO Pan American Health Organization (PAHO) and Western Pacific Regional Office (WPRO). / By , WHO was in the process of establishing in New Delhi an operational support team for the Global Outbreak and Alert Response Network (GOARN). This is a mechanism for technical collaboration among existing institutions and networks to pool human and technical resources for the rapid identification, confirmation and response to outbreaks of international importance. The WHO team had the task of coordinating support from GOARN partners. GOARN was activated by 8 January 2005 and 120 epidemiologists were on standby. Twelve expert epidemiologists from GOARN and 10 from WHO were deployed in various affected areas. 3 January 2005 On 27 December 2004 By 3 January 2005 F r o m r e l i e f t o r e c o v e r y ASSESSMENT AND EMERGENCY RELIEF WHO PRIMARY FUNCTIONS Surveillance and response: Access to essential health care: In the first days, WHO aimed to maximize the life-saving and life-preserving impact of all humanitarian action through support to countries (and the international community) for the following actions: 1. Track patterns of life-threatening diseases among those at risk through prompt setting-up of a surveillance and early warning system with daily epidemiological reports. 2. Work with all partners to ensure equitable access G e a r i n g u p t o r e s p o n d Predicting disease following the emergency Days 1–3 Injury/drowning and deaths Safe disposal of corpses Injury management Needs assessment Days 3–5 Diarrhoeal diseases Health promotion Acute respiratory infections –Sanitation, environment –Water purification –Personal hygiene –Immunization (measles) –ORS Emerging disease surveillance (morbidity/mortality) 5–10 days As above plus: dehydration, As above plus: pneumonia, conjunctivitis, skin Antibiotics for pneumonia infections Drugs for skin infections and conjunctivitis >10 days As above plus: vector-borne Ongoing surveillance, health education, measures for diseases (malaria, dengue fever), vector control, antimalarials, supplementary typhoid fever, measles and feeding programme malnutrition Psychosocial support Psychosocial problems Rebuilding health infrastructure to adequate quality of essential health care through key hospitals and health centres. 3. Provide guidance on critical public health issues (response to disease outbreaks, water quality, excreta management, chemical threats, chronic disease management and mental health). The Organization aimed to fill critical gaps till others were able to take on the task. 4. Contribute to ensuring that medical supply chains functioned as efficiently as possible and responded to the needs of those affected. 5. Coordinate health actors at the local, national and international levels, with agreed strategies and joint action. Implementing the above required a marked scaling-up of WHO capacity and had considerable staffing/resource implications. A critical step was the establishment of operational platforms at the country level (both at national levels and in the worst- affected areas, especially in Indonesia and Sri Lanka) and in SEARO. SEARO determined country by country staffing requirements based on the functions listed above. The Health Action in Crises (HAC) division in WHO Headquarters in Geneva assisted with special assets in the areas of logistics, communications and security. Public health: Medical supplies: Joint action: Operational platform / A senior WHO official and the Emergency and Humanitarian Action (EHA) focal point in the Country Office was on the UNDAC evaluation team conducting assessments in the affected areas. / In Indonesia, WHO joined the MoH in a rapid assessment of the situation in North Sumatra; joint UN Missions were also conducted to search for staff and assess the situation within the week. / The WR for Thailand assessed affected areas in that country. / Two staff from WHO office in Nepal were mobilized to assist the regional relief operations. / Two senior staff from Headquarters travelled to Delhi, and additional experts were mobilized from Headquarters, and Regional Offices for Europe and the Western Pacific. Staff was on standby in the WHO Pan American Health Organization (PAHO) and Western Pacific Regional Office (WPRO). / By , WHO was in the process of establishing in New Delhi an operational support team for the Global Outbreak and Alert Response Network (GOARN). This is a mechanism for technical collaboration among existing institutions and networks to pool human and technical resources for the rapid identification, confirmation and response to outbreaks of international importance. The WHO team had the task of coordinating support from GOARN partners. GOARN was activated by 8 January 2005 and 120 epidemiologists were on standby. Twelve expert epidemiologists from GOARN and 10 from WHO were deployed in various affected areas. 3 January 2005 On 27 December 2004 By 3 January 2005 G e a r i n g u p t o r e s p o n dF r o m r e l i e f t o r e c o v e r y THE OPERATIONS ROOM: WHO SOUTH-EAST ASIA REGIONAL OFFICE Organization EHA Task Force Policy Group: EHA Task Force Working Group: Following the phone call from the Maldives, WHO SEARO moved into action immediately. Dr Samlee Plianbangchang, Regional Director, prepared to launch emergency response measures. He assigned responsibility for all aspects of the operations to Dr Poonam Khetrapal Singh, the Deputy Regional Director. With six Member Countries reeling under the impact of the disaster, WHO SEARO was the nodal point for coordinating WHO's efforts in the rescue and relief operations. WHO Headquarters provided constant support, particularly the HAC Division. Response plans were set in motion on 27 December 2004. The Operations Room (Ops Room) that was set up in SEARO formed the hub of WHO's response. It functioned 24 hours a day, and was manned entirely by Emergency and Humanitarian Action (EHA) and SEARO staff through the day, and in the evenings by volunteer professional and general staff. The team was constantly in touch with the affected countries. The Ops Room was organized as follows: The Policy Group was responsible for the policy decisions made by the Working Group. This group comprised senior management; its main functions were to guide the work of the Working Group and make decisions on certain issues that arose as the operations evolved. This Group was responsible for day-to-day operations. The team comprised the Ops Room coordinator, an information manager, a public health expert who looked at various problems arising from the situation, a logistics and supplies expert, staff dedicated to resource mobilization; a group dedicated to recruitment and travel of staff needed in the countries, and a communications person to deal with the media and various communication needs. The Task Force focused on the following: = coordinating the operations with countries; = identifying public health needs and deciding how best to address them; = coordinating of technical support to be provided to countries; and = managing and disseminating information. The Task Force also helped in the development of proposals for immediate and medium-term restoration of public health services, as well as for procurement of supplies for life-saving interventions. G e a r i n g u p t o r e s p o n dF r o m r e l i e f t o r e c o v e r y THE OPERATIONS ROOM: WHO SOUTH-EAST ASIA REGIONAL OFFICE Organization EHA Task Force Policy Group: EHA Task Force Working Group: Following the phone call from the Maldives, WHO SEARO moved into action immediately. Dr Samlee Plianbangchang, Regional Director, prepared to launch emergency response measures. He assigned responsibility for all aspects of the operations to Dr Poonam Khetrapal Singh, the Deputy Regional Director. With six Member Countries reeling under the impact of the disaster, WHO SEARO was the nodal point for coordinating WHO's efforts in the rescue and relief operations. WHO Headquarters provided constant support, particularly the HAC Division. Response plans were set in motion on 27 December 2004. The Operations Room (Ops Room) that was set up in SEARO formed the hub of WHO's response. It functioned 24 hours a day, and was manned entirely by Emergency and Humanitarian Action (EHA) and SEARO staff through the day, and in the evenings by volunteer professional and general staff. The team was constantly in touch with the affected countries. The Ops Room was organized as follows: The Policy Group was responsible for the policy decisions made by the Working Group. This group comprised senior management; its main functions were to guide the work of the Working Group and make decisions on certain issues that arose as the operations evolved. This Group was responsible for day-to-day operations. The team comprised the Ops Room coordinator, an information manager, a public health expert who looked at various problems arising from the situation, a logistics and supplies expert, staff dedicated to resource mobilization; a group dedicated to recruitment and travel of staff needed in the countries, and a communications person to deal with the media and various communication needs. The Task Force focused on the following: = coordinating the operations with countries; = identifying public health needs and deciding how best to address them; = coordinating of technical support to be provided to countries; and = managing and disseminating information. The Task Force also helped in the development of proposals for immediate and medium-term restoration of public health services, as well as for procurement of supplies for life-saving interventions. G e a r i n g u p t o r e s p o n d Scope of work Human resources: Media: Partnerships: The HR Cell took charge of recruiting doctors, nurses and health professionals from around the world. The best experts were recruited and deployed where they were most needed. Epidemiologists, water and sanitation experts, communicable disease experts, logisticians, information technology and communication experts responded to WHO's call for assistance. Since the first reports of the tsunami became available, mediapersons from all parts of the world looked to WHO to provide them with expert information about health concerns, outbreak precautions and measures taken to ensure health. Senior staff at WHO Headquarters and SEARO untiringly answered media queries. WHO's long-established partnerships with national and local authorities in each of the affected countries helped immensely. The immediate task at hand was to protect the health of the survivors and people rendered vulnerable by the disaster. WHO Representatives (WRs) in each of the affected countries were in close contact with the respective ministries of health, and worked together to develop strategies for response, such as providing supplies where needed, monitoring public health to prevent or contain outbreaks, replacing lost health assets and providing technical expertise to fill gaps. Basic health-care systems had to be re-established, safe drinking water provided, and disease surveillance systems set up for a target population of five million people. A few days after the tsunami struck, WHO officials formed a part of the United Nations Office for the Coordination of Humanitarian Affairs (UN OCHA) team. This team made a preliminary assessment of the extent and impact of the disaster on the ground. F r o m r e l i e f t o r e c o v e r y Information and communication technology (ICT): A subgroup to coordinate technical matters: It was essential to put effective communication systems in place. In the affected sites, local telecommunication infrastructure was badly damaged, which impeded relief operations considerably. The Tsunami Technical Group (TTG) was established under the guidance of the Communicable Diseases Director. This group coordinated mobilization of expertise, and prepared a database of experts who could be contacted when needed. Guidelines and tools were adapted and dispatched to the ravaged countries to help them cope with the disaster. A representative of the TTG was located in the Ops Room for better coordination of all the Group's activities and to anticipate requirements. Tsunami Technical Group (TTG) Coordinator »Facilitate meetings » mobilize technical units » attend SEARO task force meetings and coordinate response activities including resource mobilization Guidelines and tools Mobilization of experts* Surveillance/EWS/data management Communication update/ outbreaks update = Identify/adapt if required = Respond to specific requests = Technical proposals = Webpage posting = Consult WCO on needs = Database of technical experts = Short-list of experts for deployment = Directories—contact list = Compiling and analysis of data = Dissemination and use = Epidemic preparedness = Outbreak response = Feedback = Liaison with OR = Contact with WCO = Contact with field team (*) GOARN, WHO/HQ, other WHO Regions and countries mobilized OR Operations Room WCO WHO Country Office EWS Early Warning System GOARN Global Outbreak Alert and Response Network G e a r i n g u p t o r e s p o n d Scope of work Human resources: Media: Partnerships: The HR Cell took charge of recruiting doctors, nurses and health professionals from around the world. The best experts were recruited and deployed where they were most needed. Epidemiologists, water and sanitation experts, communicable disease experts, logisticians, information technology and communication experts responded to WHO's call for assistance. Since the first reports of the tsunami became available, mediapersons from all parts of the world looked to WHO to provide them with expert information about health concerns, outbreak precautions and measures taken to ensure health. Senior staff at WHO Headquarters and SEARO untiringly answered media queries. WHO's long-established partnerships with national and local authorities in each of the affected countries helped immensely. The immediate task at hand was to protect the health of the survivors and people rendered vulnerable by the disaster. WHO Representatives (WRs) in each of the affected countries were in close contact with the respective ministries of health, and worked together to develop strategies for response, such as providing supplies where needed, monitoring public health to prevent or contain outbreaks, replacing lost health assets and providing technical expertise to fill gaps. Basic health-care systems had to be re-established, safe drinking water provided, and disease surveillance systems set up for a target population of five million people. A few days after the tsunami struck, WHO officials formed a part of the United Nations Office for the Coordination of Humanitarian Affairs (UN OCHA) team. This team made a preliminary assessment of the extent and impact of the disaster on the ground. F r o m r e l i e f t o r e c o v e r y Information and communication technology (ICT): A subgroup to coordinate technical matters: It was essential to put effective communication systems in place. In the affected sites, local telecommunication infrastructure was badly damaged, which impeded relief operations considerably. The Tsunami Technical Group (TTG) was established under the guidance of the Communicable Diseases Director. This group coordinated mobilization of expertise, and prepared a database of experts who could be contacted when needed. Guidelines and tools were adapted and dispatched to the ravaged countries to help them cope with the disaster. A representative of the TTG was located in the Ops Room for better coordination of all the Group's activities and to anticipate requirements. Tsunami Technical Group (TTG) Coordinator »Facilitate meetings » mobilize technical units » attend SEARO task force meetings and coordinate response activities including resource mobilization Guidelines and tools Mobilization of experts* Surveillance/EWS/data management Communication update/ outbreaks update = Identify/adapt if required = Respond to specific requests = Technical proposals = Webpage posting = Consult WCO on needs = Database of technical experts = Short-list of experts for deployment = Directories—contact list = Compiling and analysis of data = Dissemination and use = Epidemic preparedness = Outbreak response = Feedback = Liaison with OR = Contact with WCO = Contact with field team (*) GOARN, WHO/HQ, other WHO Regions and countries mobilized OR Operations Room WCO WHO Country Office EWS Early Warning System GOARN Global Outbreak Alert and Response Network G e a r i n g u p t o r e s p o n d Activities Products and services Office set-ups in countries and field/suboffices: Information and communication technology (ICT): The Ops Room was the place where all decisions were made. The television in the background kept everyone updated with the latest news. From weeks 1 to 4, there was one day shift and two night shifts. At 8:30 in the morning, the Working Group met daily to decide on the tasks of the day. At 11:00 a.m., there were meetings with the Policy Group and teleconferences with the WRs in the countries. At 13:30 p.m., there were teleconferences between Senior Management and HQ Operations. The Technical Coordination Forum met every day during weeks 1–3, and twice a week thereafter. Demands from countries were received and had to be met. Pipelines (people, supplies, resources and information) within SEARO were kept track of in coordination with countries and WHO HQ, and the progress made in the countries was tracked on a weekly basis. = Situation reports from each of the countries were analysed and a regional summary situation report was sent out by evening to key people, including donors. These reports were also posted on the web. = Daily video and teleconferences were held in the initial two weeks and weekly thereafter. = Media support: Daily question and answer updates were held for all Ops Room staff so that they would be able to answer queries from the media. = Assistance and facilitation of country requests were provided, whether technical or administrative. = Responses were tracked and requests for assistance followed up. = Information archiving and filing was carried out. WHO's long partnership with the affected countries, and knowledge of prevalent local conditions and customs helped in dealing with the crisis. WHO placed its resources and expertise at the disposal of local governments. In each country, WRs were in close touch with the ministries of health. In the Ops Room, staff heard requests for help—human and material resources—and mobilized access to these. Assistance was provided for staffing and deployment to affected areas, as well as for procurement of medicines and vaccines. More than 80 guidelines were developed, transmitted to the field and posted on the web. ICT played a crucial role in F r o m r e l i e f t o r e c o v e r y assessment of the situation. Several information systems were used to disseminate accurate information effectively through electronic means such as web portals and list servers. The Ops Room and staff received ICT support and equipment, and the bandwidth was expanded. Tsunami country focal points were directly online, and collaborative workspace was developed. Support to WRs in the affected countries consisted of sending necessary supplies such as oral rehydration salts (ORS), chlorine powder, emergency medicine and surgical kits. Experts in disease surveillance and outbreak response, water and sanitation, logistics and management were sent to the countries, both to ascertain country needs and to ensure proper coordination among all health agencies for the best support to countries. Technical staff from other Regional Offices were sent where needed and some staff from SEARO were deputed to work full time in the tsunami operations (e.g. HR, Finance). = Guidelines were issued for fast-track supplies and procurement, finance management and disbursement, human resources, etc. = Staff support was provided in WHO Country Offices (WCOs), Field Offices and in SEARO. A 100-day strategy for dealing with the crisis was adopted at the end of December 2004. It was expected to run till the end of March 2005. During this period, WHO focused its operational activities in Indonesia, Sri Lanka and the Maldives. India and Thailand did not request or require financial help. The WHO Office in Yangon supported the international efforts. = Monitoring public health to provide early warning of emerging health threats and enabling timely organization of necessary response; = Replacing lost assets, infrastructure and supplies that were crucial to meeting additional health threats consequent to the disaster, as well as the reactivation of previously available health services; SEARO support to WHO Country Offices SEARO team in countries Administrative support THE 100-DAY STRATEGY Objectives G e a r i n g u p t o r e s p o n d Activities Products and services Office set-ups in countries and field/suboffices: Information and communication technology (ICT): The Ops Room was the place where all decisions were made. The television in the background kept everyone updated with the latest news. From weeks 1 to 4, there was one day shift and two night shifts. At 8:30 in the morning, the Working Group met daily to decide on the tasks of the day. At 11:00 a.m., there were meetings with the Policy Group and teleconferences with the WRs in the countries. At 13:30 p.m., there were teleconferences between Senior Management and HQ Operations. The Technical Coordination Forum met every day during weeks 1–3, and twice a week thereafter. Demands from countries were received and had to be met. Pipelines (people, supplies, resources and information) within SEARO were kept track of in coordination with countries and WHO HQ, and the progress made in the countries was tracked on a weekly basis. = Situation reports from each of the countries were analysed and a regional summary situation report was sent out by evening to key people, including donors. These reports were also posted on the web. = Daily video and teleconferences were held in the initial two weeks and weekly thereafter. = Media support: Daily question and answer updates were held for all Ops Room staff so that they would be able to answer queries from the media. = Assistance and facilitation of country requests were provided, whether technical or administrative. = Responses were tracked and requests for assistance followed up. = Information archiving and filing was carried out. WHO's long partnership with the affected countries, and knowledge of prevalent local conditions and customs helped in dealing with the crisis. WHO placed its resources and expertise at the disposal of local governments. In each country, WRs were in close touch with the ministries of health. In the Ops Room, staff heard requests for help—human and material resources—and mobilized access to these. Assistance was provided for staffing and deployment to affected areas, as well as for procurement of medicines and vaccines. More than 80 guidelines were developed, transmitted to the field and posted on the web. ICT played a crucial role in F r o m r e l i e f t o r e c o v e r y assessment of the situation. Several information systems were used to disseminate accurate information effectively through electronic means such as web portals and list servers. The Ops Room and staff received ICT support and equipment, and the bandwidth was expanded. Tsunami country focal points were directly online, and collaborative workspace was developed. Support to WRs in the affected countries consisted of sending necessary supplies such as oral rehydration salts (ORS), chlorine powder, emergency medicine and surgical kits. Experts in disease surveillance and outbreak response, water and sanitation, logistics and management were sent to the countries, both to ascertain country needs and to ensure proper coordination among all health agencies for the best support to countries. Technical staff from other Regional Offices were sent where needed and some staff from SEARO were deputed to work full time in the tsunami operations (e.g. HR, Finance). = Guidelines were issued for fast-track supplies and procurement, finance management and disbursement, human resources, etc. = Staff support was provided in WHO Country Offices (WCOs), Field Offices and in SEARO. A 100-day strategy for dealing with the crisis was adopted at the end of December 2004. It was expected to run till the end of March 2005. During this period, WHO focused its operational activities in Indonesia, Sri Lanka and the Maldives. India and Thailand did not request or require financial help. The WHO Office in Yangon supported the international efforts. = Monitoring public health to provide early warning of emerging health threats and enabling timely organization of necessary response; = Replacing lost assets, infrastructure and supplies that were crucial to meeting additional health threats consequent to the disaster, as well as the reactivation of previously available health services; SEARO support to WHO Country Offices SEARO team in countries Administrative support THE 100-DAY STRATEGY Objectives G e a r i n g u p t o r e s p o n dF r o m r e l i e f t o r e c o v e r y = Providing technical expertise to health authorities to enable gap-filling; = Establishing and sustaining effective regional, national and local health coordination to ensure efficient deployment of assistance; = Ensuring up-to-date information on the health situation to local, national and international partners; = Refining health needs assessment and facilitating early recovery and rehabilitation. Finalize assessments and establish disease surveillance. Provide medical and surgical care to the injured. Ensure that survivors had access to clean water in adequate quantity and that those who had lost their homes did not live in conditions that were overcrowded, unhygienic and/or dangerous. Prepare for possible outbreaks of malaria and dengue fever that were endemic in South-East Asia. Assess the environmental risks posed by contamination from toxic chemicals as hazardous industries, pesticide warehouses for agriculture, gasoline tanks, oil pipelines and/or waste disposal sites had been either flooded or destroyed. = WHO supported national capacities for disease investigation and verification in Sri Lanka, Indonesia, Thailand and India. Epidemic intelligence was extended on the ground through local health authorities, nongovernmental organizations (NGOs) and UN Agencies. = Assessments were carried out on health infrastructure, and requirements for medical care and supplies in collaboration with local authorities and the wider UN system. = WHO's 24-hour crisis rooms operated in Geneva and New Delhi. Emergency management units (EMUs) were set up in strategic locations and additional logisticians were moved to the field. = Teams of health experts were deployed to Indonesia, Sri Lanka and the Maldives. = WHO mobilized health kits to cover essential medicine needs. = WHO circulated an Emergency Health Action Programme for South-East Asia, identifying the immediate needs for the next three months. The financial requirements for WHO's action over this period was US$ 40 million. Health priorities for WHO First: Second: Third: Fourth: Fifth: Action taken by WHO G e a r i n g u p t o r e s p o n dF r o m r e l i e f t o r e c o v e r y = Providing technical expertise to health authorities to enable gap-filling; = Establishing and sustaining effective regional, national and local health coordination to ensure efficient deployment of assistance; = Ensuring up-to-date information on the health situation to local, national and international partners; = Refining health needs assessment and facilitating early recovery and rehabilitation. Finalize assessments and establish disease surveillance. Provide medical and surgical care to the injured. Ensure that survivors had access to clean water in adequate quantity and that those who had lost their homes did not live in conditions that were overcrowded, unhygienic and/or dangerous. Prepare for possible outbreaks of malaria and dengue fever that were endemic in South-East Asia. Assess the environmental risks posed by contamination from toxic chemicals as hazardous industries, pesticide warehouses for agriculture, gasoline tanks, oil pipelines and/or waste disposal sites had been either flooded or destroyed. = WHO supported national capacities for disease investigation and verification in Sri Lanka, Indonesia, Thailand and India. Epidemic intelligence was extended on the ground through local health authorities, nongovernmental organizations (NGOs) and UN Agencies. = Assessments were carried out on health infrastructure, and requirements for medical care and supplies in collaboration with local authorities and the wider UN system. = WHO's 24-hour crisis rooms operated in Geneva and New Delhi. Emergency management units (EMUs) were set up in strategic locations and additional logisticians were moved to the field. = Teams of health experts were deployed to Indonesia, Sri Lanka and the Maldives. = WHO mobilized health kits to cover essential medicine needs. = WHO circulated an Emergency Health Action Programme for South-East Asia, identifying the immediate needs for the next three months. The financial requirements for WHO's action over this period was US$ 40 million. Health priorities for WHO First: Second: Third: Fourth: Fifth: Action taken by WHO G e a r i n g u p t o r e s p o n d WHO collaborated with the ministries of health and international partners in the affected countries to help determine the damage, needs and capacities. WHO also drew up strategic plans to provide effective support. A few core concerns were focused on: = Small teams were dispatched to all affected countries to make a rapid assessment of the extent of damage to the health infrastructure, the number of people displaced, their living conditions, access to safe water, sanitation and food. = WHO mobilized 190 emergency health kits. Each of these kits caters to the needs of 10 000 people for more than three months. These kits had enough medical supplies to cover the essential medicine needs of about two million people for three months. The nine kits that were immediately available were distributed in the Region, and 140 other kits to treat diarrhoea and surgical conditions were put in place. = WHO's priority was to pre-empt outbreaks of communicable diseases. Steps were taken to set up effective surveillance systems that would provide early warning of impending outbreaks. Anticipated health problems were mapped and a predictive chart devised based on previous data and experience. = Experts in various fields were identified and deployed as and where needed. Worldwide solidarity with the affected populations was swift and generous, but needed to continue well beyond the immediate disaster period. The Flash Appeal reflected the efforts of about forty UN agencies and NGOs to plan and implement a strategic, efficient and coordinated response to the needs of approximately five million people. It focused on supporting people in Indonesia, Maldives, Myanmar, Making a rapid assessment of the situation: Meeting the immediate needs of the survivors: Preparing for disease outbreaks and malnutrition: Mobilizing human resources to meet the immediate challenges: FLASH APPEAL F r o m r e l i e f t o r e c o v e r y Seychelles, Somalia and Sri Lanka from January to the end of June 2005, and called for US$ 977 million to fund the critical work of many UN agencies and NGOs. Programmes focused on keeping people alive and supporting their efforts to recover in the agriculture, education, health, food, shelter, and water and sanitation sectors. Reaching isolated communities was a serious challenge because of the destruction of transport infrastructure and communication systems. This required the establishment of complex logistics and operations platforms. Strong coordination with and between governments, and the international aid community ensured that assistance was efficient and reached the people who needed it most. The regional scope of the tsunami disaster required a response in part on a regional scale. Logistics, procurement, coordination, information systems, resource allocation and management conducted at a regional level, with full information and economies of scale, would significantly improve the efficiency and effectiveness of the aid response. The projects that operated on a regional level comprised food aid, joint logistics and air services, coordination, regional health, technical support, early warning systems, management, monitoring and evaluation, protection and human rights, capacity-building, and security for humanitarian operations. The funding requested for regional-level aid amounted to US$ 352 908 700. For an optimally effective and efficient aid response that would confront the regional extent of this disaster, coordination would have to operate on a regional level. Agencies therefore sought support to establish or reinforce regional support systems, enhance field-level coordination of relief activities, keep the international community informed of the situation and needs in affected countries, and avert gaps in response to the disaster for a period of six months. Throughout these activities, agencies aimed at ensuring a smooth transition to the recovery and reconstruction phase, and at monitoring the implementation of projects contained in the Appeal. Agencies also aimed at strengthening response preparedness, including contingency planning and early warning mechanisms to Regional programme Response plans Coordination and support services G e a r i n g u p t o r e s p o n d WHO collaborated with the ministries of health and international partners in the affected countries to help determine the damage, needs and capacities. WHO also drew up strategic plans to provide effective support. A few core concerns were focused on: = Small teams were dispatched to all affected countries to make a rapid assessment of the extent of damage to the health infrastructure, the number of people displaced, their living conditions, access to safe water, sanitation and food. = WHO mobilized 190 emergency health kits. Each of these kits caters to the needs of 10 000 people for more than three months. These kits had enough medical supplies to cover the essential medicine needs of about two million people for three months. The nine kits that were immediately available were distributed in the Region, and 140 other kits to treat diarrhoea and surgical conditions were put in place. = WHO's priority was to pre-empt outbreaks of communicable diseases. Steps were taken to set up effective surveillance systems that would provide early warning of impending outbreaks. Anticipated health problems were mapped and a predictive chart devised based on previous data and experience. = Experts in various fields were identified and deployed as and where needed. Worldwide solidarity with the affected populations was swift and generous, but needed to continue well beyond the immediate disaster period. The Flash Appeal reflected the efforts of about forty UN agencies and NGOs to plan and implement a strategic, efficient and coordinated response to the needs of approximately five million people. It focused on supporting people in Indonesia, Maldives, Myanmar, Making a rapid assessment of the situation: Meeting the immediate needs of the survivors: Preparing for disease outbreaks and malnutrition: Mobilizing human resources to meet the immediate challenges: FLASH APPEAL F r o m r e l i e f t o r e c o v e r y Seychelles, Somalia and Sri Lanka from January to the end of June 2005, and called for US$ 977 million to fund the critical work of many UN agencies and NGOs. Programmes focused on keeping people alive and supporting their efforts to recover in the agriculture, education, health, food, shelter, and water and sanitation sectors. Reaching isolated communities was a serious challenge because of the destruction of transport infrastructure and communication systems. This required the establishment of complex logistics and operations platforms. Strong coordination with and between governments, and the international aid community ensured that assistance was efficient and reached the people who needed it most. The regional scope of the tsunami disaster required a response in part on a regional scale. Logistics, procurement, coordination, information systems, resource allocation and management conducted at a regional level, with full information and economies of scale, would significantly improve the efficiency and effectiveness of the aid response. The projects that operated on a regional level comprised food aid, joint logistics and air services, coordination, regional health, technical support, early warning systems, management, monitoring and evaluation, protection and human rights, capacity-building, and security for humanitarian operations. The funding requested for regional-level aid amounted to US$ 352 908 700. For an optimally effective and efficient aid response that would confront the regional extent of this disaster, coordination would have to operate on a regional level. Agencies therefore sought support to establish or reinforce regional support systems, enhance field-level coordination of relief activities, keep the international community informed of the situation and needs in affected countries, and avert gaps in response to the disaster for a period of six months. Throughout these activities, agencies aimed at ensuring a smooth transition to the recovery and reconstruction phase, and at monitoring the implementation of projects contained in the Appeal. Agencies also aimed at strengthening response preparedness, including contingency planning and early warning mechanisms to Regional programme Response plans Coordination and support services G e a r i n g u p t o r e s p o n d ensure that humanitarian action in tsunami-affected countries was supported and coordinated for optimal efficiency, effectiveness and speed. UN OCHA = Maintained and strengthened its support to the UN country teams in Indonesia, Maldives and Sri Lanka. To support Aceh, Indonesia, which suffered serious human loss and damage in coastal areas that were difficult to access, OCHA established an area support office in Sumatra and a Humanitar ian Information Centre (HIC) in Aceh. = Established and strengthened its Regional Support Office in Bangkok to support all the disaster-affected countries, thereby promoting regional cooperation. A suboffice was also established near the most affected countries to provide logistic support. = In Geneva, at headquarters level, OCHA's Special Task Force for the tsunami disaster was strengthened to support field and regional relief activities. The success of all humanitarian work is measured by human survival and attainment of health. Urgent action was needed to address the critical public health needs of about five million people in the South-East Asia Region. They lacked access to basic needs such as clean water, adequate shelter, food, sanitation and health infrastructure, and this would have a significant impact on their near- and long-term health. Therefore, the global response to this public health crisis would be a critical indicator of the success of the overall relief and recovery effort. The Regional Appeal supported and complemented the various country-specific Coordination activities Health F r o m r e l i e f t o r e c o v e r y appeals that were part of the Flash Appeal. WHO provided a speedy, credible and appropriate emergency response to countries that were severely affected and also worked with the national authorities of those less badly affected. The core elements of this programme were developed in order to have an effective impact on urgent life-saving measures, and medium- and longer-term recovery efforts in the affected South-East Asian countries. These included: (i) prompt set t ing-up of d isease surveillance and response efforts through early warning systems and the GOARN; (ii) coordination of health actors at the local, national and international level; (iii) guidance on addressing all major public health issues in the region and filling critical gaps; (iv) assessment of health infrastructure and the quality of services in hospitals and health centres; and (v) monitoring the effective and efficient functioning of medical supply chains. WHO requested a total of US$ 60.3 m i l l i o n f o r t h e s u c c e s s f u l implementation of tsunami-related emergency programmes. Following more detailed assessments, if a substantial deterioration in the structures was found, then the health needs would escalate. Effective management at the regional level was essential to ensuring that the delivery of this programme was efficient and met the needs of the affected population so as to save lives and reduce suffering. The Regional Support Office established in Bangkok ensured connectivity with the Joint Task Force and the core group. Regional-level planning was carried out so that WHO could integrate the emergency plan with the long-term WHO Plan of Work in the countries to ensure the continuum from relief to recovery and G e a r i n g u p t o r e s p o n d ensure that humanitarian action in tsunami-affected countries was supported and coordinated for optimal efficiency, effectiveness and speed. UN OCHA = Maintained and strengthened its support to the UN country teams in Indonesia, Maldives and Sri Lanka. To support Aceh, Indonesia, which suffered serious human loss and damage in coastal areas that were difficult to access, OCHA established an area support office in Sumatra and a Humanitar ian Information Centre (HIC) in Aceh. = Established and strengthened its Regional Support Office in Bangkok to support all the disaster-affected countries, thereby promoting regional cooperation. A suboffice was also established near the most affected countries to provide logistic support. = In Geneva, at headquarters level, OCHA's Special Task Force for the tsunami disaster was strengthened to support field and regional relief activities. The success of all humanitarian work is measured by human survival and attainment of health. Urgent action was needed to address the critical public health needs of about five million people in the South-East Asia Region. They lacked access to basic needs such as clean water, adequate shelter, food, sanitation and health infrastructure, and this would have a significant impact on their near- and long-term health. Therefore, the global response to this public health crisis would be a critical indicator of the success of the overall relief and recovery effort. The Regional Appeal supported and complemented the various country-specific Coordination activities Health F r o m r e l i e f t o r e c o v e r y appeals that were part of the Flash Appeal. WHO provided a speedy, credible and appropriate emergency response to countries that were severely affected and also worked with the national authorities of those less badly affected. The core elements of this programme were developed in order to have an effective impact on urgent life-saving measures, and medium- and longer-term recovery efforts in the affected South-East Asian countries. These included: (i) prompt set t ing-up of d isease surveillance and response efforts through early warning systems and the GOARN; (ii) coordination of health actors at the local, national and international level; (iii) guidance on addressing all major public health issues in the region and filling critical gaps; (iv) assessment of health infrastructure and the quality of services in hospitals and health centres; and (v) monitoring the effective and efficient functioning of medical supply chains. WHO requested a total of US$ 60.3 m i l l i o n f o r t h e s u c c e s s f u l implementation of tsunami-related emergency programmes. Following more detailed assessments, if a substantial deterioration in the structures was found, then the health needs would escalate. Effective management at the regional level was essential to ensuring that the delivery of this programme was efficient and met the needs of the affected population so as to save lives and reduce suffering. The Regional Support Office established in Bangkok ensured connectivity with the Joint Task Force and the core group. Regional-level planning was carried out so that WHO could integrate the emergency plan with the long-term WHO Plan of Work in the countries to ensure the continuum from relief to recovery and G e a r i n g u p t o r e s p o n dF r o m r e l i e f t o r e c o v e r y development. WHO also supported the ministries of health in each of the affected countries to conduct in-depth assessments of the recovery and reconstruction needs of the health sector, building on its expertise accumulated in handling crisis situations such as floods and internal conflict in Sri Lanka, earthquake and internal conflict in Indonesia, and epidemics and pandemics such as severe acute respiratory syndrome (SARS) and avian flu in various countries. This ensured that programmes such as disease surveillance and health information systems would persist after the emergency phase. Looking forward, there was a need to organize lessons learnt exercises to determine how the UN system and the health sector reacted to the unprecedented disaster. Critical evaluation of the response to this disaster by the humanitarian community was conducted in the affected areas. = Prompt set-up of a disease surveillance system to monitor the public health situation, provide early warning of emerging health threats to enable the timely organization of necessary response; = Support ministries of health in coordinating health sector activities to help ensure the best use of available resources and avoid duplication of activities; = Manage the mobilization and coordination of technical staff, health supplies and medical equipment; = Establish a functioning operations platform at the Regional Office and support the emergency joint task force in assessment and coordination activities; = Develop a strategy that would integrate the relief work into WHO's long-term plan of work; = Organize a lessons learnt exercise and conduct critical evaluation of the emergency relief work. Activities in the area of health G e a r i n g u p t o r e s p o n dF r o m r e l i e f t o r e c o v e r y development. WHO also supported the ministries of health in each of the affected countries to conduct in-depth assessments of the recovery and reconstruction needs of the health sector, building on its expertise accumulated in handling crisis situations such as floods and internal conflict in Sri Lanka, earthquake and internal conflict in Indonesia, and epidemics and pandemics such as severe acute respiratory syndrome (SARS) and avian flu in various countries. This ensured that programmes such as disease surveillance and health information systems would persist after the emergency phase. Looking forward, there was a need to organize lessons learnt exercises to determine how the UN system and the health sector reacted to the unprecedented disaster. Critical evaluation of the response to this disaster by the humanitarian community was conducted in the affected areas. = Prompt set-up of a disease surveillance system to monitor the public health situation, provide early warning of emerging health threats to enable the timely organization of necessary response; = Support ministries of health in coordinating health sector activities to help ensure the best use of available resources and avoid duplication of activities; = Manage the mobilization and coordination of technical staff, health supplies and medical equipment; = Establish a functioning operations platform at the Regional Office and support the emergency joint task force in assessment and coordination activities; = Develop a strategy that would integrate the relief work into WHO's long-term plan of work; = Organize a lessons learnt exercise and conduct critical evaluation of the emergency relief work. Activities in the area of health G e a r i n g u p t o r e s p o n d Country-specific appeals Indonesia Maldives Sri Lanka The UN, together with its partners, made a commitment to assist victims and to support Indonesia in the massive effort required to meet immediate humanitarian needs and to plan for and address longer-term recovery and rehabilitation requirements. This Appeal represented the integrated and consolidated requirements of UN agencies and NGOs operating in Indonesia, most of which had considerable experience in providing aid and development assistance in the Aceh region. At this stage, sectoral priorities for the international community included: health, water and sanitation, food, coordination and support services, shelter and non-food items, protection, education and economic recovery including infrastructure rehabilitation. The total funds requested for providing support to all sectors in Indonesia amounted to US$ 371 554 203 (plus a further US$ 102 000 000 for food). The total funds required in the health sector were US$ 69 610 000. The magnitude and scale of the disaster relative to the size and population of the Maldives were unprecedented in living memory. The tsunami inundated the entire country. The Maldives had a positive record in the effective utilization of international assistance. The World Bank ranked the country in the top five in terms of aid effectiveness. The country's response to the tsunami, along with rapid socioeconomic progress in the past two decades, promised effective and efficient use of international aid. Through this Appeal, UN Agencies sought US$ 66 497 000 to address urgent humanitarian needs and begin the recovery and reconstruction process. A sum of US$ 10 605 000 was requested in the area of health. In Sri Lanka, the Appeal requested funding support to provide food, potable water, health services, sanitation, shelter, and non- food items such as hygiene and cooking kits to the displaced as well as to those most critically affected by the tsunami. F r o m r e l i e f t o r e c o v e r y The UN and its partners requested US$ 166 936 146 to provide urgent assistance to the Sri Lankan people for a period of six months. In the area of health, the sum requested was US$ 28 600 000. Myanmar had been spared a large-scale emergency. The Government of Myanmar responded to the situation by providing support to the affected population and sharing available information on the impact of the tsunami with the relief community. Relief agencies rapidly organized and coordinated assessments in accessible areas and found needs for safe drinking water, food, medicines, shelter, and non-food items (blankets, clothes, cooking sets, etc.). UN agencies closely coordinated their response with international NGOs and the Red Cross movement. The situation required agencies to scale up and/or redirect their existing programmes to tsunami-affected areas to provide adequate support for a quick recovery. UN agencies therefore reallocated existing resources from available in-country funds and supplies as well as called for additional resources through their respective regional appeal mechanisms to cover the immediate response. Planning and costing of medium-term recovery and rehabilitation activities were based on the results of needs assessments. With the Operations Room established and fully functional in SEARO, and support extended to Country Offices, WHO moved into swift and targeted action. The entire Organization was geared up to respond to the overwhelming needs of the tsunami-affected countries. With the backing of several UN Agencies, INGOs, NGOs and several other organizations, WHO mounted a coordinated response that would ensure that affected countries would build back better. Myanmar REACHING OUT G e a r i n g u p t o r e s p o n d Country-specific appeals Indonesia Maldives Sri Lanka The UN, together with its partners, made a commitment to assist victims and to support Indonesia in the massive effort required to meet immediate humanitarian needs and to plan for and address longer-term recovery and rehabilitation requirements. This Appeal represented the integrated and consolidated requirements of UN agencies and NGOs operating in Indonesia, most of which had considerable experience in providing aid and development assistance in the Aceh region. At this stage, sectoral priorities for the international community included: health, water and sanitation, food, coordination and support services, shelter and non-food items, protection, education and economic recovery including infrastructure rehabilitation. The total funds requested for providing support to all sectors in Indonesia amounted to US$ 371 554 203 (plus a further US$ 102 000 000 for food). The total funds required in the health sector were US$ 69 610 000. The magnitude and scale of the disaster relative to the size and population of the Maldives were unprecedented in living memory. The tsunami inundated the entire country. The Maldives had a positive record in the effective utilization of international assistance. The World Bank ranked the country in the top five in terms of aid effectiveness. The country's response to the tsunami, along with rapid socioeconomic progress in the past two decades, promised effective and efficient use of international aid. Through this Appeal, UN Agencies sought US$ 66 497 000 to address urgent humanitarian needs and begin the recovery and reconstruction process. A sum of US$ 10 605 000 was requested in the area of health. In Sri Lanka, the Appeal requested funding support to provide food, potable water, health services, sanitation, shelter, and non- food items such as hygiene and cooking kits to the displaced as well as to those most critically affected by the tsunami. F r o m r e l i e f t o r e c o v e r y The UN and its partners requested US$ 166 936 146 to provide urgent assistance to the Sri Lankan people for a period of six months. In the area of health, the sum requested was US$ 28 600 000. Myanmar had been spared a large-scale emergency. The Government of Myanmar responded to the situation by providing support to the affected population and sharing available information on the impact of the tsunami with the relief community. Relief agencies rapidly organized and coordinated assessments in accessible areas and found needs for safe drinking water, food, medicines, shelter, and non-food items (blankets, clothes, cooking sets, etc.). UN agencies closely coordinated their response with international NGOs and the Red Cross movement. The situation required agencies to scale up and/or redirect their existing programmes to tsunami-affected areas to provide adequate support for a quick recovery. UN agencies therefore reallocated existing resources from available in-country funds and supplies as well as called for additional resources through their respective regional appeal mechanisms to cover the immediate response. Planning and costing of medium-term recovery and rehabilitation activities were based on the results of needs assessments. With the Operations Room established and fully functional in SEARO, and support extended to Country Offices, WHO moved into swift and targeted action. The entire Organization was geared up to respond to the overwhelming needs of the tsunami-affected countries. With the backing of several UN Agencies, INGOs, NGOs and several other organizations, WHO mounted a coordinated response that would ensure that affected countries would build back better. Myanmar REACHING OUT C O U N T R Y R E P O R T S I n d o n e s i a S r i L a n k a T h e M a l d i v e s I n d i a T h a i l a n d M y a n m a r C O U N T R Y R E P O R T S I n d o n e s i a S r i L a n k a T h e M a l d i v e s I n d i a T h a i l a n d M y a n m a r PHASE I: EMERGENCY RELIEF ASSESSMENT Affected areas Affected population Indonesia was the country closest to the earthquake. The ensuing tsunami left over 130 000 dead, 37 000 missing and over 500 000 displaced. A national disaster was declared by the President of Indonesia. The Vice President visited the disaster- affected areas on 27 December 2004. Of the 33 provinces in the country, two were primarily affected—Nanggroe Aceh Darussalam (NAD) and North Sumatra. In NAD province, 14 out of 21 districts were affected and in North Sumatra, four of 27 districts. By 24 January 2005, revised estimates reported that more than 166 000 people had died during the earthquake and tsunami. An estimated 404 693 in NAD and 4000 people in North Sumatra provinces were homeless and thousands of houses damaged. A large number suffered from injuries of different degrees. Almost all people of all age groups, particularly children and poorer households in the affected areas, had suffered from the disaster. A large number of the disaster-affected population did not have food, shelter and access to health care. At the same time, the basic infrastructure of the communities had all but collapsed. Electricity, water Indonesia 130 736 167 736 Country Fatalities Total Source1Missing 1 Some countries have not disaggregated between the deceased and the missing.M AG NI TU DE 37 000 Joint One Year Report, Dec 2005 Report undertaken by BRR, UN Office of the Recovery Coordinator, United Nations Development Program (UNDP), Asian Development Bank, International Federation of Red Cross and Red Crescent Societies (IFRC) and the World Bank. INDONESIA PHASE I: EMERGENCY RELIEF ASSESSMENT Affected areas Affected population Indonesia was the country closest to the earthquake. The ensuing tsunami left over 130 000 dead, 37 000 missing and over 500 000 displaced. A national disaster was declared by the President of Indonesia. The Vice President visited the disaster- affected areas on 27 December 2004. Of the 33 provinces in the country, two were primarily affected—Nanggroe Aceh Darussalam (NAD) and North Sumatra. In NAD province, 14 out of 21 districts were affected and in North Sumatra, four of 27 districts. By 24 January 2005, revised estimates reported that more than 166 000 people had died during the earthquake and tsunami. An estimated 404 693 in NAD and 4000 people in North Sumatra provinces were homeless and thousands of houses damaged. A large number suffered from injuries of different degrees. Almost all people of all age groups, particularly children and poorer households in the affected areas, had suffered from the disaster. A large number of the disaster-affected population did not have food, shelter and access to health care. At the same time, the basic infrastructure of the communities had all but collapsed. Electricity, water Indonesia 130 736 167 736 Country Fatalities Total Source1Missing 1 Some countries have not disaggregated between the deceased and the missing.M AG NI TU DE 37 000 Joint One Year Report, Dec 2005 Report undertaken by BRR, UN Office of the Recovery Coordinator, United Nations Development Program (UNDP), Asian Development Bank, International Federation of Red Cross and Red Crescent Societies (IFRC) and the World Bank. INDONESIA F r o m r e l i e f t o r e c o v e r y / 600 000 people in Aceh province alone (25% of its population) lost their source of livelihood, including 130 000 farmers, 300 000 fishermen, and 170 000 small businesses. (Source: OCHA Indonesia, 20 June 2005) / A total of 141 000 houses were destroyed in Aceh and Nias. (Source: BRR and World Bank, “Rebuilding a Better Aceh and Nias,” October 2005) / 2240 schools were destroyed in Aceh and Nias, and 2364 education staff were killed. (Source: IOM; BRR, October 2005) / 592 health facilities were destroyed in Aceh. (Source: WHO, February 2005) / Over 100 000 wells were contaminated with salt water or left in need of repair. (Source: United Nations Children's Fund [UNICEF] and OCHA, 20 June 2005) / 2676 bridges were either destroyed or sustained major damage. (Source: IOM, Post-Tsunami Damage Assessment in NAD; IOM, Post Tsunami Damage Assessment in Nias and Simeulue Islands, June 2005) / A total of 3229 fishing vessels were lost or damaged. (Source: FAO; Department of Social Affairs, Government of Indonesia) Damages and losses / Total estimated value of damages: US$ 4.5 billion / Total estimated needs for long-term recovery: US$ 5.0–5.5 billion / Total funds pledged for long-term recovery: US$ 6.5 billion. Funds from nongovernmental organizations (NGOs) comprised approximately US$ 2.5 billion of this total figure. The remainder came from multilateral and bilateral donors and international financial institutions. In addition, Indonesia's government spent an estimated US$ 2 billion on recovery. (Source: World Bank, July 2005; the funds from both NGOs and the Indonesian government are estimates.) / Total funds secured for long-term recovery: US$ 4.5 billion. Of this, US$ 2.5 billion were secured from NGOs and US$ 1.46 billion from multilateral and bilateral donors. (Source: World Bank, July 2005; NGO funds are estimates.) / Outstanding pledges (promised but not yet secured) from multilateral and bilateral donors: US$ 2 billion. (Source: World Bank, July 2005) Financial implications and fuel supply in large parts of the disaster-affected areas were severely disrupted, and people had few means to move away from the area because of the poor state of the roads. Impact on vulnerable populations / In Aceh province, male survivors outnumbered women by a ratio of almost 3:1. (Source: Oxfam, “Tsunami's Impact on Women,” 26 March 2005) / The tsunami severely damaged medical facilities and killed much of the female labour force. Of the 51 regional health centres with reproductive services, 41 were damaged, and 30% of midwives were reportedly dead or missing as a result of the tsunami. (United Nations Population Fund [UNFPA], August 2005) I n d o n e s i a THE RESPONSE Partnerships The Government set up temporary shelters/distribution points and distributed essential items to households. The MoH provided emergency medical care, established an early warning and surveillance system, ensured safe water and sanitation, food, instituted vector control measures, and provided immunization, health education and social mobilization immediately. All dead bodies were managed by the local people in the traditional manner. WHO's response was closely coordinated with the UN disaster preparedness and management group and with international NGOs, through the Red Cross-led Tsunami Assistance Coordination Group. WHO's primary role was that of providing technical support to the MoH. WHO technical guidelines for emergencies were disseminated. Regular updates to the diplomatic and international community were organized through distribution of situation reports and WHO press releases. WHO focused on reducing the risk of disease outbreaks and morbidity by supporting disease surveillance and providing emergency medical supplies as requested by the MoH. WHO established a field presence in Banda Aceh. A primary office was opened in Banda Aceh and suboffices in Medan, Calang and Meulaboh. The WHO Country Office was strengthened with public health experts from WHO Western Pacific F r o m r e l i e f t o r e c o v e r y / 600 000 people in Aceh province alone (25% of its population) lost their source of livelihood, including 130 000 farmers, 300 000 fishermen, and 170 000 small businesses. (Source: OCHA Indonesia, 20 June 2005) / A total of 141 000 houses were destroyed in Aceh and Nias. (Source: BRR and World Bank, “Rebuilding a Better Aceh and Nias,” October 2005) / 2240 schools were destroyed in Aceh and Nias, and 2364 education staff were killed. (Source: IOM; BRR, October 2005) / 592 health facilities were destroyed in Aceh. (Source: WHO, February 2005) / Over 100 000 wells were contaminated with salt water or left in need of repair. (Source: United Nations Children's Fund [UNICEF] and OCHA, 20 June 2005) / 2676 bridges were either destroyed or sustained major damage. (Source: IOM, Post-Tsunami Damage Assessment in NAD; IOM, Post Tsunami Damage Assessment in Nias and Simeulue Islands, June 2005) / A total of 3229 fishing vessels were lost or damaged. (Source: FAO; Department of Social Affairs, Government of Indonesia) Damages and losses / Total estimated value of damages: US$ 4.5 billion / Total estimated needs for long-term recovery: US$ 5.0–5.5 billion / Total funds pledged for long-term recovery: US$ 6.5 billion. Funds from nongovernmental organizations (NGOs) comprised approximately US$ 2.5 billion of this total figure. The remainder came from multilateral and bilateral donors and international financial institutions. In addition, Indonesia's government spent an estimated US$ 2 billion on recovery. (Source: World Bank, July 2005; the funds from both NGOs and the Indonesian government are estimates.) / Total funds secured for long-term recovery: US$ 4.5 billion. Of this, US$ 2.5 billion were secured from NGOs and US$ 1.46 billion from multilateral and bilateral donors. (Source: World Bank, July 2005; NGO funds are estimates.) / Outstanding pledges (promised but not yet secured) from multilateral and bilateral donors: US$ 2 billion. (Source: World Bank, July 2005) Financial implications and fuel supply in large parts of the disaster-affected areas were severely disrupted, and people had few means to move away from the area because of the poor state of the roads. Impact on vulnerable populations / In Aceh province, male survivors outnumbered women by a ratio of almost 3:1. (Source: Oxfam, “Tsunami's Impact on Women,” 26 March 2005) / The tsunami severely damaged medical facilities and killed much of the female labour force. Of the 51 regional health centres with reproductive services, 41 were damaged, and 30% of midwives were reportedly dead or missing as a result of the tsunami. (United Nations Population Fund [UNFPA], August 2005) I n d o n e s i a THE RESPONSE Partnerships The Government set up temporary shelters/distribution points and distributed essential items to households. The MoH provided emergency medical care, established an early warning and surveillance system, ensured safe water and sanitation, food, instituted vector control measures, and provided immunization, health education and social mobilization immediately. All dead bodies were managed by the local people in the traditional manner. WHO's response was closely coordinated with the UN disaster preparedness and management group and with international NGOs, through the Red Cross-led Tsunami Assistance Coordination Group. WHO's primary role was that of providing technical support to the MoH. WHO technical guidelines for emergencies were disseminated. Regular updates to the diplomatic and international community were organized through distribution of situation reports and WHO press releases. WHO focused on reducing the risk of disease outbreaks and morbidity by supporting disease surveillance and providing emergency medical supplies as requested by the MoH. WHO established a field presence in Banda Aceh. A primary office was opened in Banda Aceh and suboffices in Medan, Calang and Meulaboh. The WHO Country Office was strengthened with public health experts from WHO Western Pacific F r o m r e l i e f t o r e c o v e r y Regional Office (WPRO), WHO Pan American Health Organization (PAHO) and the US. Five logisticians were deployed in the field. In conjunction with the Government of Indonesia, other UN agencies, and the military, WHO conducted helicopter-assisted Rapid Health Assessments in areas of difficult access along the western coast of Aceh. In addition, WHO also provided direct financial support for operational costs at both the central and provincial levels. More than 720 000 people in Aceh were directly affected. The situation in Aceh was grim, not just because of the tsunami crisis, but also because supply stockpiles had dwindled in the months prior to the disaster due to a series of emergencies in various part of Indonesia. Aceh was suffering from various vector-borne diseases, such as malaria and dengue. Many remote areas in Aceh were difficult to reach or contact due to decades of conflict in the Province. A national disaster was declared and an open-door policy for relief operation endorsed. The Vice President of Indonesia welcomed international aid for Aceh Province. Hundreds of health agencies began to arrive in Aceh to help with the relief and rehabilitation efforts. At the request of the Aceh authorities, WHO coordinated relief operations in the health sector to streamline effective delivery of goods and services. Relief delivery was hampered by extensive damage to transportation infrastructure and parts of Aceh were inaccessible. A bottleneck of humanitarian relief supplies occurred in Jakarta and Medan, as supplies could not be forwarded to Aceh. Damage to public health infrastructure was extensive; six hospitals, 41 health centres, 59 sub-community health centres, 44 integrated health services units and 240 village maternity posts in Aceh were damaged or destroyed. In both Banda Aceh and Meulaboh, only one hospital remained functional on the outskirts of each city. Field hospitals were deployed throughout Aceh. With no water distribution system left intact and no large reservoirs available, water had to be distributed from centralized points, requiring large-scale production, large-capacity containers and watering points. There was also the problem of disposal of the thousands of deceased, who needed a dignified burial or cremation. = In the affected districts, 50% of health facilities were destroyed or damaged. = The Provincial General Hospital was non-functional and the Army was called in to help. Taking stock of the situation Health situation and challenges I n d o n e s i a F r o m r e l i e f t o r e c o v e r y Regional Office (WPRO), WHO Pan American Health Organization (PAHO) and the US. Five logisticians were deployed in the field. In conjunction with the Government of Indonesia, other UN agencies, and the military, WHO conducted helicopter-assisted Rapid Health Assessments in areas of difficult access along the western coast of Aceh. In addition, WHO also provided direct financial support for operational costs at both the central and provincial levels. More than 720 000 people in Aceh were directly affected. The situation in Aceh was grim, not just because of the tsunami crisis, but also because supply stockpiles had dwindled in the months prior to the disaster due to a series of emergencies in various part of Indonesia. Aceh was suffering from various vector-borne diseases, such as malaria and dengue. Many remote areas in Aceh were difficult to reach or contact due to decades of conflict in the Province. A national disaster was declared and an open-door policy for relief operation endorsed. The Vice President of Indonesia welcomed international aid for Aceh Province. Hundreds of health agencies began to arrive in Aceh to help with the relief and rehabilitation efforts. At the request of the Aceh authorities, WHO coordinated relief operations in the health sector to streamline effective delivery of goods and services. Relief delivery was hampered by extensive damage to transportation infrastructure and parts of Aceh were inaccessible. A bottleneck of humanitarian relief supplies occurred in Jakarta and Medan, as supplies could not be forwarded to Aceh. Damage to public health infrastructure was extensive; six hospitals, 41 health centres, 59 sub-community health centres, 44 integrated health services units and 240 village maternity posts in Aceh were damaged or destroyed. In both Banda Aceh and Meulaboh, only one hospital remained functional on the outskirts of each city. Field hospitals were deployed throughout Aceh. With no water distribution system left intact and no large reservoirs available, water had to be distributed from centralized points, requiring large-scale production, large-capacity containers and watering points. There was also the problem of disposal of the thousands of deceased, who needed a dignified burial or cremation. = In the affected districts, 50% of health facilities were destroyed or damaged. = The Provincial General Hospital was non-functional and the Army was called in to help. Taking stock of the situation Health situation and challenges I n d o n e s i a F r o m r e l i e f t o r e c o v e r y = In the Provincial Health Office (PHO), 50% of the health staff were dead or missing. Only 17 reported for duty following the tsunami. = Out of six health centres in Banda Aceh, only three were functioning partially. = The provincial and municipal health services had collapsed and services were running at a capacity of 20–30%. = No surveillance system was in place. The government sent staff from Jakarta and other provinces to help out. = No laboratory was left in Banda Aceh. A total of 693 health facilities in Aceh were incapacitated. = Warehouses had a limited capacity and distribution of supplies was a problem. = Coordinating the activities of hundreds of health sector partners was a difficult task. WHO, as the lead health organization, sought to provide efficient and effective coverage of health needs by ensuring coordination among all the agencies, the MoH and the provincial and district health authorities. This role was crucial with more than 250 NGOs present in Aceh after the disaster. = The breakdown in the communications network made coordination nearly impossible for the first two days. The remaining medical facilities, such as field hospitals, had to be maintained and utilized to deliver services. = At the request of the MoH, WHO facilitated and led the coordination of health actors at the local, national and international levels. In response to the request, WHO organized a health emergency response strategy to assist the Government, NGOs and other organizations in providing proper health care to the affected people. = Immediately after the disaster, WHO collaborated with both the PHO in Banda Aceh and the MoH in Jakarta to coordinate and manage the health sector support needed for the disaster, and set up surveillance systems. = WHO supported the restoration of government capacity and organization until operations were re-established, as functioning of the PHO and some District Health Offices (DHOs) was disrupted. = WHO coordinated with government counterparts and implementing agencies both in and outside the health sector. = As a member of the UN Disaster Management Team, WHO worked jointly with the government in conducting a preliminary needs assessment. Based on a review Support from WHO Planning and coordination I n d o n e s i a F r o m r e l i e f t o r e c o v e r y = In the Provincial Health Office (PHO), 50% of the health staff were dead or missing. Only 17 reported for duty following the tsunami. = Out of six health centres in Banda Aceh, only three were functioning partially. = The provincial and municipal health services had collapsed and services were running at a capacity of 20–30%. = No surveillance system was in place. The government sent staff from Jakarta and other provinces to help out. = No laboratory was left in Banda Aceh. A total of 693 health facilities in Aceh were incapacitated. = Warehouses had a limited capacity and distribution of supplies was a problem. = Coordinating the activities of hundreds of health sector partners was a difficult task. WHO, as the lead health organization, sought to provide efficient and effective coverage of health needs by ensuring coordination among all the agencies, the MoH and the provincial and district health authorities. This role was crucial with more than 250 NGOs present in Aceh after the disaster. = The breakdown in the communications network made coordination nearly impossible for the first two days. The remaining medical facilities, such as field hospitals, had to be maintained and utilized to deliver services. = At the request of the MoH, WHO facilitated and led the coordination of health actors at the local, national and international levels. In response to the request, WHO organized a health emergency response strategy to assist the Government, NGOs and other organizations in providing proper health care to the affected people. = Immediately after the disaster, WHO collaborated with both the PHO in Banda Aceh and the MoH in Jakarta to coordinate and manage the health sector support needed for the disaster, and set up surveillance systems. = WHO supported the restoration of government capacity and organization until operations were re-established, as functioning of the PHO and some District Health Offices (DHOs) was disrupted. = WHO coordinated with government counterparts and implementing agencies both in and outside the health sector. = As a member of the UN Disaster Management Team, WHO worked jointly with the government in conducting a preliminary needs assessment. Based on a review Support from WHO Planning and coordination I n d o n e s i a of the findings, WHO worked to address priority issues in coordination with other health sector actors. = WHO and the MoH established the Health Emergency Information Unit which maintained an account of national and international health service providers. = WHO assisted in developing a sound Master Plan to re-build health systems in NAD and North Sumatra. WHO worked with partners to ensure equitable access to quality essential health care through key hospitals and health centres, and by supporting health staff in satellite health posts in IDP camps. The initial focus was on trauma and emergency care. = WHO worked to ensure that medical supply chains functioned efficiently and responded to the needs of tsunami survivors despite significant challenges resulting from damaged and destroyed communication channels and infrastructure. Shipments of health supplies began arriving on 29 December 2004. = WHO sought to facilitate adequate availability of essential drugs and emergency needs as well as ensure that supply demands were met for adequate mental health, reproductive health, child health, nutrition, and water and sanitation services. = An emergency surveillance early warning and response unit was established to track life-threatening diseases, especially among those affected by the tsunami. = WHO provided logistical support and technical guidance for strengthening Expanded Programme on Immunization (EPI) activities and for an effective transition to routine surveillance. = Laboratories, including the Provincial Public Health Laboratory, were strengthened as a priority. = WHO played a key role in providing technical guidance to the MoH, the PHO and DHOs as well as other health sector actors on critical public health issues such as response to disease outbreaks, water quality, excreta management, chemical threats, chronic disease management, mental health, reproductive health, child and adolescent health, nutrition and pharmaceutical waste management. Essential health services Communicable disease surveillance and control Technical support = F r o m r e l i e f t o r e c o v e r y I n d o n e s i a = A joint MoH–WHO Committee was created to provide guidelines; review, update and modify proposals; keep track of pledged and allotted budgets; and monitor and evaluate the implementation of work plans. Operational units also had to be supported. On 26 March 2005, the Government of Indonesia declared an end to the emergency phase. NAD Province entered the reconstruction and rehabilitation phase. However, another massive earthquake occurred on 28 March in Nias, an island in the Province of North Sumatra. More than 900 died and 2400 people were injured in the second earthquake. Over half of the health facilities were destroyed or damaged and those remaining were operating under reduced capacity with fewer health personnel and limited supplies. WHO redirected emergency response mechanisms and established another suboffice in Nias. New rounds of health assessments were made and coordination activities organized in addition to providing needed medical supplies. WHO provided 98 emergency health kits, 10 basic health kits and 2000 Malaria Rapid Detection Kits to hospitals, IDP camps, mobile clinics and other health centres. WHO was requested by the DHO to lead the coordination of 22 organizations Earthquake in Nias of the findings, WHO worked to address priority issues in coordination with other health sector actors. = WHO and the MoH established the Health Emergency Information Unit which maintained an account of national and international health service providers. = WHO assisted in developing a sound Master Plan to re-build health systems in NAD and North Sumatra. WHO worked with partners to ensure equitable access to quality essential health care through key hospitals and health centres, and by supporting health staff in satellite health posts in IDP camps. The initial focus was on trauma and emergency care. = WHO worked to ensure that medical supply chains functioned efficiently and responded to the needs of tsunami survivors despite significant challenges resulting from damaged and destroyed communication channels and infrastructure. Shipments of health supplies began arriving on 29 December 2004. = WHO sought to facilitate adequate availability of essential drugs and emergency needs as well as ensure that supply demands were met for adequate mental health, reproductive health, child health, nutrition, and water and sanitation services. = An emergency surveillance early warning and response unit was established to track life-threatening diseases, especially among those affected by the tsunami. = WHO provided logistical support and technical guidance for strengthening Expanded Programme on Immunization (EPI) activities and for an effective transition to routine surveillance. = Laboratories, including the Provincial Public Health Laboratory, were strengthened as a priority. = WHO played a key role in providing technical guidance to the MoH, the PHO and DHOs as well as other health sector actors on critical public health issues such as response to disease outbreaks, water quality, excreta management, chemical threats, chronic disease management, mental health, reproductive health, child and adolescent health, nutrition and pharmaceutical waste management. Essential health services Communicable disease surveillance and control Technical support = F r o m r e l i e f t o r e c o v e r y I n d o n e s i a = A joint MoH–WHO Committee was created to provide guidelines; review, update and modify proposals; keep track of pledged and allotted budgets; and monitor and evaluate the implementation of work plans. Operational units also had to be supported. On 26 March 2005, the Government of Indonesia declared an end to the emergency phase. NAD Province entered the reconstruction and rehabilitation phase. However, another massive earthquake occurred on 28 March in Nias, an island in the Province of North Sumatra. More than 900 died and 2400 people were injured in the second earthquake. Over half of the health facilities were destroyed or damaged and those remaining were operating under reduced capacity with fewer health personnel and limited supplies. WHO redirected emergency response mechanisms and established another suboffice in Nias. New rounds of health assessments were made and coordination activities organized in addition to providing needed medical supplies. WHO provided 98 emergency health kits, 10 basic health kits and 2000 Malaria Rapid Detection Kits to hospitals, IDP camps, mobile clinics and other health centres. WHO was requested by the DHO to lead the coordination of 22 organizations Earthquake in Nias initially working in the health sector. A master matrix was developed to keep a track of their activities. The matrix helped in pinpointing specific gaps in emergency health services as well as in developing mid- and long-term recovery strategies. WHO supported a detailed assessment of the status and needs of the remaining Public Health Centres (puskesmas). Water and sanitation challenges and interventions were also assessed, and weekly reporting for c o m m u n i c a b l e d i s e a s e s e s t a b l i s h e d . Epidemiological outbreak alerts were investigated following reports of suspected cholera, measles, tuberculosis and polio. In addition, training was provided for DHO staff in collecting and analysing epidemiological data and the use of geographical information system (GIS) health mapping. WHO also supported Government efforts to organize a rehabilitation plan for the Gunung Sitoli Hospital. Three working groups were established by WHO to look into the areas of hospitals, water and sanitation, and mental health. The communication link with WHO staff based in Banda Aceh prior to the tsunami was severed for two days. The old WHO office in Aceh was destroyed and a new office had to be established with more staff and emergency facilities. NAD province had been intermittently closed to the international world due to protracted conflict. Health workers and the community found it difficult to adapt to the overflow of external relief workers and their various styles of operations in a very short period of time. Policy guidance, procedures, coordination and filtering mechanisms were weak, both within the government and the UN, and were unable to provide clear guidance CHALLENGES Communications and infrastructure Regional history Health policy, coordination, health systems F r o m r e l i e f t o r e c o v e r y I n d o n e s i a on relief operations led by international and national communities in the initial phase. Control mechanisms for health service providers including services provided by the Army were poor. Different stakeholders developed plans at different levels, which caused confusion. Coordination, cooperation and collaborative support had to be ensured at the central, provincial and district levels through vertical and horizontal planning processes to strengthen health systems at all levels. Ensuring that resources pledged were received and utilized effectively was difficult, as the world poured its generosity in overwhelming measure. The tsunami affected overall health services in the country, and WHO had to find ways to balance support to other parts of the country. As almost every country in the world came forward to assist Indonesia, registration and standardization of Memoranda of Understanding (MoUs) for international organizations were essential for smooth functioning. Health services had to be provided for both IDP camps and host communities in all districts. The capacity of health staff had to be built so that the proposed activities could be implemented and funds utilized effectively. With several health workers directly affected by the tragedy, psychosocial support had to be provided to them. = Well-equipped WHO offices were established at the field level but there was a delay in supporting PHOs and DHOs in strengthening their operations. = Coordination, planning and proposal development were effectively done at the provincial level but not at the MoH and central professional levels. = Activities were directly implemented at field level but coordination with the central level was poor. = Though international professional staff arrived in large numbers, their availability at the field level was not known and reports were not received at the central level. = There was some confusion about the role of the WHO Country Office and government PHOs regarding the tsunami operations. There was also confusion between the WHO Jakarta Office and WHO Aceh Office regarding the roles to be played by each. Health service delivery enhancement WHAT COULD HAVE BEEN DONE BETTER initially working in the health sector. A master matrix was developed to keep a track of their activities. The matrix helped in pinpointing specific gaps in emergency health services as well as in developing mid- and long-term recovery strategies. WHO supported a detailed assessment of the status and needs of the remaining Public Health Centres (puskesmas). Water and sanitation challenges and interventions were also assessed, and weekly reporting for c o m m u n i c a b l e d i s e a s e s e s t a b l i s h e d . Epidemiological outbreak alerts were investigated following reports of suspected cholera, measles, tuberculosis and polio. In addition, training was provided for DHO staff in collecting and analysing epidemiological data and the use of geographical information system (GIS) health mapping. WHO also supported Government efforts to organize a rehabilitation plan for the Gunung Sitoli Hospital. Three working groups were established by WHO to look into the areas of hospitals, water and sanitation, and mental health. The communication link with WHO staff based in Banda Aceh prior to the tsunami was severed for two days. The old WHO office in Aceh was destroyed and a new office had to be established with more staff and emergency facilities. NAD province had been intermittently closed to the international world due to protracted conflict. Health workers and the community found it difficult to adapt to the overflow of external relief workers and their various styles of operations in a very short period of time. Policy guidance, procedures, coordination and filtering mechanisms were weak, both within the government and the UN, and were unable to provide clear guidance CHALLENGES Communications and infrastructure Regional history Health policy, coordination, health systems F r o m r e l i e f t o r e c o v e r y I n d o n e s i a on relief operations led by international and national communities in the initial phase. Control mechanisms for health service providers including services provided by the Army were poor. Different stakeholders developed plans at different levels, which caused confusion. Coordination, cooperation and collaborative support had to be ensured at the central, provincial and district levels through vertical and horizontal planning processes to strengthen health systems at all levels. Ensuring that resources pledged were received and utilized effectively was difficult, as the world poured its generosity in overwhelming measure. The tsunami affected overall health services in the country, and WHO had to find ways to balance support to other parts of the country. As almost every country in the world came forward to assist Indonesia, registration and standardization of Memoranda of Understanding (MoUs) for international organizations were essential for smooth functioning. Health services had to be provided for both IDP camps and host communities in all districts. The capacity of health staff had to be built so that the proposed activities could be implemented and funds utilized effectively. With several health workers directly affected by the tragedy, psychosocial support had to be provided to them. = Well-equipped WHO offices were established at the field level but there was a delay in supporting PHOs and DHOs in strengthening their operations. = Coordination, planning and proposal development were effectively done at the provincial level but not at the MoH and central professional levels. = Activities were directly implemented at field level but coordination with the central level was poor. = Though international professional staff arrived in large numbers, their availability at the field level was not known and reports were not received at the central level. = There was some confusion about the role of the WHO Country Office and government PHOs regarding the tsunami operations. There was also confusion between the WHO Jakarta Office and WHO Aceh Office regarding the roles to be played by each. Health service delivery enhancement WHAT COULD HAVE BEEN DONE BETTER PHASE II: ACTIVE INTERVENTIONS ASSESSMENTS AND MONITORING COORDINATION AND GAP-FILLING Within a few days of the tsunami, the immediate needs of disposal of human corpses, treatment of injuries and providing shelter to the homeless had been met. Providing safe drinking water, clean living conditions and protection from communicable diseases were now the need of the hour. Crowded living conditions, lack of a sanitary environment, lack of access to clean drinking water and food were ideal conditions for outbreaks of communicable diseases such as diarrhoea, food poisoning, and respiratory and wound infections. Stagnant pools of water provided breeding grounds for vector-borne diseases such as malaria, dengue, Japanese encephalitis and scrub typhus. Typhoid, hepatitis, leptospirosis could all surface due to unclean water. Measles, neonatal tetanus, meningitis were other threats. However, the mental and emotional trauma that the survivors had gone through was overwhelming and demanded immediate intervention. The shock, exhaustion and lack of proper food were likely to have weakened the immune systems of survivors. The authorities needed to think one step ahead, and be prepared to tackle emergencies. To this end, a predictive chart was devised based on previous data and experience, and the possible course of disease events and interventions were listed. This formed the template for preventive action. In Banda Aceh, the extensive damage to the health infrastructure prevented initial surveillance. There were about 10 000 IDPs in Banda Aceh itself in several small camps. Temporary medical units had been set up by various agencies, with little coordination of function or uniformity of approach. These units also served the neighbouring communities, many of whom had taken in those who had lost their homes, thus leading to overcrowded homes. In this atmosphere, epidemiologists had to ensure that all cases of disease would be brought to the notice of health-care workers, that these would be reported and recorded, and the records sent to a central unit at the F r o m r e l i e f t o r e c o v e r y I n d o n e s i a PHASE II: ACTIVE INTERVENTIONS ASSESSMENTS AND MONITORING COORDINATION AND GAP-FILLING Within a few days of the tsunami, the immediate needs of disposal of human corpses, treatment of injuries and providing shelter to the homeless had been met. Providing safe drinking water, clean living conditions and protection from communicable diseases were now the need of the hour. Crowded living conditions, lack of a sanitary environment, lack of access to clean drinking water and food were ideal conditions for outbreaks of communicable diseases such as diarrhoea, food poisoning, and respiratory and wound infections. Stagnant pools of water provided breeding grounds for vector-borne diseases such as malaria, dengue, Japanese encephalitis and scrub typhus. Typhoid, hepatitis, leptospirosis could all surface due to unclean water. Measles, neonatal tetanus, meningitis were other threats. However, the mental and emotional trauma that the survivors had gone through was overwhelming and demanded immediate intervention. The shock, exhaustion and lack of proper food were likely to have weakened the immune systems of survivors. The authorities needed to think one step ahead, and be prepared to tackle emergencies. To this end, a predictive chart was devised based on previous data and experience, and the possible course of disease events and interventions were listed. This formed the template for preventive action. In Banda Aceh, the extensive damage to the health infrastructure prevented initial surveillance. There were about 10 000 IDPs in Banda Aceh itself in several small camps. Temporary medical units had been set up by various agencies, with little coordination of function or uniformity of approach. These units also served the neighbouring communities, many of whom had taken in those who had lost their homes, thus leading to overcrowded homes. In this atmosphere, epidemiologists had to ensure that all cases of disease would be brought to the notice of health-care workers, that these would be reported and recorded, and the records sent to a central unit at the F r o m r e l i e f t o r e c o v e r y I n d o n e s i a earliest. The central unit would then analyse the data and sift it to ascertain whether a possible outbreak was on its way. Standardized forms were prepared jointly by Indonesian and international experts to record epidemic-prone diseases under local conditions. These were distributed to health workers, who were trained to use them and asked to notify authorities especially in suspected cases of measles, cholera, dysentery, meningitis, acute respiratory infections, malaria, jaundice, haemorrhagic fevers, fevers of unknown origin, or any clusters of unexplained diseases. The aim was to pick up killer diseases at the earliest. Managing the reams of data was a challenge. Communication capability had to be established, such as computer networks with the requisite data management, analysis and GIS software developed onsite by experts in data management, so that data could be looked through meaningfully to track deviations. WHO tracking systems were also established to provide “real-time” information and support comprehensive reporting. Simple parameters had to be laid down so that health workers could be trained in protocols, guidelines and standards for the seamless operation of the surveillance and response system. A contingency plan for immediate response to reports of emergencies and outbreaks was also developed. Reporting of “rumours” was encouraged, so that the Epidemic Alert and Response team was able to rapidly investigate each report, however nebulous, of a potential outbreak. Laboratory testing was essential to confirm reports of suspected cases identified by the surveillance system. Hence, laboratories were also strengthened. Before the tsunami, the provincial public health laboratory (Labkesda) was the only laboratory in Aceh province capable of providing basic microbiology cultures for clinical diagnostic purposes. An emergency laboratory was established by the MoH Institute of Health Research and Development and the US medical naval ship NAMRU-2. WHO sent reliable, validated, rapid diagnostic tools to Indonesia along with drugs for the treatment of malaria. WHO set up a temporary public health laboratory that was fully functional by February 2005 in Banda Aceh and in Meulaboh, and airlifted reagents and other supplies from Malaysia. The laboratory was established by WHO-recruited scientists from Malaysia. Laboratory equipment and support were also provided for the Food and Drug Laboratories F r o m r e l i e f t o r e c o v e r y Administration regional authority. In addition, 12 tuberculosis laboratories were upgraded. A total of 30 laboratory staff were trained in tuberculosis microscopy. More than 300 health sector aid agencies were present post-tsunami, resulting in significant overlap of activities during the early phase in Aceh. WHO sought to strengthen health sector coordination mechanisms by facilitating effective involvement of health authorities from various organizations and multilateral agencies at the provincial, district and local levels. Health coordination meetings were held several times weekly, to enable the MoH and the PHO to identify and respond to health emergencies. WHO conducted assessments to identify weaknesses, developed guidelines and provided technical direction in health sector coordination. Along with other organizations working in the health sector, WHO helped in the design and establishment of a comprehensive health system rehabilitation plan. The plan, RENSTRA (Rencana Strategis, Strategic Plan), is a provincewide health sector development policy document that sets guidelines for an integrated, comprehensive, bottom–up and sustainable action plan for Aceh. RENSTRA, which is now complete, identifies priority agendas in the recovery of the health sector so that needs still outstanding can be efficiently addressed by organizations seeking to work in Aceh. WHO, together with the MoH and the PHO, established the Health Emergency Information Unit (EIU). The EIU managed health information and disseminated it so that provincial health authorities and incoming organizations could identify needs and avoid duplication of work. WHO also assisted in cataloguing institutions working in the health sector, promoting networking and supporting optimal utilization of health resources. Though Aceh was earlier polio free, three confirmed cases of polio (wild-type) were diagnosed in March 2005, which were most likely imported. WHO and UNICEF supported the MoH in organizing polio National Immunization Days (NIDs), where 24.5 million children below the age of five years were targeted for immunization across Indonesia. In Aceh alone, approximately 550 000 children were targeted. The first round took place on 30 August, the next on 27 September Health sector coordination Health information Immunization I n d o n e s i a earliest. The central unit would then analyse the data and sift it to ascertain whether a possible outbreak was on its way. Standardized forms were prepared jointly by Indonesian and international experts to record epidemic-prone diseases under local conditions. These were distributed to health workers, who were trained to use them and asked to notify authorities especially in suspected cases of measles, cholera, dysentery, meningitis, acute respiratory infections, malaria, jaundice, haemorrhagic fevers, fevers of unknown origin, or any clusters of unexplained diseases. The aim was to pick up killer diseases at the earliest. Managing the reams of data was a challenge. Communication capability had to be established, such as computer networks with the requisite data management, analysis and GIS software developed onsite by experts in data management, so that data could be looked through meaningfully to track deviations. WHO tracking systems were also established to provide “real-time” information and support comprehensive reporting. Simple parameters had to be laid down so that health workers could be trained in protocols, guidelines and standards for the seamless operation of the surveillance and response system. A contingency plan for immediate response to reports of emergencies and outbreaks was also developed. Reporting of “rumours” was encouraged, so that the Epidemic Alert and Response team was able to rapidly investigate each report, however nebulous, of a potential outbreak. Laboratory testing was essential to confirm reports of suspected cases identified by the surveillance system. Hence, laboratories were also strengthened. Before the tsunami, the provincial public health laboratory (Labkesda) was the only laboratory in Aceh province capable of providing basic microbiology cultures for clinical diagnostic purposes. An emergency laboratory was established by the MoH Institute of Health Research and Development and the US medical naval ship NAMRU-2. WHO sent reliable, validated, rapid diagnostic tools to Indonesia along with drugs for the treatment of malaria. WHO set up a temporary public health laboratory that was fully functional by February 2005 in Banda Aceh and in Meulaboh, and airlifted reagents and other supplies from Malaysia. The laboratory was established by WHO-recruited scientists from Malaysia. Laboratory equipment and support were also provided for the Food and Drug Laboratories F r o m r e l i e f t o r e c o v e r y Administration regional authority. In addition, 12 tuberculosis laboratories were upgraded. A total of 30 laboratory staff were trained in tuberculosis microscopy. More than 300 health sector aid agencies were present post-tsunami, resulting in significant overlap of activities during the early phase in Aceh. WHO sought to strengthen health sector coordination mechanisms by facilitating effective involvement of health authorities from various organizations and multilateral agencies at the provincial, district and local levels. Health coordination meetings were held several times weekly, to enable the MoH and the PHO to identify and respond to health emergencies. WHO conducted assessments to identify weaknesses, developed guidelines and provided technical direction in health sector coordination. Along with other organizations working in the health sector, WHO helped in the design and establishment of a comprehensive health system rehabilitation plan. The plan, RENSTRA (Rencana Strategis, Strategic Plan), is a provincewide health sector development policy document that sets guidelines for an integrated, comprehensive, bottom–up and sustainable action plan for Aceh. RENSTRA, which is now complete, identifies priority agendas in the recovery of the health sector so that needs still outstanding can be efficiently addressed by organizations seeking to work in Aceh. WHO, together with the MoH and the PHO, established the Health Emergency Information Unit (EIU). The EIU managed health information and disseminated it so that provincial health authorities and incoming organizations could identify needs and avoid duplication of work. WHO also assisted in cataloguing institutions working in the health sector, promoting networking and supporting optimal utilization of health resources. Though Aceh was earlier polio free, three confirmed cases of polio (wild-type) were diagnosed in March 2005, which were most likely imported. WHO and UNICEF supported the MoH in organizing polio National Immunization Days (NIDs), where 24.5 million children below the age of five years were targeted for immunization across Indonesia. In Aceh alone, approximately 550 000 children were targeted. The first round took place on 30 August, the next on 27 September Health sector coordination Health information Immunization I n d o n e s i a 2005 and the third on 30 November 2005. Training was conducted for EPI focal persons and independent monitors drawn from UN agencies and other NGOs at the PHO on EPI and vaccine-preventable disease surveillance, with special emphasis on acute flaccid paralysis (AFP). Ten WHO staff also monitored progress in 5 districts where NGO staff was not available. To prevent outbreaks of measles, measles immunization campaigns were held for children aged 6 months to 15 years in the affected areas. Emergency mass measles immunization campaigns were conducted from January to March in the districts of Banda Aceh, Kota Banda Aceh, Aceh Besar, Aceh Jaya, Aceh Barat, Pidie, Bireun and Nagan Raya. WHO provided technical and coordination support to the PHO, DHOs and UNICEF. UNICEF provided a briefing on the campaign as well as cold chain equipment, measles vaccine, injection supplies and vitamin A capsules. Vaccination coverage in Banda Aceh and Aceh Besar was over 83%. Following the campaign the number of measles cases decreased significantly. The Indonesian MoH decided in January 2005 to perform a three-phased cholera mass vaccination campaign using the two-dose oral cholera vaccine (OCV) to protect IDPs from a perceived risk of an outbreak. At the government's request, WHO provided vaccines, and logistical and technical support to the campaign. In Banda Aceh town, vaccination was conducted by 28 teams in five subdistricts with 27 service points between 31 May and 17 June 2005. Preliminary results confirmed that the vaccination was very well organized with good acceptance from IDPs. In Aceh Besar district, vaccination was conducted by 47 teams in 18 subdistricts, with 47 service points between 6 June and 26 June 2005. Over 54 000 IDPs were vaccinated. WHO supported the campaigns by providing vaccines, cold chain facilities, material for administration and disposal, and operational costs, along with training of vaccinators. The Organization also provided US$ 1 000 000 to support these campaigns in Aceh and North Sumatra, as well as technical support in planning, implementation and monitoring. F r o m r e l i e f t o r e c o v e r y I n d o n e s i a Health systems and infrastructure Following the first health coordination meeting on 23 February 2005 for international and domestic agencies in Calang, Aceh Jaya district, health authorities, in consultation with WHO, announced that their priorities would be the areas of communicable disease control, primary health care, maternal and child health and nutrition, in three puskesmas (health centre) sites. Seven of the eight puskesmas in Aceh Jaya were destroyed and 16 of the 53 DHO staff lost their lives. The puskesmas were reconstructed in Calang and Teunom, and improved in Lamno on a priority basis, to form a platform for local health services. In Meulaboh, WHO and the district health authorities initiated a planning exercise with health partners working in primary health care, to address the issues of access to essential health-care services and the assistance needed by the tsunami- affected population. Three health centres (Samatiga, Meureubo and Kaway XVI) were affected by the tsunami and Médicins Sans Frontières (MSF) Belgium provided physical rehabilitation through two-year and five-year strategies. During the emergency phase, over a period of six months, new medical equipment was acquired and new facilities were added to existing ones. The 2005 and the third on 30 November 2005. Training was conducted for EPI focal persons and independent monitors drawn from UN agencies and other NGOs at the PHO on EPI and vaccine-preventable disease surveillance, with special emphasis on acute flaccid paralysis (AFP). Ten WHO staff also monitored progress in 5 districts where NGO staff was not available. To prevent outbreaks of measles, measles immunization campaigns were held for children aged 6 months to 15 years in the affected areas. Emergency mass measles immunization campaigns were conducted from January to March in the districts of Banda Aceh, Kota Banda Aceh, Aceh Besar, Aceh Jaya, Aceh Barat, Pidie, Bireun and Nagan Raya. WHO provided technical and coordination support to the PHO, DHOs and UNICEF. UNICEF provided a briefing on the campaign as well as cold chain equipment, measles vaccine, injection supplies and vitamin A capsules. Vaccination coverage in Banda Aceh and Aceh Besar was over 83%. Following the campaign the number of measles cases decreased significantly. The Indonesian MoH decided in January 2005 to perform a three-phased cholera mass vaccination campaign using the two-dose oral cholera vaccine (OCV) to protect IDPs from a perceived risk of an outbreak. At the government's request, WHO provided vaccines, and logistical and technical support to the campaign. In Banda Aceh town, vaccination was conducted by 28 teams in five subdistricts with 27 service points between 31 May and 17 June 2005. Preliminary results confirmed that the vaccination was very well organized with good acceptance from IDPs. In Aceh Besar district, vaccination was conducted by 47 teams in 18 subdistricts, with 47 service points between 6 June and 26 June 2005. Over 54 000 IDPs were vaccinated. WHO supported the campaigns by providing vaccines, cold chain facilities, material for administration and disposal, and operational costs, along with training of vaccinators. The Organization also provided US$ 1 000 000 to support these campaigns in Aceh and North Sumatra, as well as technical support in planning, implementation and monitoring. F r o m r e l i e f t o r e c o v e r y I n d o n e s i a Health systems and infrastructure Following the first health coordination meeting on 23 February 2005 for international and domestic agencies in Calang, Aceh Jaya district, health authorities, in consultation with WHO, announced that their priorities would be the areas of communicable disease control, primary health care, maternal and child health and nutrition, in three puskesmas (health centre) sites. Seven of the eight puskesmas in Aceh Jaya were destroyed and 16 of the 53 DHO staff lost their lives. The puskesmas were reconstructed in Calang and Teunom, and improved in Lamno on a priority basis, to form a platform for local health services. In Meulaboh, WHO and the district health authorities initiated a planning exercise with health partners working in primary health care, to address the issues of access to essential health-care services and the assistance needed by the tsunami- affected population. Three health centres (Samatiga, Meureubo and Kaway XVI) were affected by the tsunami and Médicins Sans Frontières (MSF) Belgium provided physical rehabilitation through two-year and five-year strategies. During the emergency phase, over a period of six months, new medical equipment was acquired and new facilities were added to existing ones. The F r o m r e l i e f t o r e c o v e r y I n d o n e s i a activities were unfortunately not based on a needs assessment, conducted without rational distribution of resources and without a proper inventory system in place. This situation sometimes led to chaotic hospital management or, in the worst case, a waste of resources. In response, WHO undertook an assessment of existing medical equipment and hospital facilities to provide evidence-based information for the planning and reconstruction phase of health facility recovery in NAD and Nias, focusing on better utilization of existing resources. Assessment results indicated that the uneven distribution of donations irrespective of real needs often resulted in over-equipped facilities. This was indeed the case for vehicles and medical gear. If existing electrical and water infrastructure had been inspected prior to the allocation of the equipment, it would have prevented their wasteful accumulation as, in some cases, hospital power or water supply was insufficient or inappropriate. The results of this study will be shared with the international donor community and disseminated through the MoH, PHO and directors of the health facilities involved in this survey. WHO supported a rapid assessment of health facilities following the tsunami disaster, which was conducted by Gadjah Mada University. WHO worked with the PHO in Aceh, Zainoel Abidin Provincial Hospital, Psychiatric Provincial Hospital, USAID, UNICEF, and the Badan Rehabilitasi dan Rekonstruksi (BRR Reconstruction and Rehabilitation) Agency to develop a matrix of health indicators which would form the basis for data collection. A matrix showing health status, health services and health resources from data collected in 21 districts was finalized. The mapping of human resources in health facilities at Aceh was completed. Under the leadership of the MoH Medical Service Directorate General and Gadjah Mada University, WHO supported a hospital sector redevelopment project. WHO provided: (1) documentation of the needs of each hospital, and (2) a blueprint of the plan for hospital sector redevelopment. Together with the PHO, WHO took the lead in initiating the effort and providing technical support to develop human resources for a health database in NAD, working closely with international NGOs. WHO assessed the training needs of service and facility managers, and staff for evidence-based management and training. Two-day workshops on Health Information and Planning were conducted in July and September 2005. Another workshop was conducted on 19–22 September 2005 in Medan to look into issues related to information needs, information management and computerization in support of management within hospitals. The aim of the workshop was to identify weaknesses and related problems, recommend solutions and locate areas where WHO could assist. Five months after the earthquake in Nias, the WHO operations in Nias were closed down as the DHOs were operational again, and supported by the PHO and WHO in Medan. By 3 January 2005, WHO was in the process of establishing a Global Outbreak and Alert Response Network (GOARN) operational support team in New Delhi. GOARN pools human and technical resources for the rapid identification, confirmation of and response to disease outbreaks of international importance. WHO's task was to coordinate support from GOARN partners. Besides technical expertise in the form of manpower for communicable disease alerts and response, several structural and operational elements were needed to establish an early Surveillance systems F r o m r e l i e f t o r e c o v e r y I n d o n e s i a activities were unfortunately not based on a needs assessment, conducted without rational distribution of resources and without a proper inventory system in place. This situation sometimes led to chaotic hospital management or, in the worst case, a waste of resources. In response, WHO undertook an assessment of existing medical equipment and hospital facilities to provide evidence-based information for the planning and reconstruction phase of health facility recovery in NAD and Nias, focusing on better utilization of existing resources. Assessment results indicated that the uneven distribution of donations irrespective of real needs often resulted in over-equipped facilities. This was indeed the case for vehicles and medical gear. If existing electrical and water infrastructure had been inspected prior to the allocation of the equipment, it would have prevented their wasteful accumulation as, in some cases, hospital power or water supply was insufficient or inappropriate. The results of this study will be shared with the international donor community and disseminated through the MoH, PHO and directors of the health facilities involved in this survey. WHO supported a rapid assessment of health facilities following the tsunami disaster, which was conducted by Gadjah Mada University. WHO worked with the PHO in Aceh, Zainoel Abidin Provincial Hospital, Psychiatric Provincial Hospital, USAID, UNICEF, and the Badan Rehabilitasi dan Rekonstruksi (BRR Reconstruction and Rehabilitation) Agency to develop a matrix of health indicators which would form the basis for data collection. A matrix showing health status, health services and health resources from data collected in 21 districts was finalized. The mapping of human resources in health facilities at Aceh was completed. Under the leadership of the MoH Medical Service Directorate General and Gadjah Mada University, WHO supported a hospital sector redevelopment project. WHO provided: (1) documentation of the needs of each hospital, and (2) a blueprint of the plan for hospital sector redevelopment. Together with the PHO, WHO took the lead in initiating the effort and providing technical support to develop human resources for a health database in NAD, working closely with international NGOs. WHO assessed the training needs of service and facility managers, and staff for evidence-based management and training. Two-day workshops on Health Information and Planning were conducted in July and September 2005. Another workshop was conducted on 19–22 September 2005 in Medan to look into issues related to information needs, information management and computerization in support of management within hospitals. The aim of the workshop was to identify weaknesses and related problems, recommend solutions and locate areas where WHO could assist. Five months after the earthquake in Nias, the WHO operations in Nias were closed down as the DHOs were operational again, and supported by the PHO and WHO in Medan. By 3 January 2005, WHO was in the process of establishing a Global Outbreak and Alert Response Network (GOARN) operational support team in New Delhi. GOARN pools human and technical resources for the rapid identification, confirmation of and response to disease outbreaks of international importance. WHO's task was to coordinate support from GOARN partners. Besides technical expertise in the form of manpower for communicable disease alerts and response, several structural and operational elements were needed to establish an early Surveillance systems warning system for potential outbreaks. By mid-February, the Epidemic Alert and Response Team in WHO Banda Aceh developed a weekly surveillance system that included hospitals and laboratories in Banda Aceh, Meulaboh and other towns. The team had six GOARN epidemiologists in collaboration with the Provincial MoH. The system was geared to identify diseases with epidemic potential based on syndromic reporting for cholera, shigellosis, acute respiratory infections, malaria, dengue fever, measles and meningitis, as well as tetanus and injuries among inpatients. Initially, injury-related tetanus was a serious threat in Indonesia. A daily early warning system was established by SMS, telephone and email reporting of suspect cases. Daily reporting was done by laboratories on the number and types of specimens tested and pathogens identified. Field investigations, specimen collecting and testing were part of rapid responses, which were carried out jointly by the Provincial MoH staff and WHO epidemiology team. If needed, action was taken relevant to the need, such as providing treatment, immunization or a more suitable environment. Surveillance information was shared with all stakeholders at health coordination meetings. Contingency plans were developed for immediate response to reports of emergencies and outbreaks. In preparation for a disease outbreak a review of all stockpiled drugs and vaccines was conducted to ensure that appropriate supplies were available in the event of an epidemic. Sustained vigilance for any potential disease outbreak remains particularly important as avian influenza has emerged in the province and people remain in temporary shelters in less-than-ideal conditions. An electronic system for data entry, analysis and creation of routine and ad-hoc reports on key health conditions in the field was developed and implemented. Initially, getting the national surveillance system operational in Aceh Province was a big challenge. The national system relied on the availability of computers in each and every health centre in order to utilize the software created. However, many health centres in Aceh did not have electricity to run the computers and were therefore not able to implement the national system. The system was installed and operational in WHO and MoH offices, and staff were trained in its use. Data summarizing the disease situation from the first week of January 2005 in real-time were available since mid-January. An application based on EPI-DATA/EPI-INFO and HealthMapper was developed by the WHO epidemiology team and was used by PHO data managers during the emergency. The same application was installed in the WHO office at Meulaboh. F r o m r e l i e f t o r e c o v e r y Data management and entry were computerized and health personnel were trained to use the system. Twice-weekly discussions on the progress and achievements were carried out with provincial health authorities and NGOs. A weekly epidemiology bulletin was published in the local language and English, and disseminated to Provincial MoH districts, NGOs, MoH Jakarta and WHO. Guidelines and standard protocols for the diagnosis and management of all common communicable diseases were made available and widely disseminated. Standard case definitions for epidemic-prone diseases were printed on the back of surveillance forms which were in Bahasa Indonesia and English. Data related to nine epidemic-prone clinical syndromes (cholera, dysentery, typhoid, hepatitis, measles, malaria, dengue, meningitis and tetanus) were collected by each subdistrict. Reports of inpatients, including laboratory reports, were collected from five area hospitals (four government hospitals and one NGO field hospital). Over time, there were roughly 122 sites reporting on a weekly basis, but a cumulative total of over 60 organizations and over 200 reporting sites participated in the first two months. Over 100 alerts involving more than 465 disease events were received and promptly investigated by outbreak alert and response teams. Reports also included the total number of pregnancy-related deaths, neonatal deaths and the weekly number of consultations and deaths. The post-tsunami emergency surveillance system that was set up by WHO in partnership with the MoH and PHO was designed to transition into an Integrated Disease Surveillance System (STP) once Aceh entered the rehabilitation phase. Response efforts shifted to the PHO under the overall direction of a manager from the Centers for Disease Control (CDC), and PHO surveillance staff interacted daily with WHO surveillance staff in field investigations and response activities. The PHO now coordinates all response activities while the WHO surveillance unit provides technical advice and facilitates laboratory and logistical support. Data continues to be collected at health centres using the STP reporting system, which needs to be further streamlined to avoid overlap in reporting and minimize reporting requirements. Formal training, supported by WHO, included two training workshops for District Surveillance Officers in Medan and Lhokseumawe, and surveillance training workshops for 273 public health workers from all districts and health centres. During each of the five-day sessions, 25–30 participants were trained. Resource Data collection, reporting and analysis Capacity building in disease surveillance and control I n d o n e s i a warning system for potential outbreaks. By mid-February, the Epidemic Alert and Response Team in WHO Banda Aceh developed a weekly surveillance system that included hospitals and laboratories in Banda Aceh, Meulaboh and other towns. The team had six GOARN epidemiologists in collaboration with the Provincial MoH. The system was geared to identify diseases with epidemic potential based on syndromic reporting for cholera, shigellosis, acute respiratory infections, malaria, dengue fever, measles and meningitis, as well as tetanus and injuries among inpatients. Initially, injury-related tetanus was a serious threat in Indonesia. A daily early warning system was established by SMS, telephone and email reporting of suspect cases. Daily reporting was done by laboratories on the number and types of specimens tested and pathogens identified. Field investigations, specimen collecting and testing were part of rapid responses, which were carried out jointly by the Provincial MoH staff and WHO epidemiology team. If needed, action was taken relevant to the need, such as providing treatment, immunization or a more suitable environment. Surveillance information was shared with all stakeholders at health coordination meetings. Contingency plans were developed for immediate response to reports of emergencies and outbreaks. In preparation for a disease outbreak a review of all stockpiled drugs and vaccines was conducted to ensure that appropriate supplies were available in the event of an epidemic. Sustained vigilance for any potential disease outbreak remains particularly important as avian influenza has emerged in the province and people remain in temporary shelters in less-than-ideal conditions. An electronic system for data entry, analysis and creation of routine and ad-hoc reports on key health conditions in the field was developed and implemented. Initially, getting the national surveillance system operational in Aceh Province was a big challenge. The national system relied on the availability of computers in each and every health centre in order to utilize the software created. However, many health centres in Aceh did not have electricity to run the computers and were therefore not able to implement the national system. The system was installed and operational in WHO and MoH offices, and staff were trained in its use. Data summarizing the disease situation from the first week of January 2005 in real-time were available since mid-January. An application based on EPI-DATA/EPI-INFO and HealthMapper was developed by the WHO epidemiology team and was used by PHO data managers during the emergency. The same application was installed in the WHO office at Meulaboh. F r o m r e l i e f t o r e c o v e r y Data management and entry were computerized and health personnel were trained to use the system. Twice-weekly discussions on the progress and achievements were carried out with provincial health authorities and NGOs. A weekly epidemiology bulletin was published in the local language and English, and disseminated to Provincial MoH districts, NGOs, MoH Jakarta and WHO. Guidelines and standard protocols for the diagnosis and management of all common communicable diseases were made available and widely disseminated. Standard case definitions for epidemic-prone diseases were printed on the back of surveillance forms which were in Bahasa Indonesia and English. Data related to nine epidemic-prone clinical syndromes (cholera, dysentery, typhoid, hepatitis, measles, malaria, dengue, meningitis and tetanus) were collected by each subdistrict. Reports of inpatients, including laboratory reports, were collected from five area hospitals (four government hospitals and one NGO field hospital). Over time, there were roughly 122 sites reporting on a weekly basis, but a cumulative total of over 60 organizations and over 200 reporting sites participated in the first two months. Over 100 alerts involving more than 465 disease events were received and promptly investigated by outbreak alert and response teams. Reports also included the total number of pregnancy-related deaths, neonatal deaths and the weekly number of consultations and deaths. The post-tsunami emergency surveillance system that was set up by WHO in partnership with the MoH and PHO was designed to transition into an Integrated Disease Surveillance System (STP) once Aceh entered the rehabilitation phase. Response efforts shifted to the PHO under the overall direction of a manager from the Centers for Disease Control (CDC), and PHO surveillance staff interacted daily with WHO surveillance staff in field investigations and response activities. The PHO now coordinates all response activities while the WHO surveillance unit provides technical advice and facilitates laboratory and logistical support. Data continues to be collected at health centres using the STP reporting system, which needs to be further streamlined to avoid overlap in reporting and minimize reporting requirements. Formal training, supported by WHO, included two training workshops for District Surveillance Officers in Medan and Lhokseumawe, and surveillance training workshops for 273 public health workers from all districts and health centres. During each of the five-day sessions, 25–30 participants were trained. Resource Data collection, reporting and analysis Capacity building in disease surveillance and control I n d o n e s i a persons from CDC MoH and CDC PHO supported WHO trainings in all workshops. These workshops provided WHO with an opportunity to identify gaps and needs for future collaboration to improve the quality of disease surveillance in NAD. The earthquake and tsunami disrupted the provincial pharmaceutical supply storage and distribution system in NAD. The provincial and some district and hospital warehouses in Kota Banda Aceh, Aceh Barat and Aceh Jaya were destroyed, damaging the stocks of medicines and medical supplies. With a shortage of medicines, staff and appropriate storage spaces, the immediate challenges during the post-tsunami period were: = bringing essential medicines and medical supplies to areas in need, = managing the influx, inventory, storage and distribution of donated medicines, and = securing the appropriate destruction of damaged medicines. WHO and Pharmaciens Sans Frontières Comité International (PSF-CI) assessed the pharmaceutical situation in the region around Meulaboh. The warehouse of the DHO, which served all the primary health care centres in the 11 subdistricts of Aceh Barat, was affected by the tsunami. A large quantity of drugs needed to be destroyed and the rest identified, sorted and the warehouse system reorganized. Humanitarian drug donations were taken directly to the health centre or health post by the mobile teams working at the site. In the hospital, a large quantity of humanitarian donations was stored in at least five different places, with no tracking system in place. Experts in the Supply Management System (SUMA) assessed the warehouses within Banda Aceh to pre-classify supplies and assist in warehouse management. In Aceh more than 200 cubic meters of pharmaceutical waste needed Pharmaceutical waste management F r o m r e l i e f t o r e c o v e r y I n d o n e s i a safe disposal. WHO, UNEP and other international agencies worked on solutions with the MoH. In order to make the pharmaceutical supply and distribution system of the province operational, WHO supported the construction of the Calang warehouse together with AusAID, and collaborated in training the staff on good warehousing practices and providing funds for the operation of the Lambaro warehouse. WHO helped in identifying viable options that the PHO and DHOs could employ to effectively implement, monitor and evaluate the national drug policy programme in NAD. WHO conducted training of trainers (ToT) on pharmaceutical waste management, and supported the creation of a provincial health-care waste management (HCWM) Committee. This Committee addressed pharmaceutical management concerns, provided technical assistance and funding for the persons from CDC MoH and CDC PHO supported WHO trainings in all workshops. These workshops provided WHO with an opportunity to identify gaps and needs for future collaboration to improve the quality of disease surveillance in NAD. The earthquake and tsunami disrupted the provincial pharmaceutical supply storage and distribution system in NAD. The provincial and some district and hospital warehouses in Kota Banda Aceh, Aceh Barat and Aceh Jaya were destroyed, damaging the stocks of medicines and medical supplies. With a shortage of medicines, staff and appropriate storage spaces, the immediate challenges during the post-tsunami period were: = bringing essential medicines and medical supplies to areas in need, = managing the influx, inventory, storage and distribution of donated medicines, and = securing the appropriate destruction of damaged medicines. WHO and Pharmaciens Sans Frontières Comité International (PSF-CI) assessed the pharmaceutical situation in the region around Meulaboh. The warehouse of the DHO, which served all the primary health care centres in the 11 subdistricts of Aceh Barat, was affected by the tsunami. A large quantity of drugs needed to be destroyed and the rest identified, sorted and the warehouse system reorganized. Humanitarian drug donations were taken directly to the health centre or health post by the mobile teams working at the site. In the hospital, a large quantity of humanitarian donations was stored in at least five different places, with no tracking system in place. Experts in the Supply Management System (SUMA) assessed the warehouses within Banda Aceh to pre-classify supplies and assist in warehouse management. In Aceh more than 200 cubic meters of pharmaceutical waste needed Pharmaceutical waste management F r o m r e l i e f t o r e c o v e r y I n d o n e s i a safe disposal. WHO, UNEP and other international agencies worked on solutions with the MoH. In order to make the pharmaceutical supply and distribution system of the province operational, WHO supported the construction of the Calang warehouse together with AusAID, and collaborated in training the staff on good warehousing practices and providing funds for the operation of the Lambaro warehouse. WHO helped in identifying viable options that the PHO and DHOs could employ to effectively implement, monitor and evaluate the national drug policy programme in NAD. WHO conducted training of trainers (ToT) on pharmaceutical waste management, and supported the creation of a provincial health-care waste management (HCWM) Committee. This Committee addressed pharmaceutical management concerns, provided technical assistance and funding for the F r o m r e l i e f t o r e c o v e r y I n d o n e s i a preparation of a proposal on pharmaceutical waste management in Nias, and technical assistance for the preparation of a proposal on pharmaceutical waste management for NAD. A survey was financed by WHO to assess the usefulness of donated drugs for the affected population. PSF-CI, along with national and provincial health authorities, undertook a survey in health centres, hospitals and pharmaceutical warehouses in tsunami-affected districts. The objective of the survey was to assess the impact of drug donations on the public pharmaceutical system in tsunami-affected areas in NAD. Four tools were developed: a questionnaire for warehouses, a questionnaire for hospitals and health centres, a questionnaire for NGOs and a document to inventory drugs. An inventory was made using the National List of Essential Drugs of Indonesia and was based on criteria used by the WHO to define an inappropriate drug. Eight tsunami-affected districts were targeted for the survey: Banda Aceh, Aceh Besar, Pidie, Bireuen, Lhokseumawe, Aceh Jaya, Aceh Barat and Simeulue. Water supply and sanitation infrastructure, including treatment plants and their distribution network, were seriously damaged following the earthquake and tsunami. The tsunami also resulted in contamination of ground water reservoirs. The main challenge was dealing with the increased salinity along the coastal areas in Aceh. There was a need to rapidly find other sources of water such as wells on higher land or springs. In the initial phase, WHO, in association with UNICEF and other agencies, focused on ensuring that people had access to safe water. WHO also ensured that hospitals, schools and clinics had access to safe drinking water. Chloroscopes were dispatched immediately to monitor water quality. WHO worked closely with provincial health authorities, providing technical advice and support in assessing water quality. Practical water quality monitoring workshops were organized in collaboration with UNICEF and the MoH. WHO trained 21 agencies and NGOs in water quality monitoring and testing. In addition, equipment such as tankers, sludge pumps and consumables were supplied and emergency repair to damaged plants was coordinated. WHO guidelines were adapted to Aceh conditions and translated into the local language. Pharmaceutical supply survey Water and sanitation In most of the affected areas, sanitation facilities were destroyed. Proper disposal of human excreta was urgently required to prevent outbreaks of diarrhoea and worm infestations. Constructing toilets for such large numbers of displaced persons took some time. Hospitals and health centres were severely damaged. Many hospitals also had damaged equipment. Improper disposal and management of clinical wastes by these facilities could cause serious health hazards. With many IDPs in the disaster-affected areas crowded in several different camps and served by temporary health posts, clinical waste disposal was a major problem and posed a very serious risk to large- scale disease outbreaks. A majority of the health personnel in the area had no training in clinical waste management. WHO's role in HCWM centred on assisting the PHO and technical partners by providing technical support and coordination. The activities included assessment; Health-care waste management (HCWM) Findings of the pharmaceutical survey / 4000 tons of drugs were received for a population of 2 million people. / 60% of the drugs were not on the national list of essential drugs. / 70% of the drugs were labelled in a foreign language. / 25% of the drugs had an inadequate expiry date. / Extremely large quantities of appropriate drugs posed a substantial problem for utilization such as ORS (5–8 years of supply), dextromethorphan 15 mg (6 years of supply) and tetracycline 250 mg (4 years of supply). / Large quantities of drugs overburdened the already compromised storage spaces. / Improper storage affected the quality of stored drugs. / No waste disposal protocol was available in the surveyed districts. / Taking into account drugs with no expiry dates, the expired drugs at the time of their arrival and those due to expire within the next six months amounted to 17% (about 600 tons) of the supplies and needed to be destroyed without delay. / At the rate of 4 euros per kg disposed, the average disposal cost would be EUR 2 400 000. F r o m r e l i e f t o r e c o v e r y I n d o n e s i a preparation of a proposal on pharmaceutical waste management in Nias, and technical assistance for the preparation of a proposal on pharmaceutical waste management for NAD. A survey was financed by WHO to assess the usefulness of donated drugs for the affected population. PSF-CI, along with national and provincial health authorities, undertook a survey in health centres, hospitals and pharmaceutical warehouses in tsunami-affected districts. The objective of the survey was to assess the impact of drug donations on the public pharmaceutical system in tsunami-affected areas in NAD. Four tools were developed: a questionnaire for warehouses, a questionnaire for hospitals and health centres, a questionnaire for NGOs and a document to inventory drugs. An inventory was made using the National List of Essential Drugs of Indonesia and was based on criteria used by the WHO to define an inappropriate drug. Eight tsunami-affected districts were targeted for the survey: Banda Aceh, Aceh Besar, Pidie, Bireuen, Lhokseumawe, Aceh Jaya, Aceh Barat and Simeulue. Water supply and sanitation infrastructure, including treatment plants and their distribution network, were seriously damaged following the earthquake and tsunami. The tsunami also resulted in contamination of ground water reservoirs. The main challenge was dealing with the increased salinity along the coastal areas in Aceh. There was a need to rapidly find other sources of water such as wells on higher land or springs. In the initial phase, WHO, in association with UNICEF and other agencies, focused on ensuring that people had access to safe water. WHO also ensured that hospitals, schools and clinics had access to safe drinking water. Chloroscopes were dispatched immediately to monitor water quality. WHO worked closely with provincial health authorities, providing technical advice and support in assessing water quality. Practical water quality monitoring workshops were organized in collaboration with UNICEF and the MoH. WHO trained 21 agencies and NGOs in water quality monitoring and testing. In addition, equipment such as tankers, sludge pumps and consumables were supplied and emergency repair to damaged plants was coordinated. WHO guidelines were adapted to Aceh conditions and translated into the local language. Pharmaceutical supply survey Water and sanitation In most of the affected areas, sanitation facilities were destroyed. Proper disposal of human excreta was urgently required to prevent outbreaks of diarrhoea and worm infestations. Constructing toilets for such large numbers of displaced persons took some time. Hospitals and health centres were severely damaged. Many hospitals also had damaged equipment. Improper disposal and management of clinical wastes by these facilities could cause serious health hazards. With many IDPs in the disaster-affected areas crowded in several different camps and served by temporary health posts, clinical waste disposal was a major problem and posed a very serious risk to large- scale disease outbreaks. A majority of the health personnel in the area had no training in clinical waste management. WHO's role in HCWM centred on assisting the PHO and technical partners by providing technical support and coordination. The activities included assessment; Health-care waste management (HCWM) Findings of the pharmaceutical survey / 4000 tons of drugs were received for a population of 2 million people. / 60% of the drugs were not on the national list of essential drugs. / 70% of the drugs were labelled in a foreign language. / 25% of the drugs had an inadequate expiry date. / Extremely large quantities of appropriate drugs posed a substantial problem for utilization such as ORS (5–8 years of supply), dextromethorphan 15 mg (6 years of supply) and tetracycline 250 mg (4 years of supply). / Large quantities of drugs overburdened the already compromised storage spaces. / Improper storage affected the quality of stored drugs. / No waste disposal protocol was available in the surveyed districts. / Taking into account drugs with no expiry dates, the expired drugs at the time of their arrival and those due to expire within the next six months amounted to 17% (about 600 tons) of the supplies and needed to be destroyed without delay. / At the rate of 4 euros per kg disposed, the average disposal cost would be EUR 2 400 000. F r o m r e l i e f t o r e c o v e r y I n d o n e s i a training and capacity building; developing information, education and motivational (IEM) materials; providing supplies and equipment; and developing monitoring systems. With financial support from the European Commission Humanitarian Aid (ECHO), WHO developed an HCWM project in Aceh, which was one of the largest such initiatives in a developing country. This project was initiated on 8 March 2005 and ran until 30 April 2006. Target institutions for interventions were prioritized to include 180 puskesmas and 20 hospitals in tsunami-affected districts including Nias District in North Sumatra. Initial assessment showed that systems for proper waste disposal did not exist, and universal precautions were not being practised. Supplies and equipment were not available as ready-made products. A major challenge was to procure these items. The procurement process began in late August 2005. Model packages for puskesmas and District Hospitals were worked out, giving due importance to making available needed consumable items such as bleaching powder, disposable gloves, colour-coded plastic bags and plastic debris pots for needle-cutter devices for at least one year for hospitals and two to three years for puskesmas. To facilitate segregation of waste at source, colour-coded foot operated bins, needle cutters and water tanks for waste sharps management, plastic basins for the preparation of disinfectant solution and personal protective equipment were procured. Autoclaves, trolleys and colour-coded bins to facilitate safe transportation of waste were also procured. Plastic shredders for the management of plastic waste and incinerators for infected waste arrived in May 2006. A ToT Programme was held for representatives of all tsunami-affected districts. Trained personnel continued with 21 cascading trainings creating a resource base of trained health staff in 176 puskesmas and district hospitals in 13 districts. As child and adolescent health programmes and services were severely disrupted in NAD Province, WHO assisted in establishing a coordination mechanism at the central as well as at the provincial and district levels. Several meetings took place at all levels in collaboration with other UN Agencies, international and local NGOs to develop and recommend a list of activities for Child and Adolescent Health (CAH) needed for Aceh. Several meetings were also held with DHOs to collect information on the needs and problems of CAH programmes. A planning meeting was held on Child and adolescent health F r o m r e l i e f t o r e c o v e r y I n d o n e s i a training and capacity building; developing information, education and motivational (IEM) materials; providing supplies and equipment; and developing monitoring systems. With financial support from the European Commission Humanitarian Aid (ECHO), WHO developed an HCWM project in Aceh, which was one of the largest such initiatives in a developing country. This project was initiated on 8 March 2005 and ran until 30 April 2006. Target institutions for interventions were prioritized to include 180 puskesmas and 20 hospitals in tsunami-affected districts including Nias District in North Sumatra. Initial assessment showed that systems for proper waste disposal did not exist, and universal precautions were not being practised. Supplies and equipment were not available as ready-made products. A major challenge was to procure these items. The procurement process began in late August 2005. Model packages for puskesmas and District Hospitals were worked out, giving due importance to making available needed consumable items such as bleaching powder, disposable gloves, colour-coded plastic bags and plastic debris pots for needle-cutter devices for at least one year for hospitals and two to three years for puskesmas. To facilitate segregation of waste at source, colour-coded foot operated bins, needle cutters and water tanks for waste sharps management, plastic basins for the preparation of disinfectant solution and personal protective equipment were procured. Autoclaves, trolleys and colour-coded bins to facilitate safe transportation of waste were also procured. Plastic shredders for the management of plastic waste and incinerators for infected waste arrived in May 2006. A ToT Programme was held for representatives of all tsunami-affected districts. Trained personnel continued with 21 cascading trainings creating a resource base of trained health staff in 176 puskesmas and district hospitals in 13 districts. As child and adolescent health programmes and services were severely disrupted in NAD Province, WHO assisted in establishing a coordination mechanism at the central as well as at the provincial and district levels. Several meetings took place at all levels in collaboration with other UN Agencies, international and local NGOs to develop and recommend a list of activities for Child and Adolescent Health (CAH) needed for Aceh. Several meetings were also held with DHOs to collect information on the needs and problems of CAH programmes. A planning meeting was held on Child and adolescent health 25–27 April 2005 in support of the development of a work plan for activities at the central, provincial and district levels. The School Health Programme was a strategic intervention for targeting school-age children as part of the Tsunami Recovery Programme of 2005. Children, vulnerable to mental and physical traumatic disorders, needed to have access to health services immediately. This was particularly weak in NAD Province. The School Health Programme was an operationally viable starting point for child health rehabilitation in NAD, as it has been running in Indonesia for about 20 years and provided a framework for collaboration. The “Little Doctors” programme encourages student involvement in the School Health Programme, and emphasizes the promotion of good hygiene and healthy behavioural practices. WHO provided support to revitalize the Programme in seven selected districts by supporting the DHO and health centres in conducting training for school health programmes, procuring and printing school health protocols, and guidelines. Coverage of the training reached 280 schools and 1680 students trained as “Little Doctors”. School health F r o m r e l i e f t o r e c o v e r y I n d o n e s i a IMCI (Integrated Management of Childhood Illness) Programme IMCI is a comprehensive approach to the management of sick children by community health workers and health personnel at primary health-care centres. WHO supported 11 DHOs in implementing IMCI programmes through the delivery of IMCI socialization and training workshops and sessions for 220 health- care providers including nurses, midwives and doctors. WHO also provided health centres with IMCI recording forms and equipment for ToT in health clinics. WHO supported the PHO and DHOs with monitoring and evaluation tools, helped in identifying bottlenecks and providing solutions, and established a recording and reporting system in health centres on IMCI implementation. Four training sessions on IMCI for health centre staff were held (three batches were supported by WHO and 1 batch by UNICEF). Follow up after IMCI training was conducted by a team consisting of representatives from the MoH, PHO and districts. Problems were identified and solutions proposed to improve IMCI implementation. 25–27 April 2005 in support of the development of a work plan for activities at the central, provincial and district levels. The School Health Programme was a strategic intervention for targeting school-age children as part of the Tsunami Recovery Programme of 2005. Children, vulnerable to mental and physical traumatic disorders, needed to have access to health services immediately. This was particularly weak in NAD Province. The School Health Programme was an operationally viable starting point for child health rehabilitation in NAD, as it has been running in Indonesia for about 20 years and provided a framework for collaboration. The “Little Doctors” programme encourages student involvement in the School Health Programme, and emphasizes the promotion of good hygiene and healthy behavioural practices. WHO provided support to revitalize the Programme in seven selected districts by supporting the DHO and health centres in conducting training for school health programmes, procuring and printing school health protocols, and guidelines. Coverage of the training reached 280 schools and 1680 students trained as “Little Doctors”. School health F r o m r e l i e f t o r e c o v e r y I n d o n e s i a IMCI (Integrated Management of Childhood Illness) Programme IMCI is a comprehensive approach to the management of sick children by community health workers and health personnel at primary health-care centres. WHO supported 11 DHOs in implementing IMCI programmes through the delivery of IMCI socialization and training workshops and sessions for 220 health- care providers including nurses, midwives and doctors. WHO also provided health centres with IMCI recording forms and equipment for ToT in health clinics. WHO supported the PHO and DHOs with monitoring and evaluation tools, helped in identifying bottlenecks and providing solutions, and established a recording and reporting system in health centres on IMCI implementation. Four training sessions on IMCI for health centre staff were held (three batches were supported by WHO and 1 batch by UNICEF). Follow up after IMCI training was conducted by a team consisting of representatives from the MoH, PHO and districts. Problems were identified and solutions proposed to improve IMCI implementation. Nutrition Reproductive health Midwifery In the identification of and care for malnourished children, WHO and UNICEF worked together with the PHO in supporting trainings for health centre staff on the active identification of cases of malnutrition and dissemination of information about nutritional health. With 12 obstetrics and gynaecology specialists and 5500 midwives in Aceh, coverage of antenatal care (ANC) was 53% with only 43% of deliveries attended by skilled birth attendants. This situation resulted in a high maternal mortality ratio compared to the national average (373–800 maternal deaths as compared with 307 maternal deaths/100 000 live births, national average). In Indonesia midwives provide more than 60% of all family planning services, and more than 90% of maternity and newborn care services. The MoH estimated that midwives in Aceh were directly impacted by the disaster, losing their lives, homes, clinical practices and family members. In Aceh, WHO assisted the PHO in re-establishing midwifery and maternal health services in an integrated manner with other primary health care services. In each of the 49 resettlement points in Aceh, a satellite health post was created to provide 24-hour basic health services through health providers, including a doctor, a midwife and two nurses. WHO also provided US$ 762 000 to re-establish a functional provincial and district health office for reproductive health services. A sum of US$ 1.2 million was also provided for the re-establishment of a midwifery clinic in Aceh. The midwifery education system was also severely impacted. Prior to the tsunami, there were three midwifery schools in Banda Aceh: Poltekkes Aceh, Muhammadiyah and Mona. Muhammadiyah was heavily damaged, Mona was nearly completely destroyed, and Poltekkes Aceh suffered severe damage from water and mud. Following a review of the situation it was decided that only two of the academies would be rehabilitated in the short term, Poltekkes Aceh and Muhammadiyah. MoH Indonesia requested WHO's assistance, as part of the tsunami relief and rehabilitation plan, to include a plan to re-establish midwifery education in Banda Aceh. With collaborating partner JHPIEGO, an international health organization affiliated with the Johns Hopkins University, WHO worked to revitalize the F r o m r e l i e f t o r e c o v e r y I n d o n e s i a Poltekkes and Muhammadiyah academies. JHPIEGO and WHO trained 30 faculty educators in effective teaching skills, 50 educators in maternal–neonatal health updates, and 30 educators in basic delivery care. WHO equipped one hospital and five maternity clinics with 600 teaching aids sets and 850 delivery sets. Both midwifery schools also received rehabilitation equipment and student tuition funds. WHO supported Poltekkes through rental of the building, providing clinical practice training in Medan and Padang, and office equipment. English and Indonesian language reference materials were provided. WHO publications, MoH standard RH materials and RH training packages were made available for midwifery students. The Centre for Secondary Clinical Training (P2KS) in Aceh suffered substantial damage. With support from WHO, P2KS held clinical training events outside of Banda Aceh during the first three months following the tsunami. During this time, WHO, UN agencies and JHPIEGO held coordination meetings and provided support to re-establish the P2KS training institution. In August 2005, P2KS began conducting updates in maternal and neonatal health, infection prevention and contraceptive technology in NAD. In September 2005, WHO assisted P2KS in conducting Advanced Practice Nurse (APN) training and Clinical Training Skills workshops. P2KS resumed some clinical training by October 2005. WHO helped equip P2KS with the knowledge, skills and tools for qualifying post-training health providers as well as providing accreditation capabilities for health facilities applying best practices and standardized Reproductive Health/Maternal, Newborn and Child Health (RH/MNCH) services. In October 2005, WHO assisted UNICEF in the evaluation of basic delivery care, site preparation and post-training for 12 health facilities. Responsibilities were transferred to the Provincial Training Centre of West Java for primary health care preparation and the provision of Basic Emergency Obstetric and Neonatal Care (BEmONC) at the district level. PHO and UNICEF requested WHO conduct the site preparation and APN post-training evaluation. The evaluation identified several weaknesses. After the post-training evaluation was completed, WHO coordinated with the PHO, DHO, UNICEF and the Provincial Training Centre (PTC) in Banda Aceh to conduct a qualification and accreditation process for East Coast districts. On Strengthening in-service midwifery education Evaluation, qualification and accreditation activities Nutrition Reproductive health Midwifery In the identification of and care for malnourished children, WHO and UNICEF worked together with the PHO in supporting trainings for health centre staff on the active identification of cases of malnutrition and dissemination of information about nutritional health. With 12 obstetrics and gynaecology specialists and 5500 midwives in Aceh, coverage of antenatal care (ANC) was 53% with only 43% of deliveries attended by skilled birth attendants. This situation resulted in a high maternal mortality ratio compared to the national average (373–800 maternal deaths as compared with 307 maternal deaths/100 000 live births, national average). In Indonesia midwives provide more than 60% of all family planning services, and more than 90% of maternity and newborn care services. The MoH estimated that midwives in Aceh were directly impacted by the disaster, losing their lives, homes, clinical practices and family members. In Aceh, WHO assisted the PHO in re-establishing midwifery and maternal health services in an integrated manner with other primary health care services. In each of the 49 resettlement points in Aceh, a satellite health post was created to provide 24-hour basic health services through health providers, including a doctor, a midwife and two nurses. WHO also provided US$ 762 000 to re-establish a functional provincial and district health office for reproductive health services. A sum of US$ 1.2 million was also provided for the re-establishment of a midwifery clinic in Aceh. The midwifery education system was also severely impacted. Prior to the tsunami, there were three midwifery schools in Banda Aceh: Poltekkes Aceh, Muhammadiyah and Mona. Muhammadiyah was heavily damaged, Mona was nearly completely destroyed, and Poltekkes Aceh suffered severe damage from water and mud. Following a review of the situation it was decided that only two of the academies would be rehabilitated in the short term, Poltekkes Aceh and Muhammadiyah. MoH Indonesia requested WHO's assistance, as part of the tsunami relief and rehabilitation plan, to include a plan to re-establish midwifery education in Banda Aceh. With collaborating partner JHPIEGO, an international health organization affiliated with the Johns Hopkins University, WHO worked to revitalize the F r o m r e l i e f t o r e c o v e r y I n d o n e s i a Poltekkes and Muhammadiyah academies. JHPIEGO and WHO trained 30 faculty educators in effective teaching skills, 50 educators in maternal–neonatal health updates, and 30 educators in basic delivery care. WHO equipped one hospital and five maternity clinics with 600 teaching aids sets and 850 delivery sets. Both midwifery schools also received rehabilitation equipment and student tuition funds. WHO supported Poltekkes through rental of the building, providing clinical practice training in Medan and Padang, and office equipment. English and Indonesian language reference materials were provided. WHO publications, MoH standard RH materials and RH training packages were made available for midwifery students. The Centre for Secondary Clinical Training (P2KS) in Aceh suffered substantial damage. With support from WHO, P2KS held clinical training events outside of Banda Aceh during the first three months following the tsunami. During this time, WHO, UN agencies and JHPIEGO held coordination meetings and provided support to re-establish the P2KS training institution. In August 2005, P2KS began conducting updates in maternal and neonatal health, infection prevention and contraceptive technology in NAD. In September 2005, WHO assisted P2KS in conducting Advanced Practice Nurse (APN) training and Clinical Training Skills workshops. P2KS resumed some clinical training by October 2005. WHO helped equip P2KS with the knowledge, skills and tools for qualifying post-training health providers as well as providing accreditation capabilities for health facilities applying best practices and standardized Reproductive Health/Maternal, Newborn and Child Health (RH/MNCH) services. In October 2005, WHO assisted UNICEF in the evaluation of basic delivery care, site preparation and post-training for 12 health facilities. Responsibilities were transferred to the Provincial Training Centre of West Java for primary health care preparation and the provision of Basic Emergency Obstetric and Neonatal Care (BEmONC) at the district level. PHO and UNICEF requested WHO conduct the site preparation and APN post-training evaluation. The evaluation identified several weaknesses. After the post-training evaluation was completed, WHO coordinated with the PHO, DHO, UNICEF and the Provincial Training Centre (PTC) in Banda Aceh to conduct a qualification and accreditation process for East Coast districts. On Strengthening in-service midwifery education Evaluation, qualification and accreditation activities completion, PTC/P2KS submitted their conclusion to PHO and UNICEF in order to inform further improvements and subsequent monitoring systems. All trained health providers and public health centres needed further assistance and technical support to achieve the expected level of competency. Seven of the centres were qualified and accredited in December 2005 and 12 in January 2006. Maternal and Child Health handbooks distributed in Indonesia in the past were adapted for use in Aceh following the tsunami. WHO supported a workshop held in collaboration with stakeholders, the MoH and local government that led to the local adaptation of the MCH workbook for distribution in Aceh. During the emergency, WHO supported 11 districts on warehousing practices to store nutritional material, such as supplementary foods provided by the MoH, before distribution to subdistricts and health centres. WHO additionally supported health centres in conducting active case finding for malnutrition cases in their coverage area through sessions held in satellite health posts. Nutrition health Nutrition F r o m r e l i e f t o r e c o v e r y I n d o n e s i a education materials were also disseminated during satellite health post sessions. Cases of severe malnutrition were reported in NAD Province and the risk of an increase in cases was likely. UNICEF, as the lead agency in nutrition, supported sector coordination by establishing a functional nutrition surveillance system, supporting the provision of nutritional services in health centres and health posts, and community therapeutic care services. WHO focused on supporting the application of policies and standard procedures and guidelines, nutrition programme coordination, monitoring and evaluation of nutrition interventions, capacity building through competency-based training in the areas of nutrition education and counselling, hospital and health-based management of severely malnourished children, support to supplementary feeding of vulnerable groups, and institutional support at the central, provincial and district levels. WHO strengthened coordination among UN Agencies and other partners in nutrition programme implementation through regular nutrition group coordination meetings. Based on field assessments and consultations, a three-pronged strategy was developed with partners in this area—the province's Nutrition Directorate, UNICEF and NGOs. The strategy involved three levels of the health-care system. At the primary level, screening and evaluation of severe cases of malnutrition was carried out and referred to the health centres. Here, the cases were further evaluated and treated or referred to hospitals in case of complications. Thereafter, the patient was referred back for rehabilitation at the community level. WHO also supported trainings for nutrition counsellors stationed in health centres, trainings in severe malnutrition management for hospital staff in seven hospitals in NAD Province, and for breastfeeding counsellors. WHO provided training, capacity-building and logistical support for the clinic-based management of severe malnutrition for DHO staff and staff of 42 health centres from 11 districts affected by the tsunami. Technical support and expertise was provided by WHO at the ambulatory and community levels. UNICEF and NGOs worked at the community level, which was key to recovery. WHO also boosted food safety efforts through posters in the local language among IDP settlements. WHO further supported four batches of training nutrition counsellors for 72 health staff (nutritionists and midwives) from health centres. Technical support completion, PTC/P2KS submitted their conclusion to PHO and UNICEF in order to inform further improvements and subsequent monitoring systems. All trained health providers and public health centres needed further assistance and technical support to achieve the expected level of competency. Seven of the centres were qualified and accredited in December 2005 and 12 in January 2006. Maternal and Child Health handbooks distributed in Indonesia in the past were adapted for use in Aceh following the tsunami. WHO supported a workshop held in collaboration with stakeholders, the MoH and local government that led to the local adaptation of the MCH workbook for distribution in Aceh. During the emergency, WHO supported 11 districts on warehousing practices to store nutritional material, such as supplementary foods provided by the MoH, before distribution to subdistricts and health centres. WHO additionally supported health centres in conducting active case finding for malnutrition cases in their coverage area through sessions held in satellite health posts. Nutrition health Nutrition F r o m r e l i e f t o r e c o v e r y I n d o n e s i a education materials were also disseminated during satellite health post sessions. Cases of severe malnutrition were reported in NAD Province and the risk of an increase in cases was likely. UNICEF, as the lead agency in nutrition, supported sector coordination by establishing a functional nutrition surveillance system, supporting the provision of nutritional services in health centres and health posts, and community therapeutic care services. WHO focused on supporting the application of policies and standard procedures and guidelines, nutrition programme coordination, monitoring and evaluation of nutrition interventions, capacity building through competency-based training in the areas of nutrition education and counselling, hospital and health-based management of severely malnourished children, support to supplementary feeding of vulnerable groups, and institutional support at the central, provincial and district levels. WHO strengthened coordination among UN Agencies and other partners in nutrition programme implementation through regular nutrition group coordination meetings. Based on field assessments and consultations, a three-pronged strategy was developed with partners in this area—the province's Nutrition Directorate, UNICEF and NGOs. The strategy involved three levels of the health-care system. At the primary level, screening and evaluation of severe cases of malnutrition was carried out and referred to the health centres. Here, the cases were further evaluated and treated or referred to hospitals in case of complications. Thereafter, the patient was referred back for rehabilitation at the community level. WHO also supported trainings for nutrition counsellors stationed in health centres, trainings in severe malnutrition management for hospital staff in seven hospitals in NAD Province, and for breastfeeding counsellors. WHO provided training, capacity-building and logistical support for the clinic-based management of severe malnutrition for DHO staff and staff of 42 health centres from 11 districts affected by the tsunami. Technical support and expertise was provided by WHO at the ambulatory and community levels. UNICEF and NGOs worked at the community level, which was key to recovery. WHO also boosted food safety efforts through posters in the local language among IDP settlements. WHO further supported four batches of training nutrition counsellors for 72 health staff (nutritionists and midwives) from health centres. Technical support Mental health The Acehnese had already been affected psychologically by the long-standing civil conflict; the tsunami was thus shattering. In early January 2005, a team of 15 people comprising psychiatrists, psychologists and nurses was sent to Banda Aceh. Several NGOs were already providing counselling to the severely traumatized people. To coordinate the activities of about 130 international and local NGOs working in the area of mental health and psychosocial recovery, a subgroup was established to the main Health Coordination Group, the PsychoSocial Coordination Group (PSCG). This group was coordinated jointly by WHO, other UN agencies and NGOs. By the end of January, a draft plan was drawn up to address the psychosocial and mental health needs of the tsunami-affected population. This plan was modified by the provincial government to suit local needs. Through intensive discussion with the Directorate of Community Mental Health of the MoH, WHO put forward a recommendation on mental health in Aceh. This recommendation, adopted into the MoH Strategic Plan for Mental Health, included emergency strategies as well as rehabilitation and reconstruction strategies in five components: (1) Assessment and monitoring; (2) Coordination; (3) Evidence-based interventions; (4) Strengthening the capacity of communities and the health system; and (5) Building a comprehensive mental health system. The provision of direct psychosocial support to the community was immediately identified as a major need. Several guidelines for providing psychosocial support were developed by a Task Force created by the MoH. Three guidelines were developed for the adult population. Guidelines were also developed for understanding the mental and emotional problems of children after a disaster and for the appropriate interventions. These guidelines were disseminated to various organizations that had psychosocial programmes in Aceh. Eight batches of trainers in psychosocial support were sent from Jakarta to Banda Aceh and Lhokseumawe in February–March 2005. Each batch consisted of two psychiatrists, two psychologists and two mental health nurses. Around 600 community leaders, teachers, religious leaders and women leaders were trained, using the guidelines that had been developed earlier. A total of 8000 posters and 15 000 leaflets on mental health and psychosocial issues were created to give reassurance and encouragement. A proposal to assist the mental hospital to restart its clinical activities was F r o m r e l i e f t o r e c o v e r y I n d o n e s i a Mental health The Acehnese had already been affected psychologically by the long-standing civil conflict; the tsunami was thus shattering. In early January 2005, a team of 15 people comprising psychiatrists, psychologists and nurses was sent to Banda Aceh. Several NGOs were already providing counselling to the severely traumatized people. To coordinate the activities of about 130 international and local NGOs working in the area of mental health and psychosocial recovery, a subgroup was established to the main Health Coordination Group, the PsychoSocial Coordination Group (PSCG). This group was coordinated jointly by WHO, other UN agencies and NGOs. By the end of January, a draft plan was drawn up to address the psychosocial and mental health needs of the tsunami-affected population. This plan was modified by the provincial government to suit local needs. Through intensive discussion with the Directorate of Community Mental Health of the MoH, WHO put forward a recommendation on mental health in Aceh. This recommendation, adopted into the MoH Strategic Plan for Mental Health, included emergency strategies as well as rehabilitation and reconstruction strategies in five components: (1) Assessment and monitoring; (2) Coordination; (3) Evidence-based interventions; (4) Strengthening the capacity of communities and the health system; and (5) Building a comprehensive mental health system. The provision of direct psychosocial support to the community was immediately identified as a major need. Several guidelines for providing psychosocial support were developed by a Task Force created by the MoH. Three guidelines were developed for the adult population. Guidelines were also developed for understanding the mental and emotional problems of children after a disaster and for the appropriate interventions. These guidelines were disseminated to various organizations that had psychosocial programmes in Aceh. Eight batches of trainers in psychosocial support were sent from Jakarta to Banda Aceh and Lhokseumawe in February–March 2005. Each batch consisted of two psychiatrists, two psychologists and two mental health nurses. Around 600 community leaders, teachers, religious leaders and women leaders were trained, using the guidelines that had been developed earlier. A total of 8000 posters and 15 000 leaflets on mental health and psychosocial issues were created to give reassurance and encouragement. A proposal to assist the mental hospital to restart its clinical activities was F r o m r e l i e f t o r e c o v e r y I n d o n e s i a developed. In a planned pilot project, four community mental health teams were placed in four districts. Five teams of researchers from the Department of Psychiatry, University of Indonesia conducted an epidemiological study of mental disorders. Local mental health professionals and psychiatrists from the MoH conducted group sessions with all the staff of Zainoel Abidin Hospital. Follow-up counselling and psychiatric treatment were offered to those with significant distress. Six District Mental Health Planning Meetings were held in Banda Aceh and resulted in proposals that were implemented in early September 2005. Curriculum and modules were developed for a basic course in community mental health nursing. Such training was undertaken for the first time in Indonesia. National and provincial (NAD) trainers were trained so that this could be a model for a national programme as well. There was wide collaboration and discussion about the programme between WHO and the MoH Community Mental Health Division as well as Nursing Division; Centre for Training and Education; Health Polytechnic (health training institution); Health College (Jakarta); Nursing Academy; Mental Health Nursing Forum; Faculty of Nursing, University of Indonesia; and the Indonesian Nurses Association. The aim was to train nurses who would form the mainstay of community-based care and would have the skills and competencies to function in the primary health-care setting and as part of a community mental health team. Clinical mental health nurse (CMHN) Basic Module Training was conducted in Lhoksemawe, Aceh Utara, Banda Aceh and Pidie districts of Indonesia. Nurses were trained in 11 tsunami-affected districts. A Community Mental Health Nurses ToT was conducted and the modules were revised according to the feedback from the sessions. Since the tsunami, 2602 cases of serious mental disorders (mostly chronic psychosis) have been detected and treated by community mental health nurses and doctors in public health centres (puskesmas). For the past five years MoH Indonesia has been developing a Clinical Practice Development and Management System (CPDMS) to improve the clinical performance of nurses, midwives and other health staff in hospitals and community health centres. This initiative ensures that nurses and midwives have a clear job description and understand the national clinical standards. Performance indicators are monitored and health staff coached regularly to ensure quality services. From November 2005 until May 2006, monthly monitoring was conducted by the Nursing services F r o m r e l i e f t o r e c o v e r y I n d o n e s i a district coordination team with financial and technical support from WHO and NGOs. In 2005, Bireuen district in Aceh was selected by the MoH for implementation of the CPDMS. WHO assisted in the pilot project that aimed to improve the quality of clinical teaching and learning within nursing programmes conducted at the Politeknik Kesehatan Nanggroe Aceh Darussalam and the School of Nursing at the University Syiah Kuala. Ten organizations are interested in further implementing CPDMS in Aceh. WHO will transfer the coordinating role to provincial and district health offices for collaboration with NGOs. WHO, in partnership with the Indonesian National Nurses Association (PPNI), worked on a project that sought to improve the quality of services offered by practitioners in the Community Health Nursing programme. WHO assisted in training 5 master trainers, 30 candidates trained to become trainers (ToTs) as well as 144 nurses working in health centres in Banda Aceh and Aceh Besar. The MoH and PHO were augmented by the epidemic alert and response team of GOARN on 28 December 2004 to provide support during the acute phase of the Communicable diseases developed. In a planned pilot project, four community mental health teams were placed in four districts. Five teams of researchers from the Department of Psychiatry, University of Indonesia conducted an epidemiological study of mental disorders. Local mental health professionals and psychiatrists from the MoH conducted group sessions with all the staff of Zainoel Abidin Hospital. Follow-up counselling and psychiatric treatment were offered to those with significant distress. Six District Mental Health Planning Meetings were held in Banda Aceh and resulted in proposals that were implemented in early September 2005. Curriculum and modules were developed for a basic course in community mental health nursing. Such training was undertaken for the first time in Indonesia. National and provincial (NAD) trainers were trained so that this could be a model for a national programme as well. There was wide collaboration and discussion about the programme between WHO and the MoH Community Mental Health Division as well as Nursing Division; Centre for Training and Education; Health Polytechnic (health training institution); Health College (Jakarta); Nursing Academy; Mental Health Nursing Forum; Faculty of Nursing, University of Indonesia; and the Indonesian Nurses Association. The aim was to train nurses who would form the mainstay of community-based care and would have the skills and competencies to function in the primary health-care setting and as part of a community mental health team. Clinical mental health nurse (CMHN) Basic Module Training was conducted in Lhoksemawe, Aceh Utara, Banda Aceh and Pidie districts of Indonesia. Nurses were trained in 11 tsunami-affected districts. A Community Mental Health Nurses ToT was conducted and the modules were revised according to the feedback from the sessions. Since the tsunami, 2602 cases of serious mental disorders (mostly chronic psychosis) have been detected and treated by community mental health nurses and doctors in public health centres (puskesmas). For the past five years MoH Indonesia has been developing a Clinical Practice Development and Management System (CPDMS) to improve the clinical performance of nurses, midwives and other health staff in hospitals and community health centres. This initiative ensures that nurses and midwives have a clear job description and understand the national clinical standards. Performance indicators are monitored and health staff coached regularly to ensure quality services. From November 2005 until May 2006, monthly monitoring was conducted by the Nursing services F r o m r e l i e f t o r e c o v e r y I n d o n e s i a district coordination team with financial and technical support from WHO and NGOs. In 2005, Bireuen district in Aceh was selected by the MoH for implementation of the CPDMS. WHO assisted in the pilot project that aimed to improve the quality of clinical teaching and learning within nursing programmes conducted at the Politeknik Kesehatan Nanggroe Aceh Darussalam and the School of Nursing at the University Syiah Kuala. Ten organizations are interested in further implementing CPDMS in Aceh. WHO will transfer the coordinating role to provincial and district health offices for collaboration with NGOs. WHO, in partnership with the Indonesian National Nurses Association (PPNI), worked on a project that sought to improve the quality of services offered by practitioners in the Community Health Nursing programme. WHO assisted in training 5 master trainers, 30 candidates trained to become trainers (ToTs) as well as 144 nurses working in health centres in Banda Aceh and Aceh Besar. The MoH and PHO were augmented by the epidemic alert and response team of GOARN on 28 December 2004 to provide support during the acute phase of the Communicable diseases tsunami emergency. The elements of the response were to: (1) strengthen epidemiological surveillance for epidemic-prone diseases, (2) develop an early warning and alert system for epidemic-prone diseases, (3) investigate disease alerts and initiate appropriate control measures, and (4) prepare for outbreak management and control. The dedicated emergency disease surveillance and response unit worked with the PHO and WHO in support of DHOs, WHO suboffices, NGOs and UN agencies. An early warning and response network was established in cooperation with functioning hospitals, health centres, laboratories and health sector actors. Alert notifications came from WHO surveillance reporting partners, the media and the general population. WHO provided two alert hotlines, one in English and one in Bahasa Indonesia, at the PHO and WHO for immediate contact of surveillance staff. Disease alerts were followed up through verification, investigation and response as needed. As soon as an alert was received it triggered an investigation of suspected cases to obtain demographic, clinical and epidemiological information. The first source of information was the diagnosing clinician and, if necessary, a team was sent out to investigate further. Since March 2005, field investigations were primarily conducted through the PHO and the relevant DHO, often with logistical support from WHO. WHO facilitated this process, arranged laboratory support and offered technical advice. Specimen collection items were available at WHO and could be given to agencies willing and able to collect samples. Interventions such as treatment, environmental control, health promotion and immunization were instituted, if needed. There were no major disease outbreaks in Aceh, although sporadic cases and small clusters of diseases with epidemic potential were frequently identified. This was partly because of the highly effective early warning and surveillance system supported by over 60 organizations. Reported outbreak alerts from Aceh included bloody diarrhoea, acute watery diarrhoea, dengue, typhoid, jaundice, tetanus and measles. The reports of cholera, typhoid and jaundice were false alarms, but there were small clusters of dengue cases. Reports of 40 dengue cases received in the month of August enabled a coordinated response which included the spraying of neighbourhoods found to have cases. Measles, hepatitis, malaria, dengue fever and meningitis cases were regularly F r o m r e l i e f t o r e c o v e r y I n d o n e s i a identified and investigated, resulting in the rapid implementation of control measures. Locally relevant information helped in planning the distribution of bed- nets, antimalarial drugs, water purification kits for wells and sweeping measles vaccination campaigns. Capacity building, training and knowledge transfer to the PHO and DHO staff were conducted formally and informally. Informal settings included joint surveillance data analysis for weekly health coordination meetings, and joint response and investigation of outbreak alerts. Formal training sessions were conducted for district surveillance officers. A total of 9 disease surveillance training workshops were conducted. Two hundred seventy-five surveillance officers from 21 districts were trained. WHO collaborated with partners on activities including the assessment of TB programmes, current situation and resources, training and monitoring of TB Wasors (supervisors), TB health centre staff and laboratory technicians, rational use of medicines (fixed-dose combination drugs), monitoring and supervision of TB tsunami emergency. The elements of the response were to: (1) strengthen epidemiological surveillance for epidemic-prone diseases, (2) develop an early warning and alert system for epidemic-prone diseases, (3) investigate disease alerts and initiate appropriate control measures, and (4) prepare for outbreak management and control. The dedicated emergency disease surveillance and response unit worked with the PHO and WHO in support of DHOs, WHO suboffices, NGOs and UN agencies. An early warning and response network was established in cooperation with functioning hospitals, health centres, laboratories and health sector actors. Alert notifications came from WHO surveillance reporting partners, the media and the general population. WHO provided two alert hotlines, one in English and one in Bahasa Indonesia, at the PHO and WHO for immediate contact of surveillance staff. Disease alerts were followed up through verification, investigation and response as needed. As soon as an alert was received it triggered an investigation of suspected cases to obtain demographic, clinical and epidemiological information. The first source of information was the diagnosing clinician and, if necessary, a team was sent out to investigate further. Since March 2005, field investigations were primarily conducted through the PHO and the relevant DHO, often with logistical support from WHO. WHO facilitated this process, arranged laboratory support and offered technical advice. Specimen collection items were available at WHO and could be given to agencies willing and able to collect samples. Interventions such as treatment, environmental control, health promotion and immunization were instituted, if needed. There were no major disease outbreaks in Aceh, although sporadic cases and small clusters of diseases with epidemic potential were frequently identified. This was partly because of the highly effective early warning and surveillance system supported by over 60 organizations. Reported outbreak alerts from Aceh included bloody diarrhoea, acute watery diarrhoea, dengue, typhoid, jaundice, tetanus and measles. The reports of cholera, typhoid and jaundice were false alarms, but there were small clusters of dengue cases. Reports of 40 dengue cases received in the month of August enabled a coordinated response which included the spraying of neighbourhoods found to have cases. Measles, hepatitis, malaria, dengue fever and meningitis cases were regularly F r o m r e l i e f t o r e c o v e r y I n d o n e s i a identified and investigated, resulting in the rapid implementation of control measures. Locally relevant information helped in planning the distribution of bed- nets, antimalarial drugs, water purification kits for wells and sweeping measles vaccination campaigns. Capacity building, training and knowledge transfer to the PHO and DHO staff were conducted formally and informally. Informal settings included joint surveillance data analysis for weekly health coordination meetings, and joint response and investigation of outbreak alerts. Formal training sessions were conducted for district surveillance officers. A total of 9 disease surveillance training workshops were conducted. Two hundred seventy-five surveillance officers from 21 districts were trained. WHO collaborated with partners on activities including the assessment of TB programmes, current situation and resources, training and monitoring of TB Wasors (supervisors), TB health centre staff and laboratory technicians, rational use of medicines (fixed-dose combination drugs), monitoring and supervision of TB implementation programmes, and provision of equipment, supplies and operational vehicles. A measles outbreak affected 35 people in the age group of 5 months to 15 years; most of the cases were reported from the Aceh Utara district between 8 January and 19 February 2005. Measles management guidelines were disseminated to local health centres and NGOs. An emergency vaccination campaign targeting children aged 6 months to 15 years was launched in Aceh Utara in mid-January. Measles alerts from Aceh Jaya, Nagan Raya, Aceh Besar, Pidie and Aceh Utara were investigated, but were determined to be unlikely. A measles vaccination campaign was repeated in Banda Aceh from 28 February to 5 March 2005, due to the low coverage attained during the initial campaign. Three thousand sixty-six children were vaccinated the first morning. The third measles vaccination campaign had a coverage rate at 79.4% in Banda Aceh, and the campaigns continued in all other districts until 20 March 2005. The malaria surveillance programme was established and supported in order to provide an immediate response to the threat of malaria outbreaks in Aceh. The programme identified patterns of malaria infection and the presence of mosquito vectors. Training was provided on malaria basics and strategic planning, and for malaria microscopists in the identification of malaria cases in health centres. Following reports of malaria cases, WHO, UNICEF and Mentor worked together to develop a protocol to correlate test results from Malaria Rapid Diagnostic Tests (RDT) with blood films from patients with fever. An MoH vector survey conducted in Calang revealed that 59 malaria cases had been reported in Teunom. Ninety-five per cent of these cases occurred in adults, and 75% were positive for P. falciparum, either as single or mixed infections with P. vivax (11 cases of mixed infections). There were no malaria cases in children under five. In Banda Aceh, nine teams consisting of 186 Mentor personnel, sprayed the homes of more than 193 800 people. Teams also sprayed the relocation barracks housing 341 family units. An intensive campaign along the west coast of Aceh ensured the delivery of thousands of bednets to protect from vector-borne diseases. In Bakornas, indoor residual spraying was done in 47 barracks. Measles Malaria F r o m r e l i e f t o r e c o v e r y I n d o n e s i a Tetanus Avian influenza PHASE III: REVIEW AND CONSOLIDATION HEALTH COORDINATION AND PLANNING One hundred seven cases of tetanus were admitted to hospital between 30 December and 26 January 2005 from four areas—Banda Aceh, Meulaboh, Sigli and Tapak Tuan/Blangpidie. The case fatality rate was 18.7%. This reflected the extremely high number of injuries and the poor immunization status of the Acehnese. Following the outbreak of avian influenza in NAD, the WHO surveillance unit once again became actively involved in field investigations, timely specimen collection and testing at Litbangkes Laboratory in Jakarta for suspected human cases. The task of coordinating the large number of agencies was immense. Successful coordination was dependent on reliable, relevant and complete information that was often unavailable. Health coordination meetings provided a forum for implementation programmes, and provision of equipment, supplies and operational vehicles. A measles outbreak affected 35 people in the age group of 5 months to 15 years; most of the cases were reported from the Aceh Utara district between 8 January and 19 February 2005. Measles management guidelines were disseminated to local health centres and NGOs. An emergency vaccination campaign targeting children aged 6 months to 15 years was launched in Aceh Utara in mid-January. Measles alerts from Aceh Jaya, Nagan Raya, Aceh Besar, Pidie and Aceh Utara were investigated, but were determined to be unlikely. A measles vaccination campaign was repeated in Banda Aceh from 28 February to 5 March 2005, due to the low coverage attained during the initial campaign. Three thousand sixty-six children were vaccinated the first morning. The third measles vaccination campaign had a coverage rate at 79.4% in Banda Aceh, and the campaigns continued in all other districts until 20 March 2005. The malaria surveillance programme was established and supported in order to provide an immediate response to the threat of malaria outbreaks in Aceh. The programme identified patterns of malaria infection and the presence of mosquito vectors. Training was provided on malaria basics and strategic planning, and for malaria microscopists in the identification of malaria cases in health centres. Following reports of malaria cases, WHO, UNICEF and Mentor worked together to develop a protocol to correlate test results from Malaria Rapid Diagnostic Tests (RDT) with blood films from patients with fever. An MoH vector survey conducted in Calang revealed that 59 malaria cases had been reported in Teunom. Ninety-five per cent of these cases occurred in adults, and 75% were positive for P. falciparum, either as single or mixed infections with P. vivax (11 cases of mixed infections). There were no malaria cases in children under five. In Banda Aceh, nine teams consisting of 186 Mentor personnel, sprayed the homes of more than 193 800 people. Teams also sprayed the relocation barracks housing 341 family units. An intensive campaign along the west coast of Aceh ensured the delivery of thousands of bednets to protect from vector-borne diseases. In Bakornas, indoor residual spraying was done in 47 barracks. Measles Malaria F r o m r e l i e f t o r e c o v e r y I n d o n e s i a Tetanus Avian influenza PHASE III: REVIEW AND CONSOLIDATION HEALTH COORDINATION AND PLANNING One hundred seven cases of tetanus were admitted to hospital between 30 December and 26 January 2005 from four areas—Banda Aceh, Meulaboh, Sigli and Tapak Tuan/Blangpidie. The case fatality rate was 18.7%. This reflected the extremely high number of injuries and the poor immunization status of the Acehnese. Following the outbreak of avian influenza in NAD, the WHO surveillance unit once again became actively involved in field investigations, timely specimen collection and testing at Litbangkes Laboratory in Jakarta for suspected human cases. The task of coordinating the large number of agencies was immense. Successful coordination was dependent on reliable, relevant and complete information that was often unavailable. Health coordination meetings provided a forum for discussion and coordinated action. Such action and subsequent adjustment was sometimes constrained by donor conditions, expectations and a lack of planning flexibility. Organizations that did not attend coordination meetings also posed a problem as some of them began work in Aceh without coordinating with any governmental health office leading to complaints from the government. The availability of a clear process and protocols for responsibility sharing between governmental levels during the emergency would have reduced some confusion and delay over how best to develop MoUs and proceed with implementation. Strengthening health sector coordination mechanisms in support of priorities outlined in RENSTRA at provincial, district and local levels, and supporting the alignment of donor contributions with RENSTRA will be a continued responsibility of health authorities in coordination activities. Continuing the health sector coordination mechanisms at provincial and district levels through regular monthly multi-stakeholder health forum meetings would still be of use as recovery programmes are ongoing. F r o m r e l i e f t o r e c o v e r y I n d o n e s i a Support for the maintenance, management and updating of the website and mailing list will ensure that strategic guidelines, resources and information regarding policy directions outlined in RENSTRA are available and accessible to all organizations active in the health sector. Training of local staff is needed to update and manage the database on existing health resources operating in Aceh, and on the overall health situation in the region. With only slightly more than 10% of health sector funding originating from the Government of Indonesia during the reconstruction and rehabilitation phase, the relative proportion of total recurrent and capital expenditure that will eventually need to be financed by internal resources, and the expected lag time before such a shift in financing will occur, must be further examined. The composition of financing in 2005 was exceptional, both in the source of funds and the composition of expenditure. Because of the tsunami, external funding vastly increased on both recurrent and capital expenditures in 2005. The current availability of donor funding has led to expansive aid-induced planning that may erode the stability of longer-term planning cycles in the absence of a sound review of currently planned health expenditures. The need to restore Health Information Systems (HIS) infrastructure damaged by the tsunami is a priority and the PHO should be assisted in developing standards for minimum HIS infrastructure in puskesmas. There is a need to develop guidelines for data management at all levels as current reporting is compartmentalized. Use of information for management is still not optimal and data management at health facilities is not adequate. Organizational aspects of data management at all levels need to be strengthened. The flow of information from the grassroots community level to the provincial level and vice versa needs more support and an established system. There is a need for capacity building for data analysis and action taken following the flow of information. Although inappropriate distribution of medical equipment was unavoidable in the aftermath of the tsunami and during the emergency phase, it is now imperative to address and tackle the problem to maximize reconstruction efforts. Management in the health facilities is currently exclusively clinically oriented. Clinical issues need to be considered along with logistics, structural and human resources issues, as water supply and distribution networks are overall inappropriate; sterilization is suboptimal and waste management is still not perceived as a major issue. acehhealthinfo.com Health systems WHO vector-borne disease prevention and control efforts / A total of 22 800 long-lasting insecticidal nets (LLIN) were distributed in Pidie and Simeulue districts. / 150 boxes of rapid diagnostic tests (RDTs) were given to the PHO to replenish buffer stock. / 3000 doses of arthemeter were given to PHO as buffer stock. An additional 50 000 doses of arthemeter and 25 000 of artesunate were prepared for distribution as needed. / Insecticide and over 250 spraying pumps for vector-borne diseases were distributed. discussion and coordinated action. Such action and subsequent adjustment was sometimes constrained by donor conditions, expectations and a lack of planning flexibility. Organizations that did not attend coordination meetings also posed a problem as some of them began work in Aceh without coordinating with any governmental health office leading to complaints from the government. The availability of a clear process and protocols for responsibility sharing between governmental levels during the emergency would have reduced some confusion and delay over how best to develop MoUs and proceed with implementation. Strengthening health sector coordination mechanisms in support of priorities outlined in RENSTRA at provincial, district and local levels, and supporting the alignment of donor contributions with RENSTRA will be a continued responsibility of health authorities in coordination activities. Continuing the health sector coordination mechanisms at provincial and district levels through regular monthly multi-stakeholder health forum meetings would still be of use as recovery programmes are ongoing. F r o m r e l i e f t o r e c o v e r y I n d o n e s i a Support for the maintenance, management and updating of the website and mailing list will ensure that strategic guidelines, resources and information regarding policy directions outlined in RENSTRA are available and accessible to all organizations active in the health sector. Training of local staff is needed to update and manage the database on existing health resources operating in Aceh, and on the overall health situation in the region. With only slightly more than 10% of health sector funding originating from the Government of Indonesia during the reconstruction and rehabilitation phase, the relative proportion of total recurrent and capital expenditure that will eventually need to be financed by internal resources, and the expected lag time before such a shift in financing will occur, must be further examined. The composition of financing in 2005 was exceptional, both in the source of funds and the composition of expenditure. Because of the tsunami, external funding vastly increased on both recurrent and capital expenditures in 2005. The current availability of donor funding has led to expansive aid-induced planning that may erode the stability of longer-term planning cycles in the absence of a sound review of currently planned health expenditures. The need to restore Health Information Systems (HIS) infrastructure damaged by the tsunami is a priority and the PHO should be assisted in developing standards for minimum HIS infrastructure in puskesmas. There is a need to develop guidelines for data management at all levels as current reporting is compartmentalized. Use of information for management is still not optimal and data management at health facilities is not adequate. Organizational aspects of data management at all levels need to be strengthened. The flow of information from the grassroots community level to the provincial level and vice versa needs more support and an established system. There is a need for capacity building for data analysis and action taken following the flow of information. Although inappropriate distribution of medical equipment was unavoidable in the aftermath of the tsunami and during the emergency phase, it is now imperative to address and tackle the problem to maximize reconstruction efforts. Management in the health facilities is currently exclusively clinically oriented. Clinical issues need to be considered along with logistics, structural and human resources issues, as water supply and distribution networks are overall inappropriate; sterilization is suboptimal and waste management is still not perceived as a major issue. acehhealthinfo.com Health systems WHO vector-borne disease prevention and control efforts / A total of 22 800 long-lasting insecticidal nets (LLIN) were distributed in Pidie and Simeulue districts. / 150 boxes of rapid diagnostic tests (RDTs) were given to the PHO to replenish buffer stock. / 3000 doses of arthemeter were given to PHO as buffer stock. An additional 50 000 doses of arthemeter and 25 000 of artesunate were prepared for distribution as needed. / Insecticide and over 250 spraying pumps for vector-borne diseases were distributed. Strengthening of overall management capabilities and technical issues is recommended. Appropriate policies and guidelines must be developed for medical and hospital equipment management (as per donation, distribution, procurement, inventory and maintenance). The concept of a referral system exists, though it is weak and sometimes non- functional. Strengthening the referral system is strongly recommended, especially for communicable diseases and vulnerable populations, namely women and children. Capacity building for health promotion has been recommended in the WHO Biennium Plan of Action 2006–2007 for Aceh. Presentations on health promotion programmes were given to staff of WHO Aceh, especially for the newly recruited. Minimal technical assistance has been extended to implement health promotion activities due to a reluctance of partners to adopt the concepts, theories and principles of health promotion programmes. The poor understanding of health promotion and the application of cross-cutting programmes with intersectoral and multisectoral stakeholders can be complicated, especially in the identification of funding sources. Most of the programme-implementing agencies use health education interchangeably for health promotion. Health promotion is not equal to health education. For the sake of clarity and best practice, it is critical to provide health promotion training workshops for internal and external agencies. Infrastructure should be strengthened for health promotion at PHO, DHO and community levels (NGO communities, UN agencies and donor agencies). Programme policies should be developed to include a health promotion component in every health programme with public health concerns. Increased internal marketing of health promotion programmes among WHO technical staff could be undertaken so that they can then influence health authorities to advocate health promotion in their health programmes. Training on the evolution of mass media communications on behavioural change impact and social marketing of health could be offered as a combination of science and art rather than the traditional method of dissemination of health education through posters and leaflets. Health promotion Capacity building F r o m r e l i e f t o r e c o v e r y I n d o n e s i a Pharmaceutical supply and management systems Water and sanitation Unwanted donated pharmaceuticals can cause to harm to humans and the environment. Government agencies in the health, environment, and food and drugs sectors must collaborate to locate, sort, segregate, and safely and securely store these unwanted items before destruction, in compliance with national and international standards, issuance and guidelines. Improvements in access to quality, safe, effective and affordable essential medicines for priority illnesses and life-threatening conditions must be supported by guidelines and practices on essential and rational drug use. Guidelines for drug donations are currently not being observed. Such guidelines should be included in the national drug policy of countries and be internationally regulated as a public health protection measure. Although much was accomplished during 2005, many important goals were yet to be reached to support the foundations that were laid in the development of a rehabilitated water supply system. Institutions and government agencies continued to strive for clarity in health policies and the bolstering of health staff capacity. Water quality in tankers used to supply water revealed that the water was inadequately chlorinated as well as contaminated. WHO assisted in outlining a plan of action. With the International Red Cross (IRC) and UNICEF, a manual was prepared in Bahasa Indonesia, and WHO issued recommendations for minimum chlorine dosage and an improved monitoring system. Sustainability of supply costs and mid- and long-term prospects for the use of trucks must be addressed. De-sludging costs must be affordable or there is a risk of fecal contamination of water due to uncontrolled practices. Many IDP settlements were provided with a number of refilling tanks made of Strengthening of overall management capabilities and technical issues is recommended. Appropriate policies and guidelines must be developed for medical and hospital equipment management (as per donation, distribution, procurement, inventory and maintenance). The concept of a referral system exists, though it is weak and sometimes non- functional. Strengthening the referral system is strongly recommended, especially for communicable diseases and vulnerable populations, namely women and children. Capacity building for health promotion has been recommended in the WHO Biennium Plan of Action 2006–2007 for Aceh. Presentations on health promotion programmes were given to staff of WHO Aceh, especially for the newly recruited. Minimal technical assistance has been extended to implement health promotion activities due to a reluctance of partners to adopt the concepts, theories and principles of health promotion programmes. The poor understanding of health promotion and the application of cross-cutting programmes with intersectoral and multisectoral stakeholders can be complicated, especially in the identification of funding sources. Most of the programme-implementing agencies use health education interchangeably for health promotion. Health promotion is not equal to health education. For the sake of clarity and best practice, it is critical to provide health promotion training workshops for internal and external agencies. Infrastructure should be strengthened for health promotion at PHO, DHO and community levels (NGO communities, UN agencies and donor agencies). Programme policies should be developed to include a health promotion component in every health programme with public health concerns. Increased internal marketing of health promotion programmes among WHO technical staff could be undertaken so that they can then influence health authorities to advocate health promotion in their health programmes. Training on the evolution of mass media communications on behavioural change impact and social marketing of health could be offered as a combination of science and art rather than the traditional method of dissemination of health education through posters and leaflets. Health promotion Capacity building F r o m r e l i e f t o r e c o v e r y I n d o n e s i a Pharmaceutical supply and management systems Water and sanitation Unwanted donated pharmaceuticals can cause to harm to humans and the environment. Government agencies in the health, environment, and food and drugs sectors must collaborate to locate, sort, segregate, and safely and securely store these unwanted items before destruction, in compliance with national and international standards, issuance and guidelines. Improvements in access to quality, safe, effective and affordable essential medicines for priority illnesses and life-threatening conditions must be supported by guidelines and practices on essential and rational drug use. Guidelines for drug donations are currently not being observed. Such guidelines should be included in the national drug policy of countries and be internationally regulated as a public health protection measure. Although much was accomplished during 2005, many important goals were yet to be reached to support the foundations that were laid in the development of a rehabilitated water supply system. Institutions and government agencies continued to strive for clarity in health policies and the bolstering of health staff capacity. Water quality in tankers used to supply water revealed that the water was inadequately chlorinated as well as contaminated. WHO assisted in outlining a plan of action. With the International Red Cross (IRC) and UNICEF, a manual was prepared in Bahasa Indonesia, and WHO issued recommendations for minimum chlorine dosage and an improved monitoring system. Sustainability of supply costs and mid- and long-term prospects for the use of trucks must be addressed. De-sludging costs must be affordable or there is a risk of fecal contamination of water due to uncontrolled practices. Many IDP settlements were provided with a number of refilling tanks made of fibre-glass (15 000 L capacity or so). However, there was no water supply for those tanks by tankers on a regular basis. Taps on tanks were often broken or leaking. Point-of-use disinfection was limited within the settlements. As the majority of the people living in shelters boil water before drinking, there was a demand for containers to collect, boil and store water. Long-term field testing found the WagTech testing kits to be inappropriate for water quality surveillance in Aceh. WHO recommended the procurement of DelAgua water testing kits and upgradation of the existing WagTech kits to acceptable performance standards. Water quality monitoring and surveillance at district level should be strengthened by equipping water testing laboratories and conducting training programmes. The goal of 20 persons per latrine inside the settlements was never met. Construction of additional latrines was needed in the majority of settlements. Toilets in buildings used to provide shelter were overcrowded with wastewater running over the floor, open drains that were blocked, and water left flowing. The implementation of a sanitation clinic approach at selected district and health centre levels should be considered through the provision of portable water testing kits and sanitation kits. Disaster preparedness is non-existent in the area of environmental health in Aceh, but should be recommended in case of major pollution, accidents or large outbreaks. Staff should be prepared and material available to perform quick assessments of water quality. Knowledge management and compilation are equally important in the preparation of mid- or longer-term plans. Valuable information and time could be lost with no adequate way to sort, validate, convey and keep track of work completed. There continues to be a lack of clear, enforceable policies and budget for environmental health issues in Aceh. Simple, preventive actions can be taken such as enforcing basic sanitation standards to decrease fecal contamination risks and securing water intake catchment areas. Further strengthening of the PHO and DHOs in dealing with environmental health issues through infrastructure improvement and staff development is needed. Plans for the expansion of the HCWM programme would include the dissemination of educational materials, establishment of monitoring and evaluation Environmental health Health-care waste management F r o m r e l i e f t o r e c o v e r y I n d o n e s i a fibre-glass (15 000 L capacity or so). However, there was no water supply for those tanks by tankers on a regular basis. Taps on tanks were often broken or leaking. Point-of-use disinfection was limited within the settlements. As the majority of the people living in shelters boil water before drinking, there was a demand for containers to collect, boil and store water. Long-term field testing found the WagTech testing kits to be inappropriate for water quality surveillance in Aceh. WHO recommended the procurement of DelAgua water testing kits and upgradation of the existing WagTech kits to acceptable performance standards. Water quality monitoring and surveillance at district level should be strengthened by equipping water testing laboratories and conducting training programmes. The goal of 20 persons per latrine inside the settlements was never met. Construction of additional latrines was needed in the majority of settlements. Toilets in buildings used to provide shelter were overcrowded with wastewater running over the floor, open drains that were blocked, and water left flowing. The implementation of a sanitation clinic approach at selected district and health centre levels should be considered through the provision of portable water testing kits and sanitation kits. Disaster preparedness is non-existent in the area of environmental health in Aceh, but should be recommended in case of major pollution, accidents or large outbreaks. Staff should be prepared and material available to perform quick assessments of water quality. Knowledge management and compilation are equally important in the preparation of mid- or longer-term plans. Valuable information and time could be lost with no adequate way to sort, validate, convey and keep track of work completed. There continues to be a lack of clear, enforceable policies and budget for environmental health issues in Aceh. Simple, preventive actions can be taken such as enforcing basic sanitation standards to decrease fecal contamination risks and securing water intake catchment areas. Further strengthening of the PHO and DHOs in dealing with environmental health issues through infrastructure improvement and staff development is needed. Plans for the expansion of the HCWM programme would include the dissemination of educational materials, establishment of monitoring and evaluation Environmental health Health-care waste management F r o m r e l i e f t o r e c o v e r y I n d o n e s i a systems, and identification of entrepreneurs or organizations to provide recycling services for plastic, metal and intact glassware. Continuous consultation with the PHO, participation in health coordination meetings and frequent interactions with health-care staff made it possible to create a positive response to and acceptance of the need for HCWM, when more pressing needs were present following the tsunami. HCWM was incorporated in the provincial strategic plan finalized in December 2005. The Water and Sanitation departments at provincial and district levels were identified as the coordinating units for the development of HCWM systems. The project entered the development mode from June 2006. Work plans regarding the development of HCWM systems needed to be shared among different agencies. An HCWM subcommittee was formed to oversee and adopt a common agenda and avoid duplication of efforts. The HCWM Committee was instrumental in the establishment of a provincial-level HCWM Committee. Continued facilitation of these meetings will be an ongoing challenge. F r o m r e l i e f t o r e c o v e r y I n d o n e s i a Trainings were accepted well with more demand for training coming from neighbouring provinces, non-tsunami districts and the MoH. It is expected that each of the trained personnel will further conduct awareness programmes in each of the health-care settings they represent to ensure a cascading effect. There is a need for establishing study centres and conducting periodic trainings. The curriculum, training materials and methodology have been developed and field tested. The ECHO–WHO HCWM project is the largest known HCWM initiative across a large number of health-care institutions in developing countries, in low-resource settings. Supplies and equipment were not readily available and posed a challenge. Colour-coded foot operated bins, plastic bags, trolleys and incinerators posed the greatest challenge. These were made to order according to technical specifications, cost-effectiveness and acceptability by the health-care system. The Environmental Wing of the Government was consulted and the PHO received clearance and approval for the installation of incinerators. Care must be taken to ensure that monitoring of incinerators is conducted daily. CAH programmes need to be strengthened in Aceh Province through the expansion of all activities. Trainings should be provided for health workers in support of the expansion, which include an increased awareness of early warning signs and symptoms for the integrated management of childhood illnesses (IMCI). Strengthening of health education in schools should also be supported through the expansion of the “Little Doctor” programme throughout Aceh. A number of weaknesses were identified in the current midwifery education programme in both targeted institutions (Poltekkes and Muhammadiyah) in Aceh. The main focus of project activities had been on private training sites and the maternity hospital. It was recommended and agreed that more attention should be given to making government sites more conducive to learning. Faculty in both Poltekkes and Muhammadiyah recognized the need for improving their teaching and assessment skills, both in classroom and clinical teaching. The structural rehabilitation of Muhammadiyah was slower than anticipated. This additional work is to be undertaken by AusAID. Child and adolescent health Reproductive health systems, and identification of entrepreneurs or organizations to provide recycling services for plastic, metal and intact glassware. Continuous consultation with the PHO, participation in health coordination meetings and frequent interactions with health-care staff made it possible to create a positive response to and acceptance of the need for HCWM, when more pressing needs were present following the tsunami. HCWM was incorporated in the provincial strategic plan finalized in December 2005. The Water and Sanitation departments at provincial and district levels were identified as the coordinating units for the development of HCWM systems. The project entered the development mode from June 2006. Work plans regarding the development of HCWM systems needed to be shared among different agencies. An HCWM subcommittee was formed to oversee and adopt a common agenda and avoid duplication of efforts. The HCWM Committee was instrumental in the establishment of a provincial-level HCWM Committee. Continued facilitation of these meetings will be an ongoing challenge. F r o m r e l i e f t o r e c o v e r y I n d o n e s i a Trainings were accepted well with more demand for training coming from neighbouring provinces, non-tsunami districts and the MoH. It is expected that each of the trained personnel will further conduct awareness programmes in each of the health-care settings they represent to ensure a cascading effect. There is a need for establishing study centres and conducting periodic trainings. The curriculum, training materials and methodology have been developed and field tested. The ECHO–WHO HCWM project is the largest known HCWM initiative across a large number of health-care institutions in developing countries, in low-resource settings. Supplies and equipment were not readily available and posed a challenge. Colour-coded foot operated bins, plastic bags, trolleys and incinerators posed the greatest challenge. These were made to order according to technical specifications, cost-effectiveness and acceptability by the health-care system. The Environmental Wing of the Government was consulted and the PHO received clearance and approval for the installation of incinerators. Care must be taken to ensure that monitoring of incinerators is conducted daily. CAH programmes need to be strengthened in Aceh Province through the expansion of all activities. Trainings should be provided for health workers in support of the expansion, which include an increased awareness of early warning signs and symptoms for the integrated management of childhood illnesses (IMCI). Strengthening of health education in schools should also be supported through the expansion of the “Little Doctor” programme throughout Aceh. A number of weaknesses were identified in the current midwifery education programme in both targeted institutions (Poltekkes and Muhammadiyah) in Aceh. The main focus of project activities had been on private training sites and the maternity hospital. It was recommended and agreed that more attention should be given to making government sites more conducive to learning. Faculty in both Poltekkes and Muhammadiyah recognized the need for improving their teaching and assessment skills, both in classroom and clinical teaching. The structural rehabilitation of Muhammadiyah was slower than anticipated. This additional work is to be undertaken by AusAID. Child and adolescent health Reproductive health The librarians of both institutions felt the need for more training in library management skills. Systems for students to borrow books are being refined. A request was made to WHO to provide assistance, including the development of long-term plans. Regarding clinical sites, given the involvement of many other organizations, agencies and NGOs, it was agreed that there was a need for greater coordination between all those involved in each site, and more transparent identification of what each partner was contributing. Finally, it is recommended that health authorities be more pro-active in exercising their roles and responsibilities. Recommendations have been discussed to rectify passive roles, further strengthen governance of institutions and address a long-standing gap between education and service delivery. Initially, mental health projects started very slowly as the idea of mental health system development needed to be bolstered among various stakeholders, especially decision-makers. After the Mental Health Planning Workshop and the following two District Mental Health Planning Meetings, implementation started to move faster with the advent of nursing and GP training, and monitoring–supervision implementation in the districts. In the past, despite an awareness of the huge mental health problem in the community, health officials did not have a method for addressing the issue. Currently, they have become more comfortable with developing their own mental health programme. Community mental health teams at the district level are still weak. Designed to function as a consulting body to primary care workers and deliver secondary care, the team should have more advanced knowledge and skills than the primary care workers. Capacity building of human resources including the development of training modules is needed for the training of nurses and doctors in the affected districts. The curriculum for the training of doctors and nurses in community mental health has not been agreed upon. This is a long process involving many parties such as the Indonesian College of Psychiatrists, the Indonesian Psychiatric Association, the Indonesian National Nurses Association and the MoH. To have a comprehensive mental health system, the training of community mental health nurses needs to be continued to the advanced level, doctors need to have continuing Mental health F r o m r e l i e f t o r e c o v e r y I n d o n e s i a education, and the capacity of district general hospitals needs to be developed to provide acute psychiatric care . In the emergency phase, there was a tendency to provide direct services to the survivors, which turned out to be ineffective. The MoH and WHO shifted the focus towards strengthening the system in May 2005, especially in the absence of mental health capacity at the primary care level. The CPDMS was initially difficult to instil at the district level. After CPDMS implementation, maintenance and sustainability depend on the commitment to quality outcomes. This commitment must come from leadership in the PHO, DHOs, hospitals and health centres. Motivation and incentives for health professionals are also key factors for sustainability. To avoid the loss of district trainers, the process of CPDMS and the role of district trainers must be explained prior to implementation to ensure appropriate selection of candidates. A high level of motivation and commitment to improve health services should also be emphasized during candidate selection. The sustainability of the changes in Clinical Teaching and Learning in pre-service nursing programmes, and the capacity of staff to implement the identified changes and continue to improve, are areas of concern. More work needs to be done if the changes are to be sustained and integrated into the day-to-day activities of nursing. An ongoing educational strategy that will continue to improve both clinical supervision and teaching skills of clinical instructors is needed to ensure sustainability. The potentially hazardous nature of nursing work needs to be recognized, and policies and procedures to ensure safe practices must be formulated and adhered to, to minimize harm to patients, staff and students. The population of Aceh was mobile within the province prior to the tsunami because of prolonged conflict. The numbers of IDPs increased dramatically following the tsunami. Population figures and numbers of IDPs were difficult to calculate in the emergency period making the denotation of disease rates and health targets difficult. Nursing Communicable diseases control and surveillance The librarians of both institutions felt the need for more training in library management skills. Systems for students to borrow books are being refined. A request was made to WHO to provide assistance, including the development of long-term plans. Regarding clinical sites, given the involvement of many other organizations, agencies and NGOs, it was agreed that there was a need for greater coordination between all those involved in each site, and more transparent identification of what each partner was contributing. Finally, it is recommended that health authorities be more pro-active in exercising their roles and responsibilities. Recommendations have been discussed to rectify passive roles, further strengthen governance of institutions and address a long-standing gap between education and service delivery. Initially, mental health projects started very slowly as the idea of mental health system development needed to be bolstered among various stakeholders, especially decision-makers. After the Mental Health Planning Workshop and the following two District Mental Health Planning Meetings, implementation started to move faster with the advent of nursing and GP training, and monitoring–supervision implementation in the districts. In the past, despite an awareness of the huge mental health problem in the community, health officials did not have a method for addressing the issue. Currently, they have become more comfortable with developing their own mental health programme. Community mental health teams at the district level are still weak. Designed to function as a consulting body to primary care workers and deliver secondary care, the team should have more advanced knowledge and skills than the primary care workers. Capacity building of human resources including the development of training modules is needed for the training of nurses and doctors in the affected districts. The curriculum for the training of doctors and nurses in community mental health has not been agreed upon. This is a long process involving many parties such as the Indonesian College of Psychiatrists, the Indonesian Psychiatric Association, the Indonesian National Nurses Association and the MoH. To have a comprehensive mental health system, the training of community mental health nurses needs to be continued to the advanced level, doctors need to have continuing Mental health F r o m r e l i e f t o r e c o v e r y I n d o n e s i a education, and the capacity of district general hospitals needs to be developed to provide acute psychiatric care . In the emergency phase, there was a tendency to provide direct services to the survivors, which turned out to be ineffective. The MoH and WHO shifted the focus towards strengthening the system in May 2005, especially in the absence of mental health capacity at the primary care level. The CPDMS was initially difficult to instil at the district level. After CPDMS implementation, maintenance and sustainability depend on the commitment to quality outcomes. This commitment must come from leadership in the PHO, DHOs, hospitals and health centres. Motivation and incentives for health professionals are also key factors for sustainability. To avoid the loss of district trainers, the process of CPDMS and the role of district trainers must be explained prior to implementation to ensure appropriate selection of candidates. A high level of motivation and commitment to improve health services should also be emphasized during candidate selection. The sustainability of the changes in Clinical Teaching and Learning in pre-service nursing programmes, and the capacity of staff to implement the identified changes and continue to improve, are areas of concern. More work needs to be done if the changes are to be sustained and integrated into the day-to-day activities of nursing. An ongoing educational strategy that will continue to improve both clinical supervision and teaching skills of clinical instructors is needed to ensure sustainability. The potentially hazardous nature of nursing work needs to be recognized, and policies and procedures to ensure safe practices must be formulated and adhered to, to minimize harm to patients, staff and students. The population of Aceh was mobile within the province prior to the tsunami because of prolonged conflict. The numbers of IDPs increased dramatically following the tsunami. Population figures and numbers of IDPs were difficult to calculate in the emergency period making the denotation of disease rates and health targets difficult. Nursing Communicable diseases control and surveillance F r o m r e l i e f t o r e c o v e r y I n d o n e s i a The emergency Early Warning and Response Unit began within the WHO Banda Aceh office, but as recovery efforts moved into the reconstruction and rehabilitation phase, the Disease Surveillance and Prevention Unit was developed to address long-term WHO programmatic activities. Technical and managerial responsibilities were incorporated to a greater degree than that required in the emergency early warning and surveillance system. WHO has continual contact with the PHO surveillance staff within the PHO CDC unit that is now responsible for all response activities. As the pre-tsunami surveillance system was weak, there is a need to do more in order to overcome the infrastructure and logistic limitations that the routine surveillance system currently faces. Some laboratories received few clinical samples for diagnostic purposes due to lack of direct supervision and follow up, lack of awareness of medical staff of the importance of the microbiology laboratory and the absence of a referral system between laboratories. A follow up indicated the need for WHO to support capacity building of laboratory experts as well as a need for proper equipment for data analysis and reporting, quality control programmes, maintenance and calibration of equipment, and improved biosafety practices. The routine and contingency budgets of the PHO and DHOs were not sufficient to cover the operational costs of WHO-coordinated programmes. Funding support was needed from national and international sources leading to questionable long- term sustainability. Communication with some areas was problematic as communication infrastructure was lacking in remote and affected areas, which affected surveillance reporting. Furthermore, programme implementation was the responsibility of the DHO even prior to decentralization, with the role of the PHO being policy development, direction, aggregation of data and some training. With further administrative splits still occurring as districts continue to develop, programme implementation occurring solely at the provincial level is unlikely to provide lasting results. Immunization campaigns were difficult as there was a lack of EPI staff at the provincial level. The efficacy of immunization campaigns was difficult to assess because of population movement, unreliable census data, inconsistent reporting and lack of supervision. Logistical support was needed for the cholera vaccination campaign because of the volume of the vaccines, the need for clean water, cold chain requirements and the necessity of being able to reach the same population twice within a short time. A single-dose vaccine would enable implementation through eased logistic F r o m r e l i e f t o r e c o v e r y I n d o n e s i a The emergency Early Warning and Response Unit began within the WHO Banda Aceh office, but as recovery efforts moved into the reconstruction and rehabilitation phase, the Disease Surveillance and Prevention Unit was developed to address long-term WHO programmatic activities. Technical and managerial responsibilities were incorporated to a greater degree than that required in the emergency early warning and surveillance system. WHO has continual contact with the PHO surveillance staff within the PHO CDC unit that is now responsible for all response activities. As the pre-tsunami surveillance system was weak, there is a need to do more in order to overcome the infrastructure and logistic limitations that the routine surveillance system currently faces. Some laboratories received few clinical samples for diagnostic purposes due to lack of direct supervision and follow up, lack of awareness of medical staff of the importance of the microbiology laboratory and the absence of a referral system between laboratories. A follow up indicated the need for WHO to support capacity building of laboratory experts as well as a need for proper equipment for data analysis and reporting, quality control programmes, maintenance and calibration of equipment, and improved biosafety practices. The routine and contingency budgets of the PHO and DHOs were not sufficient to cover the operational costs of WHO-coordinated programmes. Funding support was needed from national and international sources leading to questionable long- term sustainability. Communication with some areas was problematic as communication infrastructure was lacking in remote and affected areas, which affected surveillance reporting. Furthermore, programme implementation was the responsibility of the DHO even prior to decentralization, with the role of the PHO being policy development, direction, aggregation of data and some training. With further administrative splits still occurring as districts continue to develop, programme implementation occurring solely at the provincial level is unlikely to provide lasting results. Immunization campaigns were difficult as there was a lack of EPI staff at the provincial level. The efficacy of immunization campaigns was difficult to assess because of population movement, unreliable census data, inconsistent reporting and lack of supervision. Logistical support was needed for the cholera vaccination campaign because of the volume of the vaccines, the need for clean water, cold chain requirements and the necessity of being able to reach the same population twice within a short time. A single-dose vaccine would enable implementation through eased logistic constraints, reduced costs and improved management of moving populations. Improvement in the security situation with the recent signing of a peace agreement has opened up previously inaccessible districts. This calls for the need for more financial and material resources to extend capacity building in these areas. Implementation of a revamped surveillance system with better and faster surveillance data exchange capabilities is needed. The revitalization of a surveillance data information system should ideally be harmonized with existing health information systems in the province, which operate different programmes and generate parallel, often conflicting, surveillance data for the same diseases. More formal and informal surveillance training, at provincial and district levels, should be supported. Continued support from the WHO Laboratory Strengthening Team is needed to ensure long-term capacity building and sustainability. An NAD provincial avian influenza preparedness and response coordination structure needs to be rapidly established. The goal is to strengthen and complement local capacity in this emerging threat. This should bring together WHO, the PHO, F r o m r e l i e f t o r e c o v e r y I n d o n e s i a NGOs, veterinary departments, public health laboratories and the provincial hospital. New emergencies and activities in emergency preparedness may overload existing teams. Extra staff for short periods should be employed as soon as possible to share in the workload of activities exceeding normal programmes. Staff should be rotated through different locations and positions to avoid gaps in the event of sudden staff departure. WHO headquarters should provide a CD-Rom with all necessary forms and templates to help newly recruited logisticians set up a standard system for tracking equipment loaned to WHO staff such as computers and radios. Briefing for all staff joining the mission should include advanced notice about living conditions in the field. A “survival kit” with the minimum necessary items should be available to help staff during the first 15 days. The field logistics head officer should be part of all internal field administration discussions related to supervision, and special administrative procedures should be developed for field conditions, including delegation of authority. All UN Agencies should increase collaboration in identifying common suppliers and share feedback on them. UN Agencies in Indonesia should set up a collective database to compile all donations and procurements in support of emergency or routine programmes to avoid duplication. WHO should keep an emergency stockpile ready to enable quick response. The stock should be reviewed to include more non-medical equipment needed by Emergency and Humanitarian Action (EHA) teams. Logistics constraints, reduced costs and improved management of moving populations. Improvement in the security situation with the recent signing of a peace agreement has opened up previously inaccessible districts. This calls for the need for more financial and material resources to extend capacity building in these areas. Implementation of a revamped surveillance system with better and faster surveillance data exchange capabilities is needed. The revitalization of a surveillance data information system should ideally be harmonized with existing health information systems in the province, which operate different programmes and generate parallel, often conflicting, surveillance data for the same diseases. More formal and informal surveillance training, at provincial and district levels, should be supported. Continued support from the WHO Laboratory Strengthening Team is needed to ensure long-term capacity building and sustainability. An NAD provincial avian influenza preparedness and response coordination structure needs to be rapidly established. The goal is to strengthen and complement local capacity in this emerging threat. This should bring together WHO, the PHO, F r o m r e l i e f t o r e c o v e r y I n d o n e s i a NGOs, veterinary departments, public health laboratories and the provincial hospital. New emergencies and activities in emergency preparedness may overload existing teams. Extra staff for short periods should be employed as soon as possible to share in the workload of activities exceeding normal programmes. Staff should be rotated through different locations and positions to avoid gaps in the event of sudden staff departure. WHO headquarters should provide a CD-Rom with all necessary forms and templates to help newly recruited logisticians set up a standard system for tracking equipment loaned to WHO staff such as computers and radios. Briefing for all staff joining the mission should include advanced notice about living conditions in the field. A “survival kit” with the minimum necessary items should be available to help staff during the first 15 days. The field logistics head officer should be part of all internal field administration discussions related to supervision, and special administrative procedures should be developed for field conditions, including delegation of authority. All UN Agencies should increase collaboration in identifying common suppliers and share feedback on them. UN Agencies in Indonesia should set up a collective database to compile all donations and procurements in support of emergency or routine programmes to avoid duplication. WHO should keep an emergency stockpile ready to enable quick response. The stock should be reviewed to include more non-medical equipment needed by Emergency and Humanitarian Action (EHA) teams. Logistics PHASE I: EMERGENCY RELIEF ASSESSMENT Affected areas Affected population The tsunami struck Sri Lanka by 09.00 a.m. local time. They affected coastal areas deep inland in the North-East, East, South and South-West, and the force of the waves caused enormous damage and destruction. It was initially estimated that about 13 000 people had perished. Communication with the affected areas in the country was disrupted and hampered the arrival of effective medical help, and restoration of basic services such as water and food. The damage was mainly restricted to the coastal areas, extending from Jaffna district in the north, along the east coast affecting Kilinocchchi, Mullaitivu, Trincomalee, Batticaloa and Ampara districts, Hambantota, Matara and Galle districts in the south and Kalutera, Colombo, Gampaha and Puttalam districts in the west. For Sri Lanka, it was the worst disaster the country had ever experienced. According SRI LANKA Sri Lanka 35 322 35 322 Country Fatalities Total Source1Missing 1. Some countries have not disaggregated between the deceased and the missing. 2. This report was undertaken by the Government of Sri Lanka and coordinated by a steering committee consisting of the Ministry of Finance, the National Planning Department, the Task Force for Rebuilding the Nation (TAFREN), the Asian Development Bank, UN agencies, the IFRC, and nongovernmental organizations. M AG NI TU DE = Number of fatalities: 35 322. (Source: Government of Sri Lanka, November 2005) = Number of IDPs: 516 150. (Source: Government of Sri Lanka, November 2005) = 14 out of 28 districts were affected. (Source: Government of Sri Lanka, August 2005) Joint One Year Report, December 20052 PHASE I: EMERGENCY RELIEF ASSESSMENT Affected areas Affected population The tsunami struck Sri Lanka by 09.00 a.m. local time. They affected coastal areas deep inland in the North-East, East, South and South-West, and the force of the waves caused enormous damage and destruction. It was initially estimated that about 13 000 people had perished. Communication with the affected areas in the country was disrupted and hampered the arrival of effective medical help, and restoration of basic services such as water and food. The damage was mainly restricted to the coastal areas, extending from Jaffna district in the north, along the east coast affecting Kilinocchchi, Mullaitivu, Trincomalee, Batticaloa and Ampara districts, Hambantota, Matara and Galle districts in the south and Kalutera, Colombo, Gampaha and Puttalam districts in the west. For Sri Lanka, it was the worst disaster the country had ever experienced. According SRI LANKA Sri Lanka 35 322 35 322 Country Fatalities Total Source1Missing 1. Some countries have not disaggregated between the deceased and the missing. 2. This report was undertaken by the Government of Sri Lanka and coordinated by a steering committee consisting of the Ministry of Finance, the National Planning Department, the Task Force for Rebuilding the Nation (TAFREN), the Asian Development Bank, UN agencies, the IFRC, and nongovernmental organizations. M AG NI TU DE = Number of fatalities: 35 322. (Source: Government of Sri Lanka, November 2005) = Number of IDPs: 516 150. (Source: Government of Sri Lanka, November 2005) = 14 out of 28 districts were affected. (Source: Government of Sri Lanka, August 2005) Joint One Year Report, December 20052 to the figures released by the Sri Lankan Government, the tsunami displaced more than 516 000 people immediately. As many as 23 000 were injured, while over 4200 people were reported missing. In addition, several health facilities were destroyed, including 35 hospitals. Several medical personnel also died in the calamity. The Government of Sri Lanka declared a national emergency. = Of the 28 districts in the country, 14 were affected. Of these, eight were in the conflict areas in the north-east. The impact of the tsunami on these areas was grave. = There were possible mine fields in the severely affected districts. = Manpower in these areas had been depleted even before the tsunami. = Damaged and destroyed health facilities in these districts were further destroyed by the tsunami. = Outreach services in the north-east were extremely inadequate. = Medical supplies and stockpiles in these areas had also been depleted due to the ongoing conflict. = The material impact was tremendous. Ninety-seven health facilities were affected. These included hospitals, District Health Offices, health units, regional drug stores, and maternal and child health clinics. Staff quarters and buildings, equipment, vehicles, medical supplies including vaccines were washed away or damaged. Almost every international organization wished to assist. Hundreds of volunteers from nongovernmental agencies reported for duty in the affected areas. Assistance of the military services was also offered, making this possibly the first natural Impact The response F r o m r e l i e f t o r e c o v e r y / 40 000 widows, orphans, elderly, and disabled individuals were left in need of long-term or permanent income support. (Source: International Labour Organization [ILO] Sri Lanka, June 2005) / 65% of men and 55% of women have regained some source of income. (Source: ILO Sri Lanka, June 2005) Impact on vulnerable populations / In the affected areas, 90% of working men and women lost their sources of livelihood. (Source: ILO Sri Lanka, June 2005) / 23 449 acres of cultivated land were affected, including 9000 acres of paddy, 645 acres of other crop fields, 27 710 home garden units, 559 acres of vegetable farms, and 317 acres of fruit trees. (Source: Food and Agriculture Organization [FAO]; Ministry of Fisheries and Aquaculture, August 2005) / 65 275 houses were completely damaged and 38 561 houses partially damaged but still habitable. (Source: TAFREN, November 2005) / 16 919 fishing boats were damaged or destroyed, representing approximately 75% of the total fishing fleet. (Source: Ministry of Fisheries and Aquaculture; FAO Sri Lanka) / Some 100 hospitals/dispensaries, Ministry of Health offices, and health centres were completely or partially damaged. (Source: World Health Organization [WHO] Sri Lanka, August 2005) / A total of 195 educational facilities including universities and vocational training centres were damaged with 59 schools totally destroyed and 117 partially damaged. (Source: TAFREN, August 2005) / More than 60 000 wells were contaminated or destroyed. (Source: World Bank/Asian Development Bank/Japan Bank of International Cooperation, Joint Needs Assessment) Damages and losses S r i L a n k a / Total estimated value of damages: US$ 1.5 billion.(Source: Joint Needs Assessment, January 2005) / Total estimated needs for long-term recovery: US$ 2.15 billion / Total funds pledged for long-term recovery: US$ 2.95 billion. Funds from NGOs comprise approximately US$ 853 million of this figure. The remainder comes from multilateral and bilateral donors. (Source: External Resources Department, Ministry of Finance and Planning, Government of Sri Lanka, November 2005) / Total funds secured for long-term recovery: US$ 2.24 billion. (Source: External Resources Department, Ministry of Finance and Planning, Government of Sri Lanka, November 2005) / Outstanding pledges (promised but not yet secured) from multilateral and bilateral donors: US$ 710 million. (Source: External Resources Department, Ministry of Finance and Planning, Government of Sri Lanka, November 2005) Financial implications to the figures released by the Sri Lankan Government, the tsunami displaced more than 516 000 people immediately. As many as 23 000 were injured, while over 4200 people were reported missing. In addition, several health facilities were destroyed, including 35 hospitals. Several medical personnel also died in the calamity. The Government of Sri Lanka declared a national emergency. = Of the 28 districts in the country, 14 were affected. Of these, eight were in the conflict areas in the north-east. The impact of the tsunami on these areas was grave. = There were possible mine fields in the severely affected districts. = Manpower in these areas had been depleted even before the tsunami. = Damaged and destroyed health facilities in these districts were further destroyed by the tsunami. = Outreach services in the north-east were extremely inadequate. = Medical supplies and stockpiles in these areas had also been depleted due to the ongoing conflict. = The material impact was tremendous. Ninety-seven health facilities were affected. These included hospitals, District Health Offices, health units, regional drug stores, and maternal and child health clinics. Staff quarters and buildings, equipment, vehicles, medical supplies including vaccines were washed away or damaged. Almost every international organization wished to assist. Hundreds of volunteers from nongovernmental agencies reported for duty in the affected areas. Assistance of the military services was also offered, making this possibly the first natural Impact The response F r o m r e l i e f t o r e c o v e r y / 40 000 widows, orphans, elderly, and disabled individuals were left in need of long-term or permanent income support. (Source: International Labour Organization [ILO] Sri Lanka, June 2005) / 65% of men and 55% of women have regained some source of income. (Source: ILO Sri Lanka, June 2005) Impact on vulnerable populations / In the affected areas, 90% of working men and women lost their sources of livelihood. (Source: ILO Sri Lanka, June 2005) / 23 449 acres of cultivated land were affected, including 9000 acres of paddy, 645 acres of other crop fields, 27 710 home garden units, 559 acres of vegetable farms, and 317 acres of fruit trees. (Source: Food and Agriculture Organization [FAO]; Ministry of Fisheries and Aquaculture, August 2005) / 65 275 houses were completely damaged and 38 561 houses partially damaged but still habitable. (Source: TAFREN, November 2005) / 16 919 fishing boats were damaged or destroyed, representing approximately 75% of the total fishing fleet. (Source: Ministry of Fisheries and Aquaculture; FAO Sri Lanka) / Some 100 hospitals/dispensaries, Ministry of Health offices, and health centres were completely or partially damaged. (Source: World Health Organization [WHO] Sri Lanka, August 2005) / A total of 195 educational facilities including universities and vocational training centres were damaged with 59 schools totally destroyed and 117 partially damaged. (Source: TAFREN, August 2005) / More than 60 000 wells were contaminated or destroyed. (Source: World Bank/Asian Development Bank/Japan Bank of International Cooperation, Joint Needs Assessment) Damages and losses S r i L a n k a / Total estimated value of damages: US$ 1.5 billion.(Source: Joint Needs Assessment, January 2005) / Total estimated needs for long-term recovery: US$ 2.15 billion / Total funds pledged for long-term recovery: US$ 2.95 billion. Funds from NGOs comprise approximately US$ 853 million of this figure. The remainder comes from multilateral and bilateral donors. (Source: External Resources Department, Ministry of Finance and Planning, Government of Sri Lanka, November 2005) / Total funds secured for long-term recovery: US$ 2.24 billion. (Source: External Resources Department, Ministry of Finance and Planning, Government of Sri Lanka, November 2005) / Outstanding pledges (promised but not yet secured) from multilateral and bilateral donors: US$ 710 million. (Source: External Resources Department, Ministry of Finance and Planning, Government of Sri Lanka, November 2005) Financial implications S r i L a n k a (UNICEF, IOM, UNFPA, UNHCR), bilateral donors, international NGOs and Red Cross societies. The conference room of the WHO Country Office was converted into a 24-hour Operations Room and extra administrative staff was recruited. WHO opened three operational units at Galle, Ampara and Jaffna to improve direct coordination with the district health staff. They provided a base for WHO support staff and a convenient meeting point for partners as well as improved communication between Colombo and field locations. Visiting experts provided local authorities with guidelines and technical support for health care interventions. Staff from unaffected countries in the Region were put on standby to support the emergency health protection effort in Sri Lanka. The WHO Country Office was also strengthened by sending a water and sanitation expert from Nepal, and public health experts from WHO SEARO, WHO EURO and Australia. WHO supported the MoH in the following activities: = Facilitating the deployment of foreign medical teams = Facilitating the establishment of coordination mechanisms within the MoH and with international agencies working in health-related areas = Facilitating incoming emergency supplies meant for health sector relief = Mobilizing WHO internal technical and material support = Supporting health sector coordination meetings at the national and district levels = Providing an interface with the MoH and other health-related Government and private agencies as well as NGOs = Supporting communication, transport and logistic requirements = Coordinating donor contributions with the Government of Sri Lanka. = UNDMT responsibilities included facilitating and mobilizing international public health response: B Conducting rapid health needs assessments of the affected population B Deploying foreign medical teams B Facilitating incoming emergency supply meant for health sector relief Partnerships Support to MoH Support to UN and international health partners disaster to have seen such high degrees of seamless civil–military cooperation. Many private business groups contributed key human resources such as water and sanitation engineers, and logisticians who could provide practical assistance. There was even cooperation between parties to internal conflicts. In Sri Lanka, the security forces helped civilians in LTTE-controlled areas. WHO was able to support the national efforts due to the Organization's first- hand knowledge of the affected areas, and its involvement in strengthening health systems in those regions prior to the tsunami. In the past, the Country Office had worked with the MoH following calamities such as floods. Hence, the Organization understood the district-level capacity for disease surveillance, health information and laboratory services. A good understanding of local cultures proved invaluable. This existing understanding of the country, its culture, and relationships with key people and the community helped in mobilizing a swift response. The UN and its partners requested US$ 166 936 146 to provide urgent assistance to the Sri Lankan people for a period of six months in order to save lives, alleviate suffering and begin the process of restoring livelihoods. The overall UN coordination in Sri Lanka was handled by a Disaster Assessment and Coordination (UNDAC) team deployed from the Office of the Commissioner of Humanitarian Affairs (OCHA), which assisted the UN Resident Coordinator in the coordination of all relief operations. WHO was given the responsibility of coordinating all the activities of the UN team in the health sector. WHO established an Emergency Health Task Force which met with these partners and assisted in coordinating the response as well as collecting requests coming from the districts. WHO Country Office staff took part in further assessment missions to the affected districts and provided standards of documentation for recording the health care needs of survivors. WHO helped the MoH to establish a 24-hour Tsunami Operation Cell in each district, and organized special committees, teams and working groups to oversee the distribution of medical donations and supplies, treat the injured and deploy medical teams. At the central level, regular meetings between all health partners helped in coordinating activities. A Health Coordination Meeting was held every Monday to discuss activities and the needs of the survivors. It was attended by staff from the MoH, Task Force for Rebuilding the Nation (TAFREN), UN agencies WHO coordination activities F r o m r e l i e f t o r e c o v e r y S r i L a n k a (UNICEF, IOM, UNFPA, UNHCR), bilateral donors, international NGOs and Red Cross societies. The conference room of the WHO Country Office was converted into a 24-hour Operations Room and extra administrative staff was recruited. WHO opened three operational units at Galle, Ampara and Jaffna to improve direct coordination with the district health staff. They provided a base for WHO support staff and a convenient meeting point for partners as well as improved communication between Colombo and field locations. Visiting experts provided local authorities with guidelines and technical support for health care interventions. Staff from unaffected countries in the Region were put on standby to support the emergency health protection effort in Sri Lanka. The WHO Country Office was also strengthened by sending a water and sanitation expert from Nepal, and public health experts from WHO SEARO, WHO EURO and Australia. WHO supported the MoH in the following activities: = Facilitating the deployment of foreign medical teams = Facilitating the establishment of coordination mechanisms within the MoH and with international agencies working in health-related areas = Facilitating incoming emergency supplies meant for health sector relief = Mobilizing WHO internal technical and material support = Supporting health sector coordination meetings at the national and district levels = Providing an interface with the MoH and other health-related Government and private agencies as well as NGOs = Supporting communication, transport and logistic requirements = Coordinating donor contributions with the Government of Sri Lanka. = UNDMT responsibilities included facilitating and mobilizing international public health response: B Conducting rapid health needs assessments of the affected population B Deploying foreign medical teams B Facilitating incoming emergency supply meant for health sector relief Partnerships Support to MoH Support to UN and international health partners disaster to have seen such high degrees of seamless civil–military cooperation. Many private business groups contributed key human resources such as water and sanitation engineers, and logisticians who could provide practical assistance. There was even cooperation between parties to internal conflicts. In Sri Lanka, the security forces helped civilians in LTTE-controlled areas. WHO was able to support the national efforts due to the Organization's first- hand knowledge of the affected areas, and its involvement in strengthening health systems in those regions prior to the tsunami. In the past, the Country Office had worked with the MoH following calamities such as floods. Hence, the Organization understood the district-level capacity for disease surveillance, health information and laboratory services. A good understanding of local cultures proved invaluable. This existing understanding of the country, its culture, and relationships with key people and the community helped in mobilizing a swift response. The UN and its partners requested US$ 166 936 146 to provide urgent assistance to the Sri Lankan people for a period of six months in order to save lives, alleviate suffering and begin the process of restoring livelihoods. The overall UN coordination in Sri Lanka was handled by a Disaster Assessment and Coordination (UNDAC) team deployed from the Office of the Commissioner of Humanitarian Affairs (OCHA), which assisted the UN Resident Coordinator in the coordination of all relief operations. WHO was given the responsibility of coordinating all the activities of the UN team in the health sector. WHO established an Emergency Health Task Force which met with these partners and assisted in coordinating the response as well as collecting requests coming from the districts. WHO Country Office staff took part in further assessment missions to the affected districts and provided standards of documentation for recording the health care needs of survivors. WHO helped the MoH to establish a 24-hour Tsunami Operation Cell in each district, and organized special committees, teams and working groups to oversee the distribution of medical donations and supplies, treat the injured and deploy medical teams. At the central level, regular meetings between all health partners helped in coordinating activities. A Health Coordination Meeting was held every Monday to discuss activities and the needs of the survivors. It was attended by staff from the MoH, Task Force for Rebuilding the Nation (TAFREN), UN agencies WHO coordination activities F r o m r e l i e f t o r e c o v e r y S r i L a n k a NEEDS ASSESSMENT AND SITUATION ANALYSIS A rapid health needs assessment was done by 3 teams of experts in the affected districts for situation analysis and emergency response. In addition to an MoH official, each team consisted of one national professional working in the WHO Sri Lanka Office, and one or two WHO staff from either headquarters, Geneva or from SEARO. Some of the international WHO staff, who had been holidaying in Sri Lanka when the disaster occurred, immediately volunteered their services. While these assessments were being carried out and information collated, the core tsunami team in the WHO Country Office held regular emergency planning B Facilitating health sector coordination activities B Participating in the UN Information Management and Media Strategy = Responsibility for donor relations = With UNFPA, WHO looked after the psychosocial needs of those affected. = UNICEF/WHO/Pfizer streamlined and coordinated the supply chain management. = In partnership within UN Habitat, WHO assisted in urban environment development. F r o m r e l i e f t o r e c o v e r y meetings with both the UNCT and the MoH, and helped prepare guidelines to deal with the scale of the disaster. Resources were immediately mobilized (human, material and financial) and the medical supply chain reviewed. Three logisticians were deployed, two in Colombo and one in Ampara. It was planned to send a total of 13. Immediate public health needs were identified. Curative needs in the immediate post-tsunami period consisted of treatment for the injured. In the relief camps (over 700), the needs were many. These included the following: = Provision of safe water = Ensuring good sanitation, personal hygiene and health promotion = Intensifying public health surveillance = Putting disease and vector control measures on alert = Attending to the medical supply needs of the displaced Immediately after the disaster, injuries including the resultant infections and water contamination were the most urgent health threats. Due to infusion of sea water, many people had lung injuries and often life-threatening pneumonia. Within hours after the tsunami struck, the number of injured people needing medical help had shot up. Other needs included disposal of bodies and rapid health assessments to determine planning and resource allocation. Anticipated health risks included respiratory infections, measles, and waterborne diseases such as diarrhoea and dysentery (including cholera) resulting from overcrowded conditions and poor sanitation. A system of monitoring and evaluation on an ongoing basis was needed to help identify operational difficulties, refine strategies and modify actions. Other essential activities included identifying persons at special risk such as pregnant women and children with diarrhoea, and ensuring that their health was protected. Establishing surveillance networks was important to monitor, verify and respond to outbreaks, especially among concentrations of displaced persons whose health was already fragile. While these risks continued, because of environmental conditions such as overcrowding, concerns emerged with regard to collections of stagnant water resulting in mosquito breeding, thereby creating a risky environment for vector-borne diseases. Strategic stockpiling of drugs for epidemic-prone diseases such as dysentery or cholera was also necessary. Health situation Emergency phase S r i L a n k a NEEDS ASSESSMENT AND SITUATION ANALYSIS A rapid health needs assessment was done by 3 teams of experts in the affected districts for situation analysis and emergency response. In addition to an MoH official, each team consisted of one national professional working in the WHO Sri Lanka Office, and one or two WHO staff from either headquarters, Geneva or from SEARO. Some of the international WHO staff, who had been holidaying in Sri Lanka when the disaster occurred, immediately volunteered their services. While these assessments were being carried out and information collated, the core tsunami team in the WHO Country Office held regular emergency planning B Facilitating health sector coordination activities B Participating in the UN Information Management and Media Strategy = Responsibility for donor relations = With UNFPA, WHO looked after the psychosocial needs of those affected. = UNICEF/WHO/Pfizer streamlined and coordinated the supply chain management. = In partnership within UN Habitat, WHO assisted in urban environment development. F r o m r e l i e f t o r e c o v e r y meetings with both the UNCT and the MoH, and helped prepare guidelines to deal with the scale of the disaster. Resources were immediately mobilized (human, material and financial) and the medical supply chain reviewed. Three logisticians were deployed, two in Colombo and one in Ampara. It was planned to send a total of 13. Immediate public health needs were identified. Curative needs in the immediate post-tsunami period consisted of treatment for the injured. In the relief camps (over 700), the needs were many. These included the following: = Provision of safe water = Ensuring good sanitation, personal hygiene and health promotion = Intensifying public health surveillance = Putting disease and vector control measures on alert = Attending to the medical supply needs of the displaced Immediately after the disaster, injuries including the resultant infections and water contamination were the most urgent health threats. Due to infusion of sea water, many people had lung injuries and often life-threatening pneumonia. Within hours after the tsunami struck, the number of injured people needing medical help had shot up. Other needs included disposal of bodies and rapid health assessments to determine planning and resource allocation. Anticipated health risks included respiratory infections, measles, and waterborne diseases such as diarrhoea and dysentery (including cholera) resulting from overcrowded conditions and poor sanitation. A system of monitoring and evaluation on an ongoing basis was needed to help identify operational difficulties, refine strategies and modify actions. Other essential activities included identifying persons at special risk such as pregnant women and children with diarrhoea, and ensuring that their health was protected. Establishing surveillance networks was important to monitor, verify and respond to outbreaks, especially among concentrations of displaced persons whose health was already fragile. While these risks continued, because of environmental conditions such as overcrowding, concerns emerged with regard to collections of stagnant water resulting in mosquito breeding, thereby creating a risky environment for vector-borne diseases. Strategic stockpiling of drugs for epidemic-prone diseases such as dysentery or cholera was also necessary. Health situation Emergency phase S r i L a n k aF r o m r e l i e f t o r e c o v e r y COORDINATION Challenges to coordination GAP-FILLING AND CAPACITY-BUILDING Logistics By 31 December 2004, two thirds of the displaced population were living in 700 camps. Sanitation was a key issue in these camps. Much of the public health infrastructure in the coastal areas was damaged and functional units were overwhelmed. About 300 foreign medical doctors were present in the country and their efforts needed to be coordinated. WHO teams went to the districts and led the health coordination process. Effective coordination was also required of efforts among partners on the ground, and in streamlining logistics management and ensuring transparent communication. Transportation and logistics were poor. Some of the worst-hit areas in Sri Lanka were also among the country's most inaccessible. Although Sri Lanka had a good network of roads before the disaster with a density of 1.53 km per sq.km, most of the roads in the affected areas had been severely damaged. In some cases they were rendered unusable. Here, satellite imaging technology, through Sri Lanka's well-established GIS mapping framework, was useful in studying infrastructure damage. WHO staff and consultants were fully deployed in the relief work. Technical guidelines outlining best practices in the situation were produced, transmitted to the field and posted on the web. Vaccines and life-saving drugs were procured and stockpiled in the field. WHO estimated that 65 health kits were needed. Of these, 47 arrived and 18 were in the pipeline. Forty diarrhoea kits and 10 surgical kits were needed. Two million chlorine tablets were also supplied. By 8 January 2005, three logisticians had been deployed in Sri Lanka. The main work of the logisticians was to set up a platform from where public health officials could work. In most affected areas, a drug supply chain was established for donated drugs, and it was ensured that the drugs were from WHO pre-qualified suppliers, were appropriately labelled and not past their expiry date. Many foreign donations had the labels written in the language of that country, so one could not always find out the dose of the medicine, or the printed contraindications. S r i L a n k aF r o m r e l i e f t o r e c o v e r y COORDINATION Challenges to coordination GAP-FILLING AND CAPACITY-BUILDING Logistics By 31 December 2004, two thirds of the displaced population were living in 700 camps. Sanitation was a key issue in these camps. Much of the public health infrastructure in the coastal areas was damaged and functional units were overwhelmed. About 300 foreign medical doctors were present in the country and their efforts needed to be coordinated. WHO teams went to the districts and led the health coordination process. Effective coordination was also required of efforts among partners on the ground, and in streamlining logistics management and ensuring transparent communication. Transportation and logistics were poor. Some of the worst-hit areas in Sri Lanka were also among the country's most inaccessible. Although Sri Lanka had a good network of roads before the disaster with a density of 1.53 km per sq.km, most of the roads in the affected areas had been severely damaged. In some cases they were rendered unusable. Here, satellite imaging technology, through Sri Lanka's well-established GIS mapping framework, was useful in studying infrastructure damage. WHO staff and consultants were fully deployed in the relief work. Technical guidelines outlining best practices in the situation were produced, transmitted to the field and posted on the web. Vaccines and life-saving drugs were procured and stockpiled in the field. WHO estimated that 65 health kits were needed. Of these, 47 arrived and 18 were in the pipeline. Forty diarrhoea kits and 10 surgical kits were needed. Two million chlorine tablets were also supplied. By 8 January 2005, three logisticians had been deployed in Sri Lanka. The main work of the logisticians was to set up a platform from where public health officials could work. In most affected areas, a drug supply chain was established for donated drugs, and it was ensured that the drugs were from WHO pre-qualified suppliers, were appropriately labelled and not past their expiry date. Many foreign donations had the labels written in the language of that country, so one could not always find out the dose of the medicine, or the printed contraindications. S r i L a n k a To help with mobility, WHO procured 81 vehicles for use in the affected areas with the help of the UK Air Force. Health volunteers were provided 66 bicycles. So that midwives could move even faster, particularly in urgent cases of delivery, 260 mopeds were procured for them. One hundred motorcycles were also given to public health inspectors (PHIs) to improve disease surveillance, camp management, and monitor water and sanitation. Generators were supplied to hospitals whose electricity supply had been disrupted. Twenty sets of telecommunication equipment were supplied to the affected areas to assist with transport management and communication. F r o m r e l i e f t o r e c o v e r y PHASE II: ACTIVE INTERVENTIONS ASSESSMENTS AND MONITORING Intermediate stage: Needs Management of temporary camps Restoration of health services The access to health care, referral and transportation of life-saving medicines and vaccines was profoundly disrupted in many areas, where substantial numbers of health-care workers were either dead or had left the area. Millions were living in overcrowded and unsanitary conditions. Water and sanitation were inadequate in some areas and there was a serious threat of diarrhoeal diseases. Conditions had been created which increased mosquito breeding, heightening the risk of malaria and dengue. Mental trauma was a major concern across all affected areas. The risk of communicable diseases was very high and potentially life- threatening, especially in vulnerable populations such as children, the injured, pregnant women and the elderly. Access to medicines (such as ORS for treating diarrhoea and preventing dehydration, and antibiotics for the management of pneumonia) were a priority. Immunization campaigns to prevent measles outbreaks needed to be undertaken in areas where the coverage was low. All these efforts required a comprehensive and coordinated approach to disease prevention and control based on evidence generated through effective surveillance and early warning systems. = Food and safe water supply = Sanitation = General health services = Maternal and child health services = Ambulatory services = Psychosocial and mental health support = Disease control activities = Prevention of epidemics and disease surveillance = Setting up of temporary hospitals = Replacement of damaged/destroyed equipment and drugs = Deployment of additional health staff S r i L a n k a To help with mobility, WHO procured 81 vehicles for use in the affected areas with the help of the UK Air Force. Health volunteers were provided 66 bicycles. So that midwives could move even faster, particularly in urgent cases of delivery, 260 mopeds were procured for them. One hundred motorcycles were also given to public health inspectors (PHIs) to improve disease surveillance, camp management, and monitor water and sanitation. Generators were supplied to hospitals whose electricity supply had been disrupted. Twenty sets of telecommunication equipment were supplied to the affected areas to assist with transport management and communication. F r o m r e l i e f t o r e c o v e r y PHASE II: ACTIVE INTERVENTIONS ASSESSMENTS AND MONITORING Intermediate stage: Needs Management of temporary camps Restoration of health services The access to health care, referral and transportation of life-saving medicines and vaccines was profoundly disrupted in many areas, where substantial numbers of health-care workers were either dead or had left the area. Millions were living in overcrowded and unsanitary conditions. Water and sanitation were inadequate in some areas and there was a serious threat of diarrhoeal diseases. Conditions had been created which increased mosquito breeding, heightening the risk of malaria and dengue. Mental trauma was a major concern across all affected areas. The risk of communicable diseases was very high and potentially life- threatening, especially in vulnerable populations such as children, the injured, pregnant women and the elderly. Access to medicines (such as ORS for treating diarrhoea and preventing dehydration, and antibiotics for the management of pneumonia) were a priority. Immunization campaigns to prevent measles outbreaks needed to be undertaken in areas where the coverage was low. All these efforts required a comprehensive and coordinated approach to disease prevention and control based on evidence generated through effective surveillance and early warning systems. = Food and safe water supply = Sanitation = General health services = Maternal and child health services = Ambulatory services = Psychosocial and mental health support = Disease control activities = Prevention of epidemics and disease surveillance = Setting up of temporary hospitals = Replacement of damaged/destroyed equipment and drugs = Deployment of additional health staff S r i L a n k a = Maintenance of preventive health services = Organizing special programmes for children = Clearing up and disposal of debris = Restoration of water supplies = Vector control activities = Pollution control = Waste management = Other environmental health activities Although among the hardest hit areas, Sri Lanka had a good epidemiology monitoring and reporting system in place. Complete hospital information/disease surveillance computer systems with LAN, servers and workstations, were installed in the Deputy Provincial Director of Health Services (DPDHS) offices and the main hospitals of four affected districts (Ampara, Hambantota, Matara and Jaffna). Smaller systems (with stand-alone computers but no LAN) were installed in a number of MoH offices in these districts and several others. Seven public health laboratories, as identified by the MoH, were supplemented and strengthened through procurement of equipment, supplies, reagents and training. Strategic planning for further strengthening of laboratories in all areas of laboratory medicine was discussed with the MoH. Primary health services were provided in almost all affected areas. Random checks showed that essential drugs were in adequate supply. WHO staff, including the Global Outbreak Alert and Response Network (GOARN), were deployed in Sri Lanka to assist the MoH with the establishment of supplemental surveillance, and early warning alert and response systems (EWARN). The principal objective of these surveillance systems was to detect epidemic-prone diseases occurring in the population, based on symptomatic diagnosis followed by laboratory confirmation, and to institute necessary interventions to contain further spread of disease and limit morbidity and mortality in affected populations. Ten diseases—leptospirosis, dengue, dengue haemorrhagic fever, acute flaccid paralysis (AFP), tetanus, viral hepatitis, pertussis Environmental health activities COORDINATION AND GAP-FILLING Health systems Disease surveillance F r o m r e l i e f t o r e c o v e r y S r i L a n k a = Maintenance of preventive health services = Organizing special programmes for children = Clearing up and disposal of debris = Restoration of water supplies = Vector control activities = Pollution control = Waste management = Other environmental health activities Although among the hardest hit areas, Sri Lanka had a good epidemiology monitoring and reporting system in place. Complete hospital information/disease surveillance computer systems with LAN, servers and workstations, were installed in the Deputy Provincial Director of Health Services (DPDHS) offices and the main hospitals of four affected districts (Ampara, Hambantota, Matara and Jaffna). Smaller systems (with stand-alone computers but no LAN) were installed in a number of MoH offices in these districts and several others. Seven public health laboratories, as identified by the MoH, were supplemented and strengthened through procurement of equipment, supplies, reagents and training. Strategic planning for further strengthening of laboratories in all areas of laboratory medicine was discussed with the MoH. Primary health services were provided in almost all affected areas. Random checks showed that essential drugs were in adequate supply. WHO staff, including the Global Outbreak Alert and Response Network (GOARN), were deployed in Sri Lanka to assist the MoH with the establishment of supplemental surveillance, and early warning alert and response systems (EWARN). The principal objective of these surveillance systems was to detect epidemic-prone diseases occurring in the population, based on symptomatic diagnosis followed by laboratory confirmation, and to institute necessary interventions to contain further spread of disease and limit morbidity and mortality in affected populations. Ten diseases—leptospirosis, dengue, dengue haemorrhagic fever, acute flaccid paralysis (AFP), tetanus, viral hepatitis, pertussis Environmental health activities COORDINATION AND GAP-FILLING Health systems Disease surveillance F r o m r e l i e f t o r e c o v e r y (whooping cough), rabies, rubella and measles—were selected for special notification and new investigation forms were developed for them. The surveillance system was further supported by a GIS for health mapping and health-related databases. The timely re-establishment of disease surveillance systems with assistance from WHO helped prevent any major outbreak. Needs identified in this area were increased partnerships in the area of hygiene promotion as well as increased activities. In Jaffna, WHO was identified as the lead agency for facilitating the health promotion subgroup under the auspices of the DPDHS Office. As part of the health promotion activities, hygiene kits were distributed. A workshop was held to pool experience/resources/expertise to develop a rapid training programme and toolkit for the delivery of hygiene kits. Agencies that had developed programmes and materials for health education collaborated to formulate a standardized training module for volunteers (from all agencies) to conduct hygiene and environmental health promotion in camp settings. A WHO water and sanitation specialist visited Galle and discussed the necessary water and sanitation activities with the government and other agencies. The expressed needs included cleaning drains, garbage disposal, monitoring water quality and capacity strengthening at the local level. The priorities were to provide clean water to relief camps and to health facilities, to ensure that water quality was systematically tested, to provide sanitation facilities in areas where communities were returning to their homes, and to ensure that all activities were complemented by hygiene education programmes, particularly in relief camps. Adequate supplies of drinking water of reasonable quality were available in Sri Lanka in the affected areas within a few days. Most of the water was supplied by tankers. However, adequate chlorination of the water at the collection point or household level was a challenge. Residual chlorine at the distribution point was checked with chloroscopes provided to public health inspectors and NGO field staff to facilitate water quality surveillance. Some hospitals were found to be lacking adequate water supplies and Hinneduma Hospital, for example, used obviously contaminated water pumped from a nearby stream. Health education Safe water F r o m r e l i e f t o r e c o v e r y S r i L a n k a (whooping cough), rabies, rubella and measles—were selected for special notification and new investigation forms were developed for them. The surveillance system was further supported by a GIS for health mapping and health-related databases. The timely re-establishment of disease surveillance systems with assistance from WHO helped prevent any major outbreak. Needs identified in this area were increased partnerships in the area of hygiene promotion as well as increased activities. In Jaffna, WHO was identified as the lead agency for facilitating the health promotion subgroup under the auspices of the DPDHS Office. As part of the health promotion activities, hygiene kits were distributed. A workshop was held to pool experience/resources/expertise to develop a rapid training programme and toolkit for the delivery of hygiene kits. Agencies that had developed programmes and materials for health education collaborated to formulate a standardized training module for volunteers (from all agencies) to conduct hygiene and environmental health promotion in camp settings. A WHO water and sanitation specialist visited Galle and discussed the necessary water and sanitation activities with the government and other agencies. The expressed needs included cleaning drains, garbage disposal, monitoring water quality and capacity strengthening at the local level. The priorities were to provide clean water to relief camps and to health facilities, to ensure that water quality was systematically tested, to provide sanitation facilities in areas where communities were returning to their homes, and to ensure that all activities were complemented by hygiene education programmes, particularly in relief camps. Adequate supplies of drinking water of reasonable quality were available in Sri Lanka in the affected areas within a few days. Most of the water was supplied by tankers. However, adequate chlorination of the water at the collection point or household level was a challenge. Residual chlorine at the distribution point was checked with chloroscopes provided to public health inspectors and NGO field staff to facilitate water quality surveillance. Some hospitals were found to be lacking adequate water supplies and Hinneduma Hospital, for example, used obviously contaminated water pumped from a nearby stream. Health education Safe water F r o m r e l i e f t o r e c o v e r y S r i L a n k a S r i L a n k a such equipment cannot be maintained in the long term by the community without external assistance. While there was a need for quick fixes that could produce large quantities of safe water, the final water supply option should have met community capabilities in operation and maintenance, management and affordability. Limited attention was given to restoration or construction of institutional water supply and sanitation systems in health facilities and schools. According to the Sphere guidelines, in an emergency situation, there should be one latrine per 50 people, the ratio being enhanced to one latrine per 20 people in the post-emergency phase. But in the chaotic, crowded conditions, these benchmarks were often a forlorn hope. In the first 10 days, one camp in Batticaloa was found to have only one water tank and three toilets for use by 1135 people. Clearly, sanitation facilities were not adequate. In the next couple of days, 3000 squatting plates and 300 shovels arrived. Latrines were provided to IDP camps by aid agencies and NGOs. However, the people for whom these were intended did not use or maintain them properly. Poor hygiene habits posed a health risk and WHO had to address this problem. WHO enhanced local capacity by providing ToT, practical demonstrations and personal discussions, motivating communities and providing sanitation kits. A large amount of technical literature including fact sheets, guiding notes, books and related articles were freely distributed. WHO also supported two national-level, 12 district-level and 45 divisional- level workshops for the promotion of hygiene behaviour and practices in tsunami- affected areas. These programmes were conducted through the Health Education Bureau of the MoH. A national-level consultative workshop and review was held in Colombo in October 2005. The workshop was attended by 49 participants, mostly health education officers, from all districts of the country. Fact sheets and reading material developed by WHO, and a set of seven posters developed by UNICEF, were distributed to the participants. WHO's specific mandate in the tsunami disaster response regarding Universal Precautions was to assist local health authorities in strengthening infection control within the health-care services, encourage the use of personal protective equipment and improve handling of clinical waste. Sanitation Health-care waste management As a large number of shallow wells (about 12 000) in the coastal areas were severely contaminated, there was an urgent need to empty the wells of water and chlorinate the recharged water. This was the main source of drinking water for the affected population. As supplies in the interior of Sri Lanka were largely functioning, water tankers were extensively used to supply IDP camps. At the request of the National Water Supply and Drainage Board, WHO developed a one-page good practice sheet for agencies who transported the water to the IDP camps to ensure that adequate residual chlorine remained in the water at the delivery point. This and other interventions ensured that WHO had good and regular communication with all water and sanitation sector actors. WHO also provided chlorine testing equipment (chloroscopes), dewatering pumps, chlorine tablets and water storage tanks to the health department. Laboratory equipment was purchased for the water board and the provincial health department to strengthen water testing laboratories in the affected areas . These activities were complemented by hygiene promotion campaigns. Training programmes were organized at the national, regional and district levels, including practical demonstrations of water testing, hand hygiene and water quality surveillance. Sanitation kits were provided to relief camps to enable camp management to keep the public latrines serviceable. Local water authorities confirmed that the water testing kits provided by WHO were very useful for spot testing. WHO also supported the promotion of solar disinfection of water in its training courses to health staff and NGOs, using locally available promotional materials. Eight hundred and thirty-one field officers including public health employees, engineers, supervisors and sociologists were trained in water, sanitation and hygiene-promotion issues. Training and water quality testing manuals were developed and provided to field staff for use. A total of 100 participants were provided training in water, sanitation and hygiene promotion in Ampara and Batticaloa districts. WHO supported UNICEF in water quality management. Initially, WHO staff physically sat with UNICEF in Sri Lanka and thus contributed substantially to a coordinated effort by the government, UN agencies and NGOs. The tsunami crisis did, however, cause a mismatch between needs and long- term sustainability of supplies. Desalination plants were provided even though F r o m r e l i e f t o r e c o v e r y S r i L a n k a such equipment cannot be maintained in the long term by the community without external assistance. While there was a need for quick fixes that could produce large quantities of safe water, the final water supply option should have met community capabilities in operation and maintenance, management and affordability. Limited attention was given to restoration or construction of institutional water supply and sanitation systems in health facilities and schools. According to the Sphere guidelines, in an emergency situation, there should be one latrine per 50 people, the ratio being enhanced to one latrine per 20 people in the post-emergency phase. But in the chaotic, crowded conditions, these benchmarks were often a forlorn hope. In the first 10 days, one camp in Batticaloa was found to have only one water tank and three toilets for use by 1135 people. Clearly, sanitation facilities were not adequate. In the next couple of days, 3000 squatting plates and 300 shovels arrived. Latrines were provided to IDP camps by aid agencies and NGOs. However, the people for whom these were intended did not use or maintain them properly. Poor hygiene habits posed a health risk and WHO had to address this problem. WHO enhanced local capacity by providing ToT, practical demonstrations and personal discussions, motivating communities and providing sanitation kits. A large amount of technical literature including fact sheets, guiding notes, books and related articles were freely distributed. WHO also supported two national-level, 12 district-level and 45 divisional- level workshops for the promotion of hygiene behaviour and practices in tsunami- affected areas. These programmes were conducted through the Health Education Bureau of the MoH. A national-level consultative workshop and review was held in Colombo in October 2005. The workshop was attended by 49 participants, mostly health education officers, from all districts of the country. Fact sheets and reading material developed by WHO, and a set of seven posters developed by UNICEF, were distributed to the participants. WHO's specific mandate in the tsunami disaster response regarding Universal Precautions was to assist local health authorities in strengthening infection control within the health-care services, encourage the use of personal protective equipment and improve handling of clinical waste. Sanitation Health-care waste management As a large number of shallow wells (about 12 000) in the coastal areas were severely contaminated, there was an urgent need to empty the wells of water and chlorinate the recharged water. This was the main source of drinking water for the affected population. As supplies in the interior of Sri Lanka were largely functioning, water tankers were extensively used to supply IDP camps. At the request of the National Water Supply and Drainage Board, WHO developed a one-page good practice sheet for agencies who transported the water to the IDP camps to ensure that adequate residual chlorine remained in the water at the delivery point. This and other interventions ensured that WHO had good and regular communication with all water and sanitation sector actors. WHO also provided chlorine testing equipment (chloroscopes), dewatering pumps, chlorine tablets and water storage tanks to the health department. Laboratory equipment was purchased for the water board and the provincial health department to strengthen water testing laboratories in the affected areas . These activities were complemented by hygiene promotion campaigns. Training programmes were organized at the national, regional and district levels, including practical demonstrations of water testing, hand hygiene and water quality surveillance. Sanitation kits were provided to relief camps to enable camp management to keep the public latrines serviceable. Local water authorities confirmed that the water testing kits provided by WHO were very useful for spot testing. WHO also supported the promotion of solar disinfection of water in its training courses to health staff and NGOs, using locally available promotional materials. Eight hundred and thirty-one field officers including public health employees, engineers, supervisors and sociologists were trained in water, sanitation and hygiene-promotion issues. Training and water quality testing manuals were developed and provided to field staff for use. A total of 100 participants were provided training in water, sanitation and hygiene promotion in Ampara and Batticaloa districts. WHO supported UNICEF in water quality management. Initially, WHO staff physically sat with UNICEF in Sri Lanka and thus contributed substantially to a coordinated effort by the government, UN agencies and NGOs. The tsunami crisis did, however, cause a mismatch between needs and long- term sustainability of supplies. Desalination plants were provided even though F r o m r e l i e f t o r e c o v e r y S r i L a n k a The weekly epidemiological report and its publication were reviewed. A subset of the notification data to cover only those MoH divisions directly affected by the tsunami was created and published separately. Plans for establishing Rapid Epidemic Response Teams and for ensuring that improvements made to epidemiological surveillance over the coming months were sustainable were further defined. A training workshop was held on 14–18 June 2005 on standardized procedures for the diagnosis of diseases of public health importance for laboratories in tsunami-affected districts. Training material was also prepared for an infection control workshop held on 21–22 June 2005 for laboratory consultants, medical officers and nurses involved in hospital infection control. In Balapitiya in the Southern Province, the Health Minister handed over a biochemistry auto-analyser provided by WHO to the laboratory there. In all affected areas, communicable diseases threats included vector-borne diseases such as malaria, dengue/dengue hemorrhagic fever (DHF), fly-borne bowel infections and hepatitis A. An entomologist visited Jaffna to review problems with sandflies and to investigate a suspected outbreak of leishmaniasis, although the number of cases was apparently limited, and not above the normal incidence. The topography and extent of damage in Sri Lanka warranted a coordinated approach to communicable diseases and hence WHO established three field offices. All three offices were staffed with laboratory experts recruited by WHO, who assessed not only the immediate needs but also the needs from a long-term perspective. Necessary equipment and reagents were procured quickly through the WHO mechanism, and laboratory technologists were trained in all aspects of laboratory services in collaboration with the Medical Research Institute, Colombo (the national public health laboratory). WHO professional staff provided technical support for six months post-tsunami and, with the help of considerable equipment and reagents procured through WHO, restored the laboratory services to efficiency. Three basic laboratories were identified and suitably equipped to diagnose potential outbreaks. By the end of February, 500 microscopes had been ordered to equip laboratories in Batticaloa and Kalmunai. Surveillance, laboratory and field response staff were also suitably trained in laboratory operating protocols. In Communicable diseases Activities included: = a facility survey, with dissemination of results = logistical and technical support to health institutions in tsunami-affected districts = provision of personal protection for staff = training of health and agency staff = preparation of an information, education and communication (IEC) package = advocacy for national- and district-level authorities. Almost all camps in each of the districts had a group supporting waste disposal. Once disposal could be managed in a satisfactory manner, additional waste disposal facilities would need to be constructed for solid waste and drainage in the camp. Gully emptying was done, with increasing numbers of “gully emptiers” being used. The disposal of human waste collected by the “gully emptiers” was an issue, however. The Government, UNICEF and NGOs developed guidelines for the safe disposal of human waste. The environmental conditions and disruptions created by the tsunami enhanced the breeding of vector mosquitoes and flies, and there was a need for continuous and rigorous surveillance of environmental changes, vector densities and disease incidence, especially since transmission seasons were at their peak during and after the tsunami. Activities to reduce the density of man-biting vectors and flies included: = adulticiding for rapid reduction using thermal fogging with synthetic pyrethroids = adulticiding for sustainable effects using indoor residual spraying (with hand compression sprayers) = larviciding for housefly control, with spraying of breeding sites once every 10 days (with hand compression sprayers or knapsack mist blowers) = larvicide spraying for mosquito control in drinking water containers every 2–4 weeks and every 10 days in wells = logistical support to district health institutions = technical assistance including provision of an entomologist and several vector- borne disease control experts = provision of training manuals for spraying and vector control in complex emergencies. Surveillance systems F r o m r e l i e f t o r e c o v e r y S r i L a n k a The weekly epidemiological report and its publication were reviewed. A subset of the notification data to cover only those MoH divisions directly affected by the tsunami was created and published separately. Plans for establishing Rapid Epidemic Response Teams and for ensuring that improvements made to epidemiological surveillance over the coming months were sustainable were further defined. A training workshop was held on 14–18 June 2005 on standardized procedures for the diagnosis of diseases of public health importance for laboratories in tsunami-affected districts. Training material was also prepared for an infection control workshop held on 21–22 June 2005 for laboratory consultants, medical officers and nurses involved in hospital infection control. In Balapitiya in the Southern Province, the Health Minister handed over a biochemistry auto-analyser provided by WHO to the laboratory there. In all affected areas, communicable diseases threats included vector-borne diseases such as malaria, dengue/dengue hemorrhagic fever (DHF), fly-borne bowel infections and hepatitis A. An entomologist visited Jaffna to review problems with sandflies and to investigate a suspected outbreak of leishmaniasis, although the number of cases was apparently limited, and not above the normal incidence. The topography and extent of damage in Sri Lanka warranted a coordinated approach to communicable diseases and hence WHO established three field offices. All three offices were staffed with laboratory experts recruited by WHO, who assessed not only the immediate needs but also the needs from a long-term perspective. Necessary equipment and reagents were procured quickly through the WHO mechanism, and laboratory technologists were trained in all aspects of laboratory services in collaboration with the Medical Research Institute, Colombo (the national public health laboratory). WHO professional staff provided technical support for six months post-tsunami and, with the help of considerable equipment and reagents procured through WHO, restored the laboratory services to efficiency. Three basic laboratories were identified and suitably equipped to diagnose potential outbreaks. By the end of February, 500 microscopes had been ordered to equip laboratories in Batticaloa and Kalmunai. Surveillance, laboratory and field response staff were also suitably trained in laboratory operating protocols. In Communicable diseases Activities included: = a facility survey, with dissemination of results = logistical and technical support to health institutions in tsunami-affected districts = provision of personal protection for staff = training of health and agency staff = preparation of an information, education and communication (IEC) package = advocacy for national- and district-level authorities. Almost all camps in each of the districts had a group supporting waste disposal. Once disposal could be managed in a satisfactory manner, additional waste disposal facilities would need to be constructed for solid waste and drainage in the camp. Gully emptying was done, with increasing numbers of “gully emptiers” being used. The disposal of human waste collected by the “gully emptiers” was an issue, however. The Government, UNICEF and NGOs developed guidelines for the safe disposal of human waste. The environmental conditions and disruptions created by the tsunami enhanced the breeding of vector mosquitoes and flies, and there was a need for continuous and rigorous surveillance of environmental changes, vector densities and disease incidence, especially since transmission seasons were at their peak during and after the tsunami. Activities to reduce the density of man-biting vectors and flies included: = adulticiding for rapid reduction using thermal fogging with synthetic pyrethroids = adulticiding for sustainable effects using indoor residual spraying (with hand compression sprayers) = larviciding for housefly control, with spraying of breeding sites once every 10 days (with hand compression sprayers or knapsack mist blowers) = larvicide spraying for mosquito control in drinking water containers every 2–4 weeks and every 10 days in wells = logistical support to district health institutions = technical assistance including provision of an entomologist and several vector- borne disease control experts = provision of training manuals for spraying and vector control in complex emergencies. Surveillance systems F r o m r e l i e f t o r e c o v e r y S r i L a n k a emergency measles vaccination campaign for the people living in temporary shelters. The standard WHO recommendation is to immunize in such cases. But, given the very high measles coverage in Sri Lanka and the lack of capacity to begin routine immunization at that point in time, it was decided that an emergency campaign was not necessary. On 10 March 2005, WHO Sri Lanka reported sporadic outbreaks of dengue in Trincomalee and Kinniya areas. A malaria outbreak in Illupankulam in the Trincomalee area was also reported, although no specific numbers were available for either disease. WHO Sri Lanka also reported 32 cases of viral hepatitis from the Central Dispensary, Sampoor and Thileepan Hospital, Pattalipuram. Only 4 of these cases were reported from tsunami welfare centres. WHO provided written guidelines for typhoid and hepatitis A vaccination in emergencies, which the MoH could use as technical documentation. Discussions also took place on establishing a simple emergency surveillance system that would focus on key diseases of epidemic potential. WHO Sri Lanka office drew up the forms and distributed them to all tsunami-affected districts. Among the most vulnerable of the survivors were those under medical surveillance even before the tragedy, such as expectant mothers. The UNFPA estimated that the number of pregnant women in Sri Lanka was 15 000. Pregnant and new mothers needed urgent and specialized attention. Sensitive to these requirements, 3000 new mother and newborn hygiene kits were sent by 10 January 2005 to the affected areas. Five hundred safe delivery kits were also provided for midwives. A vitamin A supplementation campaign in tsunami-affected districts commenced on 2 April 2005 following the results of a nutrition survey, which revealed that only 23% of children in camps had received vitamin A supplementation over the past six months. The campaign targeted all children in tsunami-affected districts. Over 463 000 children aged 6 months to 5 years benefited from vitamin A supplementation. WHO supported food safety efforts through posters in the local languages, by Malaria, dengue and viral hepatitis Immunization Maternal and child health Nutrition some cases, the training began at the most basic level: how to collect disease specimens and transport them safely. A cohesive regional network was established to provide local and national authorities as well as WHO with access to reference services for timely and accurate reports. A regional laboratory plan for responding to emergencies and provide surge capacity services was drawn up. Guidelines for outbreak response were produced with WHO financial and technical support, and further training was provided. Public health laboratory capacity had to be developed to support outbreak investigation and rapid diagnostics at the district level. Efforts to strengthen laboratory capacity focused on provision of supplies and equipment for clinical-based diagnostics at base and general hospitals. Training sessions were held for medical laboratory technicians (MLTs), with additional emphasis on biosafety precautions. A major concern was follow-up supervision of MLTs and the maintenance and sustainable supply of reagents for sophisticated equipment. Reporting from camp populations took place daily during the emergency surveillance phase; this reverted to routine weekly reporting from inpatient facilities as occurred pre-tsunami. In response to the risk of vector-borne diseases, 50 000 long-lasting impregnated mosquito nets (LLINs) were provided, and sufficient fogging equipment and insecticide to last for the next two years. WHO also contracted an entomologist to support these activities. The tsunami offered WHO the opportunity to work closely with the decentralized health system. It revealed a serious lack of capacity to deal with vector control, partly due to lack of entomologists in critical locations. With dengue and cutaneous leishmaniasis on the rise, this was an opportunity for WHO to strengthen vector control by helping to develop sustained capacity. To increase the capacity to diagnose and treat communicable diseases, activities included: = supply of drugs such as antimalarials and vaccines, e.g. for Japanese encephalitis, as well as rapid diagnostic tests and laboratory equipment to key institutions = production and dissemination of national treatment schedules and guidelines for malaria diagnosis and treatment. Discussions were held on whether it was necessary to immediately organize an Measles F r o m r e l i e f t o r e c o v e r y S r i L a n k a emergency measles vaccination campaign for the people living in temporary shelters. The standard WHO recommendation is to immunize in such cases. But, given the very high measles coverage in Sri Lanka and the lack of capacity to begin routine immunization at that point in time, it was decided that an emergency campaign was not necessary. On 10 March 2005, WHO Sri Lanka reported sporadic outbreaks of dengue in Trincomalee and Kinniya areas. A malaria outbreak in Illupankulam in the Trincomalee area was also reported, although no specific numbers were available for either disease. WHO Sri Lanka also reported 32 cases of viral hepatitis from the Central Dispensary, Sampoor and Thileepan Hospital, Pattalipuram. Only 4 of these cases were reported from tsunami welfare centres. WHO provided written guidelines for typhoid and hepatitis A vaccination in emergencies, which the MoH could use as technical documentation. Discussions also took place on establishing a simple emergency surveillance system that would focus on key diseases of epidemic potential. WHO Sri Lanka office drew up the forms and distributed them to all tsunami-affected districts. Among the most vulnerable of the survivors were those under medical surveillance even before the tragedy, such as expectant mothers. The UNFPA estimated that the number of pregnant women in Sri Lanka was 15 000. Pregnant and new mothers needed urgent and specialized attention. Sensitive to these requirements, 3000 new mother and newborn hygiene kits were sent by 10 January 2005 to the affected areas. Five hundred safe delivery kits were also provided for midwives. A vitamin A supplementation campaign in tsunami-affected districts commenced on 2 April 2005 following the results of a nutrition survey, which revealed that only 23% of children in camps had received vitamin A supplementation over the past six months. The campaign targeted all children in tsunami-affected districts. Over 463 000 children aged 6 months to 5 years benefited from vitamin A supplementation. WHO supported food safety efforts through posters in the local languages, by Malaria, dengue and viral hepatitis Immunization Maternal and child health Nutrition some cases, the training began at the most basic level: how to collect disease specimens and transport them safely. A cohesive regional network was established to provide local and national authorities as well as WHO with access to reference services for timely and accurate reports. A regional laboratory plan for responding to emergencies and provide surge capacity services was drawn up. Guidelines for outbreak response were produced with WHO financial and technical support, and further training was provided. Public health laboratory capacity had to be developed to support outbreak investigation and rapid diagnostics at the district level. Efforts to strengthen laboratory capacity focused on provision of supplies and equipment for clinical-based diagnostics at base and general hospitals. Training sessions were held for medical laboratory technicians (MLTs), with additional emphasis on biosafety precautions. A major concern was follow-up supervision of MLTs and the maintenance and sustainable supply of reagents for sophisticated equipment. Reporting from camp populations took place daily during the emergency surveillance phase; this reverted to routine weekly reporting from inpatient facilities as occurred pre-tsunami. In response to the risk of vector-borne diseases, 50 000 long-lasting impregnated mosquito nets (LLINs) were provided, and sufficient fogging equipment and insecticide to last for the next two years. WHO also contracted an entomologist to support these activities. The tsunami offered WHO the opportunity to work closely with the decentralized health system. It revealed a serious lack of capacity to deal with vector control, partly due to lack of entomologists in critical locations. With dengue and cutaneous leishmaniasis on the rise, this was an opportunity for WHO to strengthen vector control by helping to develop sustained capacity. To increase the capacity to diagnose and treat communicable diseases, activities included: = supply of drugs such as antimalarials and vaccines, e.g. for Japanese encephalitis, as well as rapid diagnostic tests and laboratory equipment to key institutions = production and dissemination of national treatment schedules and guidelines for malaria diagnosis and treatment. Discussions were held on whether it was necessary to immediately organize an Measles F r o m r e l i e f t o r e c o v e r y S r i L a n k aF r o m r e l i e f t o r e c o v e r y posting guidelines and fact sheets on the web and by providing technical assistance and equipment to the authorities. Preliminary findings of a nutrition survey completed at the end of January 2005 indicated that 20% of tsunami-affected children were stunted (height for age) compared to the national figure of 14%. While these figures were also found in non-tsunami affected areas, the higher risk of disease and the absence of natural sources of food put displaced children at a higher risk for malnutrition. The prevalence of acute malnutrition in the East (19.8%) and West (18.1%) were higher than the North (12.7%) and South (12.8%). The survey also assessed disease morbidity and the availability of food for the displaced population. The findings indicated that more than two-thirds of under five-year-olds had acute respiratory infections and nearly one in five children had diarrhoea. While latrines were generally available in the camps, only 25% of the population used them. Although the general food distribution for adults was adequate, children did not get appropriate supplementary food. Triposha, a blended food rich in micronutrients, was available to only 14% of under five-year- old children. Corn–soya blend (CSB), although available with WFP in adequate quantities at the national level, had not been distributed, due to logistical delays and the need to train health workers in distribution and monitoring. The then President of Sri Lanka identified psychosocial support within the community as a top priority. She established a National Psychosocial and Mental Health Committee to oversee a psychosocial support programme launched jointly by the MoH and WHO that aimed at reaching every survivor of the tsunami and providing them with appropriate services. UNICEF drafted a strategic framework for psychosocial activities in Sri Lanka in the post-tsunami context. Activities covered the four main areas of community support services, specialized services for vulnerable groups, direct support for mental health services, and district and national coordination for psychosocial services. On 7 March 2005, a one-day teacher support workshop was conducted to provide refresher training on psychosocial approaches to 150 “school advisors” who had already been trained by the Ministry of Education prior to the tsunami. Among other techniques, the advisors were taught how to facilitate group discussions with teachers working in tsunami-affected districts. All districts (DPDHSs) received their allocations for the appointment of community-level workers (CLWs). Several hundred new staff were recruited and trained. A new training programme to support staff at the primary health-care level was developed and extended to help primary care midwives and other staff in problem identification and problem-solving skills. In supporting mental health professionals, small allocations were given to individuals and the College of Psychiatrists to ensure that all areas affected by the tsunami were covered. A detailed training was held of Medical Officers of Health in Ampara and Kalmunai. Eighteen such officers were trained in this area, including mental health staff from Kandy. A training programme was also held for hospital medical staff in recognizing somatic symptoms. Mental health S r i L a n k aF r o m r e l i e f t o r e c o v e r y posting guidelines and fact sheets on the web and by providing technical assistance and equipment to the authorities. Preliminary findings of a nutrition survey completed at the end of January 2005 indicated that 20% of tsunami-affected children were stunted (height for age) compared to the national figure of 14%. While these figures were also found in non-tsunami affected areas, the higher risk of disease and the absence of natural sources of food put displaced children at a higher risk for malnutrition. The prevalence of acute malnutrition in the East (19.8%) and West (18.1%) were higher than the North (12.7%) and South (12.8%). The survey also assessed disease morbidity and the availability of food for the displaced population. The findings indicated that more than two-thirds of under five-year-olds had acute respiratory infections and nearly one in five children had diarrhoea. While latrines were generally available in the camps, only 25% of the population used them. Although the general food distribution for adults was adequate, children did not get appropriate supplementary food. Triposha, a blended food rich in micronutrients, was available to only 14% of under five-year- old children. Corn–soya blend (CSB), although available with WFP in adequate quantities at the national level, had not been distributed, due to logistical delays and the need to train health workers in distribution and monitoring. The then President of Sri Lanka identified psychosocial support within the community as a top priority. She established a National Psychosocial and Mental Health Committee to oversee a psychosocial support programme launched jointly by the MoH and WHO that aimed at reaching every survivor of the tsunami and providing them with appropriate services. UNICEF drafted a strategic framework for psychosocial activities in Sri Lanka in the post-tsunami context. Activities covered the four main areas of community support services, specialized services for vulnerable groups, direct support for mental health services, and district and national coordination for psychosocial services. On 7 March 2005, a one-day teacher support workshop was conducted to provide refresher training on psychosocial approaches to 150 “school advisors” who had already been trained by the Ministry of Education prior to the tsunami. Among other techniques, the advisors were taught how to facilitate group discussions with teachers working in tsunami-affected districts. All districts (DPDHSs) received their allocations for the appointment of community-level workers (CLWs). Several hundred new staff were recruited and trained. A new training programme to support staff at the primary health-care level was developed and extended to help primary care midwives and other staff in problem identification and problem-solving skills. In supporting mental health professionals, small allocations were given to individuals and the College of Psychiatrists to ensure that all areas affected by the tsunami were covered. A detailed training was held of Medical Officers of Health in Ampara and Kalmunai. Eighteen such officers were trained in this area, including mental health staff from Kandy. A training programme was also held for hospital medical staff in recognizing somatic symptoms. Mental health = Reconstruction of damaged health institutions = Strengthening of health infrastructure in surrounding areas = Supply of drugs and medical equipment = Long-term care of displaced populations = Provision of psychosocial and mental health support = Prevention of diseases = Maintenance of health services Rehabilitation A WHO mental health specialist visited Kilinochchi and discussed a plan for psychosocial response. Initially, the small number of staff and their limited training prevented an effective response. A plan was prepared to address both issues. Several hundred staff were recruited and trained in community mental health. A training programme was held for community staff on problem-based learning (psychosocial problems) and a curriculum for psychiatric nurse training prepared. Sixteen senior staff nurses and junior medical staff were trained in rehabilitation strategies at the National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India, with WHO support. Funds were released for training religious leaders in providing psychosocial support in times of distress. Training was provided for 100 Buddhist monks. The Community Placement Survey collected data (comprehensive assessment of every patient—approximately 3000 patients) from three major mental hospitals—Anogda, Mulleriyawa and Hendala. The Mental Health Policy 2005 was drafted and agreed to by the Minister of Health. The consultations attracted significant interest and over 30 organizations responded. In line with this policy, each district is now preparing a plan to develop comprehensive community-based services and improve local inpatient care. F r o m r e l i e f t o r e c o v e r y S r i L a n k a = Reconstruction of damaged health institutions = Strengthening of health infrastructure in surrounding areas = Supply of drugs and medical equipment = Long-term care of displaced populations = Provision of psychosocial and mental health support = Prevention of diseases = Maintenance of health services Rehabilitation A WHO mental health specialist visited Kilinochchi and discussed a plan for psychosocial response. Initially, the small number of staff and their limited training prevented an effective response. A plan was prepared to address both issues. Several hundred staff were recruited and trained in community mental health. A training programme was held for community staff on problem-based learning (psychosocial problems) and a curriculum for psychiatric nurse training prepared. Sixteen senior staff nurses and junior medical staff were trained in rehabilitation strategies at the National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India, with WHO support. Funds were released for training religious leaders in providing psychosocial support in times of distress. Training was provided for 100 Buddhist monks. The Community Placement Survey collected data (comprehensive assessment of every patient—approximately 3000 patients) from three major mental hospitals—Anogda, Mulleriyawa and Hendala. The Mental Health Policy 2005 was drafted and agreed to by the Minister of Health. The consultations attracted significant interest and over 30 organizations responded. In line with this policy, each district is now preparing a plan to develop comprehensive community-based services and improve local inpatient care. F r o m r e l i e f t o r e c o v e r y S r i L a n k a PHASE III: REVIEW AND CONSOLIDATION ASSESSMENTS AT ONE YEAR Health systems Basic needs Strengthening national capacities The reconstruction/renovation of 222 health institutions (104 directly damaged and 118 not directly damaged) was required. Approximately 98% had signed MoUs, 50% were in the design and planning stage, 29% were in progress and 6% (24 institutions) had been completed. Challenges included price escalation, land availability and the speed of the process (contractors and implementing agencies). The basic needs of the affected population had been met, including access to essential services, such as health, water, sanitation, education, nutrition and food security. The UN provided critical support to sectoral coordination in education (UNICEF), health (WHO), psychosocial support (UNFPA) and food assistance (WFP). Some UN agencies supported important policy elements (e.g. mental health policy). This included the use of standards, such as the Child Friendly School approach, for the entire recovery process. In terms of operational interventions, up to October 2005, general food distribution reached 908 700 beneficiaries and then shifted to vulnerable group feeding to reach 312 000 beneficiaries during the recovery phase. This was a critical component of the assistance package (combining food and cash allowance). UNICEF, WHO and UNFPA provided extensive support in water and sanitation, health, reproductive health and education. Under the Transitional Strategy, the UN joined their efforts with an integrated capacity-building support package to the government at the local level. UNDP and ILO signed an agreement to provide joint logistical and technical support to local authorities. Most of the 250 staff had been recruited to local government offices and logistical support was under way. UNDP supported the Development Assistance Database (DAD) (which captured US$ 2.3 billion of donor commitments) as well as the capacities of 87 CBOs (out of 160 originally identified) involved in the recovery process. A joint approach was also developed to support disaster management and F r o m r e l i e f t o r e c o v e r y S r i L a n k a early warning (including so far UNDP, UNV, UNU and ISDR Secretariat). A new Disaster Management Centre (DMC) was established and an interim early warning system put in place. A road map for disaster management was launched at the end of 2005. Although some activities of the humanitarian response do not need to be continued for long (such as supply of emergency material), other activities (such as improved health care for mothers and children, and streamlined disease notification) should clearly continue long after the effects of the disaster have subsided and merge into the long term recovery and reconstruction of sustainable development. To prevent projects folding after the sponsors have left, acute humanitarian programmes should be embedded as far as possible within existing health-care structures and systems. Although coordination of the various activities in the health sector improved during the period covered, it continues to be important. A strategy that is currently gaining popularity is the principle of subsidiarity, where policies are implemented at the lowest competent tier of government. While the Central Ministry must play a lead role in setting the standards, policies and principles to be followed, subsidiarity allows for locally appropriate solutions to be found by those dealing with the problems on a day-to-day basis. In addition, as long as there are a large number of agencies offering humanitarian assistance, it is vital that they should all follow the same standards. The logistical capacity of the Medical Supply Division needs to be enhanced to ensure timely delivery of relief supplies to victims during disaster and recovery. Clear national guidelines need to be formulated on the disposal of dead bodies well in advance of a future emergency. Forensic medicine procedures for identification of the deceased (description of the victims, their injuries, clothing and any documentation carried; digital photography) need to be codified. Health sector emergency preparedness in Sri Lanka could be summarized as follows: = Development of a WHO internal contingency plan to support the Government of Sri Lanka, UN system in Sri Lanka and NGOs = National Health Sector Emergency Preparedness plan in Sri Lanka to be Challenges ahead/recommendations EPR activities (by 31 December 2005) PHASE III: REVIEW AND CONSOLIDATION ASSESSMENTS AT ONE YEAR Health systems Basic needs Strengthening national capacities The reconstruction/renovation of 222 health institutions (104 directly damaged and 118 not directly damaged) was required. Approximately 98% had signed MoUs, 50% were in the design and planning stage, 29% were in progress and 6% (24 institutions) had been completed. Challenges included price escalation, land availability and the speed of the process (contractors and implementing agencies). The basic needs of the affected population had been met, including access to essential services, such as health, water, sanitation, education, nutrition and food security. The UN provided critical support to sectoral coordination in education (UNICEF), health (WHO), psychosocial support (UNFPA) and food assistance (WFP). Some UN agencies supported important policy elements (e.g. mental health policy). This included the use of standards, such as the Child Friendly School approach, for the entire recovery process. In terms of operational interventions, up to October 2005, general food distribution reached 908 700 beneficiaries and then shifted to vulnerable group feeding to reach 312 000 beneficiaries during the recovery phase. This was a critical component of the assistance package (combining food and cash allowance). UNICEF, WHO and UNFPA provided extensive support in water and sanitation, health, reproductive health and education. Under the Transitional Strategy, the UN joined their efforts with an integrated capacity-building support package to the government at the local level. UNDP and ILO signed an agreement to provide joint logistical and technical support to local authorities. Most of the 250 staff had been recruited to local government offices and logistical support was under way. UNDP supported the Development Assistance Database (DAD) (which captured US$ 2.3 billion of donor commitments) as well as the capacities of 87 CBOs (out of 160 originally identified) involved in the recovery process. A joint approach was also developed to support disaster management and F r o m r e l i e f t o r e c o v e r y S r i L a n k a early warning (including so far UNDP, UNV, UNU and ISDR Secretariat). A new Disaster Management Centre (DMC) was established and an interim early warning system put in place. A road map for disaster management was launched at the end of 2005. Although some activities of the humanitarian response do not need to be continued for long (such as supply of emergency material), other activities (such as improved health care for mothers and children, and streamlined disease notification) should clearly continue long after the effects of the disaster have subsided and merge into the long term recovery and reconstruction of sustainable development. To prevent projects folding after the sponsors have left, acute humanitarian programmes should be embedded as far as possible within existing health-care structures and systems. Although coordination of the various activities in the health sector improved during the period covered, it continues to be important. A strategy that is currently gaining popularity is the principle of subsidiarity, where policies are implemented at the lowest competent tier of government. While the Central Ministry must play a lead role in setting the standards, policies and principles to be followed, subsidiarity allows for locally appropriate solutions to be found by those dealing with the problems on a day-to-day basis. In addition, as long as there are a large number of agencies offering humanitarian assistance, it is vital that they should all follow the same standards. The logistical capacity of the Medical Supply Division needs to be enhanced to ensure timely delivery of relief supplies to victims during disaster and recovery. Clear national guidelines need to be formulated on the disposal of dead bodies well in advance of a future emergency. Forensic medicine procedures for identification of the deceased (description of the victims, their injuries, clothing and any documentation carried; digital photography) need to be codified. Health sector emergency preparedness in Sri Lanka could be summarized as follows: = Development of a WHO internal contingency plan to support the Government of Sri Lanka, UN system in Sri Lanka and NGOs = National Health Sector Emergency Preparedness plan in Sri Lanka to be Challenges ahead/recommendations EPR activities (by 31 December 2005) S r i L a n k a finalized by the MoH. This plan consists of preparing hospitals to deal with mass casualty events, early warning and response against outbreaks of diseases (such as avian influenza), establishment of outreach clinics in case of displacement of the population, establishment of a coordination mechanism in the health sector and necessary administrative support. = Exclusive funds made available to establish a health sector emergency control room in the MoH to coordinate health sector interventions in case of any emergency = Institutionalization of health sector emergency preparedness by introducing an appropriate training programme under the teaching calendar plan of the University of Paredeniya, Kandy. This programme would be expanded within the next two years to a diploma course through the university. = Establishment of health sector emergency units at national, 5 provincial and 15 district levels = Mass casualty plan made functional in Colombo and 5 provincial hospitals = Training programme established in the University of Paredeniya, Kandy to continue providing trained health personnel in Sri Lanka = Strengthening of emergency preparedness and response as part of the emergency health sector contingency plan = National Emergency Operations Room plan finalized and funded = Adoption of a university-based national Public Health and Emergency Management in Asia and the Pacific (PHEMAP) course through the University of Paredeniya, Kandy = Provincial and district training courses = Support for national, provincial and district Disaster Management Centres = MoH collaboration with professional associations, institutions and voluntary agencies = Continued EPR technical support by experts and regular budget activities = Adoption of a National Emergency Contingency Plan. FUTURE DIRECTIONS Road map F r o m r e l i e f t o r e c o v e r y S r i L a n k a finalized by the MoH. This plan consists of preparing hospitals to deal with mass casualty events, early warning and response against outbreaks of diseases (such as avian influenza), establishment of outreach clinics in case of displacement of the population, establishment of a coordination mechanism in the health sector and necessary administrative support. = Exclusive funds made available to establish a health sector emergency control room in the MoH to coordinate health sector interventions in case of any emergency = Institutionalization of health sector emergency preparedness by introducing an appropriate training programme under the teaching calendar plan of the University of Paredeniya, Kandy. This programme would be expanded within the next two years to a diploma course through the university. = Establishment of health sector emergency units at national, 5 provincial and 15 district levels = Mass casualty plan made functional in Colombo and 5 provincial hospitals = Training programme established in the University of Paredeniya, Kandy to continue providing trained health personnel in Sri Lanka = Strengthening of emergency preparedness and response as part of the emergency health sector contingency plan = National Emergency Operations Room plan finalized and funded = Adoption of a university-based national Public Health and Emergency Management in Asia and the Pacific (PHEMAP) course through the University of Paredeniya, Kandy = Provincial and district training courses = Support for national, provincial and district Disaster Management Centres = MoH collaboration with professional associations, institutions and voluntary agencies = Continued EPR technical support by experts and regular budget activities = Adoption of a National Emergency Contingency Plan. FUTURE DIRECTIONS Road map F r o m r e l i e f t o r e c o v e r y THE MALDIVES Maldives 82 108 Country Fatalities Total SourceMissing1 1. Some countries have not disaggregated between the deceased and the missing. M AG NI TU DE = Number of fatalities: 82. (Source: National Disaster Management Centre [NDMC], November 2005) = Number of missing: 26. (Source: National Disaster Management Centre (NDMC), November 2005) = Immediately after the tsunami, there were 29 577 IDPs. There are currently 10 531 IDPs. (Source: NDMC, July 2006) Government of the Maldives, National Disaster Management Centre, December 2005 26 PHASE I: EMERGENCY RELIEF ASSESSMENT By the time the tsunami reached the Maldives, the waves were only three or four metres high. However, since the Maldives has a maximum land height of only 1.5 metres above sea level, the impact was extensive. It is an archipelago of almost 2000 widely dispersed islands of which only 199 are inhabited and, even in normal times, 88 of them record perennial beach erosion. The tsunami affected all the islands, totally destroying some of them. The death toll reached 82, the highest in the history of the Maldives in a single disaster, with another 26 people missing. Over 29 000 were left homeless, of whom nearly 5000 had to be evacuated to other islands. The tsunami inflicted considerable damage on the health infrastructure. There was also a massive loss of medical equipment, consumables and other hospital materials. A rapid environmental assessment completed by United Nations Environment Programme (UNEP) shortly after the tsunami found that coastlines were altered, beaches and harbours eroded, and waste washed out to sea. Trees and mangroves were uprooted and coral damaged. Rubble and asbestos lay on the beaches, groundwater was polluted, and the soil was inundated with seawater. THE MALDIVES Maldives 82 108 Country Fatalities Total SourceMissing1 1. Some countries have not disaggregated between the deceased and the missing. M AG NI TU DE = Number of fatalities: 82. (Source: National Disaster Management Centre [NDMC], November 2005) = Number of missing: 26. (Source: National Disaster Management Centre (NDMC), November 2005) = Immediately after the tsunami, there were 29 577 IDPs. There are currently 10 531 IDPs. (Source: NDMC, July 2006) Government of the Maldives, National Disaster Management Centre, December 2005 26 PHASE I: EMERGENCY RELIEF ASSESSMENT By the time the tsunami reached the Maldives, the waves were only three or four metres high. However, since the Maldives has a maximum land height of only 1.5 metres above sea level, the impact was extensive. It is an archipelago of almost 2000 widely dispersed islands of which only 199 are inhabited and, even in normal times, 88 of them record perennial beach erosion. The tsunami affected all the islands, totally destroying some of them. The death toll reached 82, the highest in the history of the Maldives in a single disaster, with another 26 people missing. Over 29 000 were left homeless, of whom nearly 5000 had to be evacuated to other islands. The tsunami inflicted considerable damage on the health infrastructure. There was also a massive loss of medical equipment, consumables and other hospital materials. A rapid environmental assessment completed by United Nations Environment Programme (UNEP) shortly after the tsunami found that coastlines were altered, beaches and harbours eroded, and waste washed out to sea. Trees and mangroves were uprooted and coral damaged. Rubble and asbestos lay on the beaches, groundwater was polluted, and the soil was inundated with seawater. F r o m r e l i e f t o r e c o v e r y Affected areas Affected population The response The existing health infrastructure had suffered severely, and the health network had been affected in at least 10% of the islands. One regional hospital, two atoll hospitals and 20 health centres were totally destroyed. In addition, 21 health posts were damaged or destroyed. As contact was made with the more remote islands, the enormous havoc inflicted by the waves and flooding slowly became apparent. Sea walls were breached on most islands, causing massive flooding. In some cases, islands were temporarily submerged. Fifty-three of the nation's 199 inhabited islands were seriously damaged. Flooding also wiped out power plants on many islands and contaminated water supplies; essential infrastructure, such as jetties and harbours experienced major damage. The tsunami also destroyed agricultural equipment and fishing vessels. The population of 13 islands had to be evacuated in its entirety. Although the number of casualties was low compared to other tsunami-hit countries, the magnitude of the disaster was perhaps greater. One of every three Maldivians was affected. This brought the total of those affected to 223 957, with 2214 people confirmed injured. In places such as Kandolhudhoo in Raa Atoll, where the entire island was destroyed, the majority of the population was transported to five other islands where they were provided with food, water and shelter. IDPs were spread across 18 atolls, but 68% were concentrated in four atolls: Raa (28%); Laamu (15%); Thaa (14%) and Meemu (11%). Fifty-eight per cent of the IDPs were displaced on islands other than their own, and 42% were displaced on their own island. Damage to water supplies (mainly rainwater storage) and foodstuffs was extensive. The Government of the Maldives declared a National Emergency and appealed for clothing, dried food and water. Many of the islands are not easily accessible, and providing relief was logistically difficult. Initial reports from the Maldives were hazy, due to a breakdown in the telecommunications network. However, within the country, a UN Emergency Response Team was established immediately to coordinate the UN's support to the government's efforts. / At least 1800 pregnant womenscattered across 200 islands were impacted by the tsunami, and 500 pregnant women were left without access to delivery facilities. (Source: United Nations Children's Fund (UNICEF), "In the Maldives the situation is bleak," 8 July 2005; United Nations Populations Fund (UNFPA), "Tsunami disaster: UNFPA appeals to donors for $28 million for women and youth.") / A study of tsunami survivors and aid workers in Sri Lanka, the Maldives, Thailand, India, and Indonesia noted that displacement had increased the risk of abuse and exploitation of vulnerable groups, such as women and children. (Source: UC Berkeley, Human Rights Center Report, "After the tsunami: Human rights and vulnerable populations," 6 June 2005.) Impact on vulnerable populations / Overall, there was US$ 250 million in damage to the tourism sector. Following the tsunami, there was a 25% downturn in the tourism industry. (Source: NDMC, June 2005) Tourists have returned to the Maldives with tourist arrivals expected to exceed 2004 levels in 2006. (Source: World Bank, July 2006) / There was US$ 14 million worth of damage to the fisheries sector, which accounted for 11% of the country's pre-tsunami labour force. (Source: NDMC, June 2005) Catches in 2005 exceeded previous levels so the overall effect was minimal except at the local level on some communities, particularly IDPs who were significantly impacted. (World Bank, July 2006) / 53 of 199 inhabited islands were severely damaged. (Source: NDMC, June 2005) / Approximately 8074 houses required repair or rebuilding. To date, 779 houses have been either built or are being repaired and a further 687 are currently under construction. (Source: Government of the Maldives, February 2006) / 21 of the 87 operating resorts were forced to close temporarily due to damage and six had to be completely rebuilt. (Ministry of Planning and National Development, November 2005) / Approximately 41 health facilities were damaged. (Source: WHO, January 2005) Damages and losses T h e M a l d i v e s F r o m r e l i e f t o r e c o v e r y Affected areas Affected population The response The existing health infrastructure had suffered severely, and the health network had been affected in at least 10% of the islands. One regional hospital, two atoll hospitals and 20 health centres were totally destroyed. In addition, 21 health posts were damaged or destroyed. As contact was made with the more remote islands, the enormous havoc inflicted by the waves and flooding slowly became apparent. Sea walls were breached on most islands, causing massive flooding. In some cases, islands were temporarily submerged. Fifty-three of the nation's 199 inhabited islands were seriously damaged. Flooding also wiped out power plants on many islands and contaminated water supplies; essential infrastructure, such as jetties and harbours experienced major damage. The tsunami also destroyed agricultural equipment and fishing vessels. The population of 13 islands had to be evacuated in its entirety. Although the number of casualties was low compared to other tsunami-hit countries, the magnitude of the disaster was perhaps greater. One of every three Maldivians was affected. This brought the total of those affected to 223 957, with 2214 people confirmed injured. In places such as Kandolhudhoo in Raa Atoll, where the entire island was destroyed, the majority of the population was transported to five other islands where they were provided with food, water and shelter. IDPs were spread across 18 atolls, but 68% were concentrated in four atolls: Raa (28%); Laamu (15%); Thaa (14%) and Meemu (11%). Fifty-eight per cent of the IDPs were displaced on islands other than their own, and 42% were displaced on their own island. Damage to water supplies (mainly rainwater storage) and foodstuffs was extensive. The Government of the Maldives declared a National Emergency and appealed for clothing, dried food and water. Many of the islands are not easily accessible, and providing relief was logistically difficult. Initial reports from the Maldives were hazy, due to a breakdown in the telecommunications network. However, within the country, a UN Emergency Response Team was established immediately to coordinate the UN's support to the government's efforts. / At least 1800 pregnant womenscattered across 200 islands were impacted by the tsunami, and 500 pregnant women were left without access to delivery facilities. (Source: United Nations Children's Fund (UNICEF), "In the Maldives the situation is bleak," 8 July 2005; United Nations Populations Fund (UNFPA), "Tsunami disaster: UNFPA appeals to donors for $28 million for women and youth.") / A study of tsunami survivors and aid workers in Sri Lanka, the Maldives, Thailand, India, and Indonesia noted that displacement had increased the risk of abuse and exploitation of vulnerable groups, such as women and children. (Source: UC Berkeley, Human Rights Center Report, "After the tsunami: Human rights and vulnerable populations," 6 June 2005.) Impact on vulnerable populations / Overall, there was US$ 250 million in damage to the tourism sector. Following the tsunami, there was a 25% downturn in the tourism industry. (Source: NDMC, June 2005) Tourists have returned to the Maldives with tourist arrivals expected to exceed 2004 levels in 2006. (Source: World Bank, July 2006) / There was US$ 14 million worth of damage to the fisheries sector, which accounted for 11% of the country's pre-tsunami labour force. (Source: NDMC, June 2005) Catches in 2005 exceeded previous levels so the overall effect was minimal except at the local level on some communities, particularly IDPs who were significantly impacted. (World Bank, July 2006) / 53 of 199 inhabited islands were severely damaged. (Source: NDMC, June 2005) / Approximately 8074 houses required repair or rebuilding. To date, 779 houses have been either built or are being repaired and a further 687 are currently under construction. (Source: Government of the Maldives, February 2006) / 21 of the 87 operating resorts were forced to close temporarily due to damage and six had to be completely rebuilt. (Ministry of Planning and National Development, November 2005) / Approximately 41 health facilities were damaged. (Source: WHO, January 2005) Damages and losses T h e M a l d i v e s President Maumoon Abdul Gayoom played a crucial role in expediting relief operations immediately after the tsunami. An emergency meeting chaired by the President was convened just after the tsunami hit the country, and a special Ministerial Committee and Task Force was constituted the same day to oversee initial relief operations. Working initially out of the Iskandhar School in the capital Malé, government officials coordinated the collection and distribution of relief, provided basic counselling to the first victims, and began preliminary damage assessment. Recognizing the desperate need of people whose life savings had been washed away, a one-off cash compensation was given to every affected individual soon after the tsunami. An estimated 60 000 beneficiaries received payments through the first quarter of 2005. Ironically, the Maldives was in the process of preparing a Health Sectoral Disaster Management Plan. This country had officially been taken off the list of least developed countries three days before the tsunami struck. The tsunami put them back on that list. However, on the day of the earthquake–tsunami itself, the government instituted the National Disaster Management Centre (NDMC). F r o m r e l i e f t o r e c o v e r y T h e M a l d i v e s Financial implications The creation of the Managing Internally Displaced Persons (MIDP) Unit to address the needs of IDPs was one of the Government's many innovative actions during the humanitarian crisis in a country that had little prior experience of dealing with a disaster of this scale. Two other important units created within the NDMC were the National Economic Recovery Unit (NERU) under the Ministry of Finance and Treasury (MoFT), and the Housing and Infrastructure Redevelopment Unit (HIRU), coordinated by the Ministry of Planning and National Development. Government ministries, UN agencies, NGOs, and the Red Cross and Red Crescent Movement worked closely together with the MIDP Unit within the Government to ensure that IDPs were provided with all their basic needs. In addition to temporary shelters, additional classrooms were built, food and hygiene kits provided, and psychosocial counsellors enlisted to help communities deal with the trauma of their experiences. The National Security Service (NSS), now known as the National Defence Force (NDF), immediately launched a series of search and rescue, and logistics missions, and within two to three days the Coast Guard had visited all of the / Total damages were estimated to be 62% of the GDP. (Source: Joint World Bank, Asian Development Bank [ADB], United Nations Needs Assessment, February 2005) / Estimated direct losses: US$ 295 million (Source: Development Assistance Database [DAD], February 2006 / The cost of repairing damages is presently estimated at US$ 494 million. (Source: DAD, February 2006) / Total funds secured from international donors for long-term recovery: US$ 377 million. (Source: DAD, July 2006) / The Maldives has a funding need of US$ 80 million for post-tsunami recovery needs. (Building back better: A review of the National Recovery and Reconstruction Plan, Government of Maldives, June 2006) In addition, it faced a US$ 94 million budgetary shortfall in 2005 as a result of tsunami-related expenditures. (Source: Ministry of Finance, July 2006) President Maumoon Abdul Gayoom played a crucial role in expediting relief operations immediately after the tsunami. An emergency meeting chaired by the President was convened just after the tsunami hit the country, and a special Ministerial Committee and Task Force was constituted the same day to oversee initial relief operations. Working initially out of the Iskandhar School in the capital Malé, government officials coordinated the collection and distribution of relief, provided basic counselling to the first victims, and began preliminary damage assessment. Recognizing the desperate need of people whose life savings had been washed away, a one-off cash compensation was given to every affected individual soon after the tsunami. An estimated 60 000 beneficiaries received payments through the first quarter of 2005. Ironically, the Maldives was in the process of preparing a Health Sectoral Disaster Management Plan. This country had officially been taken off the list of least developed countries three days before the tsunami struck. The tsunami put them back on that list. However, on the day of the earthquake–tsunami itself, the government instituted the National Disaster Management Centre (NDMC). F r o m r e l i e f t o r e c o v e r y T h e M a l d i v e s Financial implications The creation of the Managing Internally Displaced Persons (MIDP) Unit to address the needs of IDPs was one of the Government's many innovative actions during the humanitarian crisis in a country that had little prior experience of dealing with a disaster of this scale. Two other important units created within the NDMC were the National Economic Recovery Unit (NERU) under the Ministry of Finance and Treasury (MoFT), and the Housing and Infrastructure Redevelopment Unit (HIRU), coordinated by the Ministry of Planning and National Development. Government ministries, UN agencies, NGOs, and the Red Cross and Red Crescent Movement worked closely together with the MIDP Unit within the Government to ensure that IDPs were provided with all their basic needs. In addition to temporary shelters, additional classrooms were built, food and hygiene kits provided, and psychosocial counsellors enlisted to help communities deal with the trauma of their experiences. The National Security Service (NSS), now known as the National Defence Force (NDF), immediately launched a series of search and rescue, and logistics missions, and within two to three days the Coast Guard had visited all of the / Total damages were estimated to be 62% of the GDP. (Source: Joint World Bank, Asian Development Bank [ADB], United Nations Needs Assessment, February 2005) / Estimated direct losses: US$ 295 million (Source: Development Assistance Database [DAD], February 2006 / The cost of repairing damages is presently estimated at US$ 494 million. (Source: DAD, February 2006) / Total funds secured from international donors for long-term recovery: US$ 377 million. (Source: DAD, July 2006) / The Maldives has a funding need of US$ 80 million for post-tsunami recovery needs. (Building back better: A review of the National Recovery and Reconstruction Plan, Government of Maldives, June 2006) In addition, it faced a US$ 94 million budgetary shortfall in 2005 as a result of tsunami-related expenditures. (Source: Ministry of Finance, July 2006) F r o m r e l i e f t o r e c o v e r y T h e M a l d i v e s inhabited islands and set up forward coordinating centres for a cluster of atolls. The Coast Guard, along with local fishermen and commercial vessels, used high- frequency radios to relay information back to the coordination centre in Malé from the most severely affected regions until telecommunications could be re- established. The NSS played a key role in providing early relief, while other militaries in the vicinity generously lent their support. Several foreign navies arrived in the Maldives to provide assistance, bringing with them much needed food supplies. The Pakistan Armed Forces picked up tourists from the affected resorts and transferred them to unaffected ones or to the international airport. The Bangladesh Armed Forces helped with initial clean-up efforts and with medical evacuations. The French Navy also conducted medical evacuations, and assisted with food distribution and the repair of generators. Under operation “Castor” the Indian Armed Forces used their helicopters and ships to reach islands with narrow harbours, or where harbours had completely collapsed, to help load and unload equipment. Much needed water was brought to the islands by US naval ships. Several Red Cross and Red Crescent Societies and the British Government made additional landing barges available to assist in the delivery of relief material, including 32 generators and construction materials, to isolated islands. The Government of Germany provided reverse osmosis (RO) equipment for several islands, as did the Government of Singapore. International NGOs such as Oxfam also contributed such units and other supplies; Australia sent a complete field hospital and governments of countries in the Middle East contributed doctors, field hospitals and supplies. Several other governments and organizations generously contributed to the relief effort in diverse ways. The NDMC coordinated all foreign military vessels and aircraft to ensure smooth running of the military assistance during the relief effort. The various militaries stayed for up to two months to help the Maldives get over the initial humanitarian crisis. The response of various communities and private sector companies was laudable. Many of them independently took in displaced families and distributed essential provisions. Even before any organized relief effort began, concerned citizens took the initiative to collect food, water and clothing, and used their undamaged boats and planes to distribute assistance to those in need. The local radio and TV stations made appeals for aid, and local boat and plane companies provided their services at no charge in the effort to reach the affected islands. This F r o m r e l i e f t o r e c o v e r y T h e M a l d i v e s inhabited islands and set up forward coordinating centres for a cluster of atolls. The Coast Guard, along with local fishermen and commercial vessels, used high- frequency radios to relay information back to the coordination centre in Malé from the most severely affected regions until telecommunications could be re- established. The NSS played a key role in providing early relief, while other militaries in the vicinity generously lent their support. Several foreign navies arrived in the Maldives to provide assistance, bringing with them much needed food supplies. The Pakistan Armed Forces picked up tourists from the affected resorts and transferred them to unaffected ones or to the international airport. The Bangladesh Armed Forces helped with initial clean-up efforts and with medical evacuations. The French Navy also conducted medical evacuations, and assisted with food distribution and the repair of generators. Under operation “Castor” the Indian Armed Forces used their helicopters and ships to reach islands with narrow harbours, or where harbours had completely collapsed, to help load and unload equipment. Much needed water was brought to the islands by US naval ships. Several Red Cross and Red Crescent Societies and the British Government made additional landing barges available to assist in the delivery of relief material, including 32 generators and construction materials, to isolated islands. The Government of Germany provided reverse osmosis (RO) equipment for several islands, as did the Government of Singapore. International NGOs such as Oxfam also contributed such units and other supplies; Australia sent a complete field hospital and governments of countries in the Middle East contributed doctors, field hospitals and supplies. Several other governments and organizations generously contributed to the relief effort in diverse ways. The NDMC coordinated all foreign military vessels and aircraft to ensure smooth running of the military assistance during the relief effort. The various militaries stayed for up to two months to help the Maldives get over the initial humanitarian crisis. The response of various communities and private sector companies was laudable. Many of them independently took in displaced families and distributed essential provisions. Even before any organized relief effort began, concerned citizens took the initiative to collect food, water and clothing, and used their undamaged boats and planes to distribute assistance to those in need. The local radio and TV stations made appeals for aid, and local boat and plane companies provided their services at no charge in the effort to reach the affected islands. This F r o m r e l i e f t o r e c o v e r y T h e M a l d i v e s prompt action was instrumental in ensuring that communities were able to cope even before government and international relief could reach the geographically dispersed islands. The Ministries of Health, Education, and Gender and Family together with the Red Cross and Red Crescent Movement and their partners in the UN system (UNICEF, UNFPA and WHO) approached the tsunami as an opportunity to make a sustained and meaningful investment in quality services in the key social sectors. These were identified as provision of safe drinking water and adequate food supplies, and shelter for the homeless. Health and hygiene programmes were needed to avert disease outbreaks and maintain good health in the shelters. Immediate psychosocial support was identified as an urgent need, as the affected population was severely traumatized. In the longer term, schools and health facilities, as well as communications had to be made functional. An intensive and strategically designed emergency preparedness plan and establishment of a tsunami early warning system had to be put in place. WHO Maldives made some significant contributions in handling the emergency phase. The Organization's first task was to bring in necessary supplies requested by the government: oral rehydration salts (ORS; 100 000 packs), chlorine powder (6.5 metric tons), as well as emergency medicine and surgical kits. By 10 p.m. on 30 December 2004, WHO had procured five emergency health kits (each kit being adequate for 10 000 people for over three months) and delivered them to the MoH in Malé. Other health priorities included provision of treatment for injuries, as well as preparing for longer-term needs such as control of vector-borne diseases, measles and other communicable diseases. The receding sea had left pockets of brackish water which provided breeding grounds for disease-causing vectors. In addition, as sewage plants and water treatment plants were damaged, the risk of water-borne communicable diseases was very high. Teams of health experts were deployed to the Maldives to control possible outbreaks of communicable diseases due to overcrowding and poor sanitary conditions. Partnerships Immediate emergency needs Health priorities for WHO COORDINATION Challenges to coordination TECHNICAL SUPPORT AND CAPACITY-BUILDING By the end of the first week, the Government had organized the NDMC to coordinate continuing relief efforts. The Minister of Defence was appointed Chief Coordinator of the NDMC and took control of operations. Ministers and government staff were co-opted from their posts to take on emergency roles, and from the first day oversaw the relief efforts. This enabled the Maldives to avoid many of the coordination pitfalls faced in other countries. Thanks to the excellent coordination among the Government, UN agencies, the International Federation of Red Cross and Red Crescent Societies (IFRC), international nongovernmental agencies (INGOs), other bilateral partners and national NGOs, the emergency relief phase was effectively concluded by the end of January 2005. This enabled the Government and international partners to concentrate on the important challenge of early-to-medium term recovery. The country had no Emergency Preparedness Response Plan in place, so when the tsunami struck, people did not know what to do. The population of the Maldives is widely dispersed across very small islands. The remoteness and inaccessibility of these islands made coordination of relief efforts logistically difficult. With the extensive damage to harbours and jetties, reaching these islands was a problem. Communication failure added to the difficulty. For several hours, there was no means of contact with the various islands and the extent of damage or the relief measures required could not be assessed. The high cost of delivery of relief supplies and unpredictable weather and rough seas were additional challenges. As the Maldives is highly import dependent, available stockpiles for emergency supply were inadequate. WHO rendered manpower and technical expertise to the WCO and GoM in the areas of budget/administration, water and sanitation, health-care waste management, mental health, media operations, donor relations, food safety, logistics, epidemiology and disease surveillance, and emergency preparedness and response. Maldivians are under pressure for fresh water at the best of times. Following the tsunami, wells and groundwater were contaminated and, in many places, the F r o m r e l i e f t o r e c o v e r y T h e M a l d i v e s prompt action was instrumental in ensuring that communities were able to cope even before government and international relief could reach the geographically dispersed islands. The Ministries of Health, Education, and Gender and Family together with the Red Cross and Red Crescent Movement and their partners in the UN system (UNICEF, UNFPA and WHO) approached the tsunami as an opportunity to make a sustained and meaningful investment in quality services in the key social sectors. These were identified as provision of safe drinking water and adequate food supplies, and shelter for the homeless. Health and hygiene programmes were needed to avert disease outbreaks and maintain good health in the shelters. Immediate psychosocial support was identified as an urgent need, as the affected population was severely traumatized. In the longer term, schools and health facilities, as well as communications had to be made functional. An intensive and strategically designed emergency preparedness plan and establishment of a tsunami early warning system had to be put in place. WHO Maldives made some significant contributions in handling the emergency phase. The Organization's first task was to bring in necessary supplies requested by the government: oral rehydration salts (ORS; 100 000 packs), chlorine powder (6.5 metric tons), as well as emergency medicine and surgical kits. By 10 p.m. on 30 December 2004, WHO had procured five emergency health kits (each kit being adequate for 10 000 people for over three months) and delivered them to the MoH in Malé. Other health priorities included provision of treatment for injuries, as well as preparing for longer-term needs such as control of vector-borne diseases, measles and other communicable diseases. The receding sea had left pockets of brackish water which provided breeding grounds for disease-causing vectors. In addition, as sewage plants and water treatment plants were damaged, the risk of water-borne communicable diseases was very high. Teams of health experts were deployed to the Maldives to control possible outbreaks of communicable diseases due to overcrowding and poor sanitary conditions. Partnerships Immediate emergency needs Health priorities for WHO COORDINATION Challenges to coordination TECHNICAL SUPPORT AND CAPACITY-BUILDING By the end of the first week, the Government had organized the NDMC to coordinate continuing relief efforts. The Minister of Defence was appointed Chief Coordinator of the NDMC and took control of operations. Ministers and government staff were co-opted from their posts to take on emergency roles, and from the first day oversaw the relief efforts. This enabled the Maldives to avoid many of the coordination pitfalls faced in other countries. Thanks to the excellent coordination among the Government, UN agencies, the International Federation of Red Cross and Red Crescent Societies (IFRC), international nongovernmental agencies (INGOs), other bilateral partners and national NGOs, the emergency relief phase was effectively concluded by the end of January 2005. This enabled the Government and international partners to concentrate on the important challenge of early-to-medium term recovery. The country had no Emergency Preparedness Response Plan in place, so when the tsunami struck, people did not know what to do. The population of the Maldives is widely dispersed across very small islands. The remoteness and inaccessibility of these islands made coordination of relief efforts logistically difficult. With the extensive damage to harbours and jetties, reaching these islands was a problem. Communication failure added to the difficulty. For several hours, there was no means of contact with the various islands and the extent of damage or the relief measures required could not be assessed. The high cost of delivery of relief supplies and unpredictable weather and rough seas were additional challenges. As the Maldives is highly import dependent, available stockpiles for emergency supply were inadequate. WHO rendered manpower and technical expertise to the WCO and GoM in the areas of budget/administration, water and sanitation, health-care waste management, mental health, media operations, donor relations, food safety, logistics, epidemiology and disease surveillance, and emergency preparedness and response. Maldivians are under pressure for fresh water at the best of times. Following the tsunami, wells and groundwater were contaminated and, in many places, the F r o m r e l i e f t o r e c o v e r y T h e M a l d i v e s rainwater storage system was damaged as well. So, bottled water, and desalination through reverse osmosis (RO) was the only recourse for several weeks. The Government rushed bottled water to the affected islands. Among WHO's first tasks was to dispatch a team of water and sanitation specialists to the affected islands. A quick, comprehensive assessment was made, helping WHO and the national government to get a clear picture. Three days after the tsunami, WHO moved two sanitary engineers/hydrologists to the Maldives. Long-term solutions were also formulated. Information technology also played a key role in the initial assessment of the disaster situation. Health mapping (GIS) support in the Maldives was an invaluable tool in making assessments of temporary camps, displaced persons, deaths, injuries, affected primary health care centres and hospitals. The Information and Communication Technology (ICT) team at SEARO was strengthened with additional staff, and professional communication officers were in place in the Maldives and the Regional Office for the longer term. The regional and country information teams worked in tandem with headquarters teams. The focus was on reviewing the situation and planning for the longer-term rehabilitation of the health systems. Several gaps were identified. These included a lack of clear protocols, and lack of training in reporting and documentation. The existing reporting system needed improvement and transport systems were poor. There was no maintenance schedule for sensitive electronic equipment. Most important, communication during emergencies needed improvement. Capacity building, both for institutions and human resources, was a key issue for WHO and other agencies in their collaboration with the MoH. Focus areas included reproductive health, mental health, health-care waste management, medical supply systems, laboratory services, health promotion, child growth monitoring, emergency preparedness, and communicable disease epidemiology and surveillance. Human resources were developed through national training programmes and workshops, and by sending health staff for training within South-East Asia. PHASE II: ACTIVE INTERVENTIONS ASSESSMENTS AND MONITORING CAPACITY BUILDING F r o m r e l i e f t o r e c o v e r y T h e M a l d i v e s rainwater storage system was damaged as well. So, bottled water, and desalination through reverse osmosis (RO) was the only recourse for several weeks. The Government rushed bottled water to the affected islands. Among WHO's first tasks was to dispatch a team of water and sanitation specialists to the affected islands. A quick, comprehensive assessment was made, helping WHO and the national government to get a clear picture. Three days after the tsunami, WHO moved two sanitary engineers/hydrologists to the Maldives. Long-term solutions were also formulated. Information technology also played a key role in the initial assessment of the disaster situation. Health mapping (GIS) support in the Maldives was an invaluable tool in making assessments of temporary camps, displaced persons, deaths, injuries, affected primary health care centres and hospitals. The Information and Communication Technology (ICT) team at SEARO was strengthened with additional staff, and professional communication officers were in place in the Maldives and the Regional Office for the longer term. The regional and country information teams worked in tandem with headquarters teams. The focus was on reviewing the situation and planning for the longer-term rehabilitation of the health systems. Several gaps were identified. These included a lack of clear protocols, and lack of training in reporting and documentation. The existing reporting system needed improvement and transport systems were poor. There was no maintenance schedule for sensitive electronic equipment. Most important, communication during emergencies needed improvement. Capacity building, both for institutions and human resources, was a key issue for WHO and other agencies in their collaboration with the MoH. Focus areas included reproductive health, mental health, health-care waste management, medical supply systems, laboratory services, health promotion, child growth monitoring, emergency preparedness, and communicable disease epidemiology and surveillance. Human resources were developed through national training programmes and workshops, and by sending health staff for training within South-East Asia. PHASE II: ACTIVE INTERVENTIONS ASSESSMENTS AND MONITORING CAPACITY BUILDING The Government of the Maldives also recruited a WHO consultant in mental health for three months to enhance the capacity of the primary care staff in basic mental health and psychosocial issues. SEARO assisted in procuring medical supplies and consumables for regional and atoll hospitals, as well as for health clinics and health posts. Laboratory equipment for forensic medical needs was provided to build up capacity for DNA identification in disaster situations. Laboratory equipment was also supplied to the Indira Gandhi Hospital including the capacity for polymerase chain reaction (PCR). Equipment and supplies for water quality testing were procured and a local tender floated for IT and communication equipment. By 8 January 2005, logisticians had been deployed by WHO in the Maldives. The main work of the logisticians was to set up a platform from where public health TECHNICAL SUPPORT AND GAP-FILLING Health policy, coordination, health systems F r o m r e l i e f t o r e c o v e r y T h e M a l d i v e s officials could work. In most affected areas, a drug supply chain was established for donated drugs, and it was ensured that the drugs were from WHO pre- qualified suppliers, were appropriately labelled and not past their expiry date. This was not always easy, as many foreign donations had the labels written in the language of that country, so one could not always find out the dose of the medicine, or the printed contraindications. Inventories were conducted to sort out medical supplies. The SEARO Integrated Data Analysis System (SIDAS) was implemented. A 3- member team visited SEARO on 24–25 August 2005 to learn about the data system. In September 2006, during the second phase of implementation, atoll- level and central officers were trained on the Maldives-specific customized version of SIDAS, and in all aspects of the tool, including the entry of daily surveillance data both online and offline. A new supply strategy was approved by the MoH. This was followed by a request for support to set up a supply and management (SUMA) system. A strategy paper for the Medical Supply System was completed in August 2005. A total of 7 warehouses were renovated and a computer system established. The MoH requested technical assistance from WHO for logistics management in order to train those in charge of the warehouses. WHO handed over two speed boats to the MoH on 14 September 2005. They were used to transport patients, supplies and equipment badly needed in remote islands, as well as to monitor and supervise activities. WHO experts, along with a government team, assessed the surveillance systems at health centre and regional hospital levels. A WHO epidemiologist and data manager visited Meemu Atoll with a team from the Maldivian government. They investigated some mumps cases that had been notified, as well as assessed the existing data system, the capacity available at the different health facility levels and the surveillance systems in operation at health centre and regional hospital levels. Rapid replacement of lost equipment and supplies, supported by UNICEF, and immediate resumption of vaccination rounds kept immunization coverage rates high. The Maldives was spared any major disease outbreak following the tsunami. German Red Cross is supporting the Government in repairing health facilities and providing medical equipment and supplies at the cost of US$ 7.5 million. Surveillance systems The Government of the Maldives also recruited a WHO consultant in mental health for three months to enhance the capacity of the primary care staff in basic mental health and psychosocial issues. SEARO assisted in procuring medical supplies and consumables for regional and atoll hospitals, as well as for health clinics and health posts. Laboratory equipment for forensic medical needs was provided to build up capacity for DNA identification in disaster situations. Laboratory equipment was also supplied to the Indira Gandhi Hospital including the capacity for polymerase chain reaction (PCR). Equipment and supplies for water quality testing were procured and a local tender floated for IT and communication equipment. By 8 January 2005, logisticians had been deployed by WHO in the Maldives. The main work of the logisticians was to set up a platform from where public health TECHNICAL SUPPORT AND GAP-FILLING Health policy, coordination, health systems F r o m r e l i e f t o r e c o v e r y T h e M a l d i v e s officials could work. In most affected areas, a drug supply chain was established for donated drugs, and it was ensured that the drugs were from WHO pre- qualified suppliers, were appropriately labelled and not past their expiry date. This was not always easy, as many foreign donations had the labels written in the language of that country, so one could not always find out the dose of the medicine, or the printed contraindications. Inventories were conducted to sort out medical supplies. The SEARO Integrated Data Analysis System (SIDAS) was implemented. A 3- member team visited SEARO on 24–25 August 2005 to learn about the data system. In September 2006, during the second phase of implementation, atoll- level and central officers were trained on the Maldives-specific customized version of SIDAS, and in all aspects of the tool, including the entry of daily surveillance data both online and offline. A new supply strategy was approved by the MoH. This was followed by a request for support to set up a supply and management (SUMA) system. A strategy paper for the Medical Supply System was completed in August 2005. A total of 7 warehouses were renovated and a computer system established. The MoH requested technical assistance from WHO for logistics management in order to train those in charge of the warehouses. WHO handed over two speed boats to the MoH on 14 September 2005. They were used to transport patients, supplies and equipment badly needed in remote islands, as well as to monitor and supervise activities. WHO experts, along with a government team, assessed the surveillance systems at health centre and regional hospital levels. A WHO epidemiologist and data manager visited Meemu Atoll with a team from the Maldivian government. They investigated some mumps cases that had been notified, as well as assessed the existing data system, the capacity available at the different health facility levels and the surveillance systems in operation at health centre and regional hospital levels. Rapid replacement of lost equipment and supplies, supported by UNICEF, and immediate resumption of vaccination rounds kept immunization coverage rates high. The Maldives was spared any major disease outbreak following the tsunami. German Red Cross is supporting the Government in repairing health facilities and providing medical equipment and supplies at the cost of US$ 7.5 million. Surveillance systems In conjunction with NICD New Delhi, the DPH and WHO organized a Maldives-based field epidemiology training programme (FETP) course. The first of three training workshops took place in November last year, with the second batch trained in February 2006 and the third batch in April–May. A total of around 60 health officials (most of them community health workers) were trained. The EPR programme concentrated on field visits to tsunami-affected atolls. These visits aimed to assess the current situation and select a pilot region for implementing a draft EPR plan. Emergency preparedness and response (EPR) F r o m r e l i e f t o r e c o v e r y T h e M a l d i v e s In July 2005, UNDP Maldives held a five-day training workshop in Malé on Disaster Risk Management. Two officials from the MoH participated. The MoH requested training for 27 staff members in 4 different areas: 9 participants for Pre-hospital Care at Christian Medical College (CMC), Vellore, India; 7 participants for Trauma Care at CMC, Vellore; 8 participants for Accidents and Emergency Care at CMC, Vellore; 3 participants for Basic and Advanced Life Support Instructor Activities at Sri Ramachandra Medical College, Chennai. UNDP and NDMC completed an Early Warning System study, and a basic Early Warning System was set up by March 2006. All atoll offices are equipped with satellite phones, and five Emergency Crisis Centres with state-of-the-art communications systems have been established. Training programmes in disaster response and first aid have been held for NDMC staff and volunteer community groups, and a Tourism Sector Disaster Management Plan has been developed. In addition, construction of safe shelters on islands identified as most at risk was undertaken by the Japan International Cooperation System (JICS), UNDP, IFRC, CRC and British Red Cross. 3 The tsunami created approximately 290 000 m of debris and waste in the Maldives, much of which accumulated on the beaches and posed a serious threat to public health, groundwater, soils and coral reefs. This situation, coupled with the country's pre-existing waste management problems, emphasized the desperate need for an effective clean-up and waste-management programme. In response, partners in the environmental sector—the UN, the Australian and Canadian Red Cross (ARC/CRC), AusAid, and the ADB—working in consultation with all the stakeholders, implemented a variety of new and more sustainable programmes. During one such programme implemented by UNEP, hazardous waste from a total of 89 islands was collected and stored, and more than 40 local men and women were trained in hazardous waste clean-up and mobilized in the field. WHO contributed to this effort by procuring waste bins worth US$ 100 000 for the collection of “toxic” waste. An interagency working group consisting of representatives from UNDP, UNEP, UNICEF, IFRC, Maldives Water and Sanitation Authority (MWSA) and WHO prepared a position paper entitled “Interagency Working Group Position Environmental health In conjunction with NICD New Delhi, the DPH and WHO organized a Maldives-based field epidemiology training programme (FETP) course. The first of three training workshops took place in November last year, with the second batch trained in February 2006 and the third batch in April–May. A total of around 60 health officials (most of them community health workers) were trained. The EPR programme concentrated on field visits to tsunami-affected atolls. These visits aimed to assess the current situation and select a pilot region for implementing a draft EPR plan. Emergency preparedness and response (EPR) F r o m r e l i e f t o r e c o v e r y T h e M a l d i v e s In July 2005, UNDP Maldives held a five-day training workshop in Malé on Disaster Risk Management. Two officials from the MoH participated. The MoH requested training for 27 staff members in 4 different areas: 9 participants for Pre-hospital Care at Christian Medical College (CMC), Vellore, India; 7 participants for Trauma Care at CMC, Vellore; 8 participants for Accidents and Emergency Care at CMC, Vellore; 3 participants for Basic and Advanced Life Support Instructor Activities at Sri Ramachandra Medical College, Chennai. UNDP and NDMC completed an Early Warning System study, and a basic Early Warning System was set up by March 2006. All atoll offices are equipped with satellite phones, and five Emergency Crisis Centres with state-of-the-art communications systems have been established. Training programmes in disaster response and first aid have been held for NDMC staff and volunteer community groups, and a Tourism Sector Disaster Management Plan has been developed. In addition, construction of safe shelters on islands identified as most at risk was undertaken by the Japan International Cooperation System (JICS), UNDP, IFRC, CRC and British Red Cross. 3 The tsunami created approximately 290 000 m of debris and waste in the Maldives, much of which accumulated on the beaches and posed a serious threat to public health, groundwater, soils and coral reefs. This situation, coupled with the country's pre-existing waste management problems, emphasized the desperate need for an effective clean-up and waste-management programme. In response, partners in the environmental sector—the UN, the Australian and Canadian Red Cross (ARC/CRC), AusAid, and the ADB—working in consultation with all the stakeholders, implemented a variety of new and more sustainable programmes. During one such programme implemented by UNEP, hazardous waste from a total of 89 islands was collected and stored, and more than 40 local men and women were trained in hazardous waste clean-up and mobilized in the field. WHO contributed to this effort by procuring waste bins worth US$ 100 000 for the collection of “toxic” waste. An interagency working group consisting of representatives from UNDP, UNEP, UNICEF, IFRC, Maldives Water and Sanitation Authority (MWSA) and WHO prepared a position paper entitled “Interagency Working Group Position Environmental health Paper on Water and Sanitation” on sludge management, sea outfalls, septic tanks, ground water quality and biomedical waste. The aim was to ensure long-term sustainable development of resources. To address long-term sustainability of potable water supplies, WHO contracted a geohydrologist to carry out detailed assessments of groundwater resources and existing water supply. MWSA staff was trained in geophysical surveying for ecologically sound management of water resources. The MoH and MWSA also drafted standards for waste water reuse in agriculture. Progress was made on water safety plans (WSPs). In collaboration with the Public Health Laboratory (PHL) and the MoH, MWSA organized training sessions on water quality surveillance and testing for staff based in three atolls in September 2005. The training covered risk management, including the design and implementation of WSPs. Participants included community health workers and family health workers from each hospital, health centre and health post. The objective was to train at least one health worker from each island in water quality testing, monitoring and reporting, and in the design and implementation of WSPs. Other objectives were to set up a water quality surveillance programme for the islands, with a view to long-term, sustainable use of water resources, and to assist island communities in carrying out a survey of rain water harvesting. A survey of water from harvested rain water was also carried out. The findings of this survey were presented at a WHO-sponsored rain water harvesting conference in New Delhi in November 2005. Participants from regional and atoll hospitals attended a 10-day training course on health-care waste management in September 2005, organized by the Department of Community Medicine, MS Ramaiah Medical College, Bangalore, India. Three batches from the Maldives attended this course. Draft guidelines were developed with Hithadhoo Regional Hospital for waste minimization, segregation and placement into containers, storage, transport, treatment and final disposal. The guidelines also covered autoclaving, chemical disinfection, encapsulation and incineration. Guidelines were also drafted on the collection and disposal of health-care liquid wastes from health-care establishments. These guidelines covered the Water and sanitation Health-care waste management F r o m r e l i e f t o r e c o v e r y T h e M a l d i v e s hazards associated with liquid wastes, disposal of organic and inorganic chemicals, as well as waste containing infectious microorganisms. The MoH decided to instal two incinerators and sixteen autoclaves with shredders to improve the safety and handling of health-care waste. This was part of a solid waste plan developed with the Ministry of Environment, Energy and Water. Three thousand drums were procured for collecting hazardous waste from tsunami-affected islands, and 13 health professionals underwent training to develop and implement a national strategy for management of health-care waste. The National Guidelines and Minimum Medical Standards for Family Planning Services developed in 1997 were updated with the technical and financial assistance of WHO and UNFPA in 2005. A chapter on emergency contraception was included, in keeping with the Reproductive Health Strategy 2005–2007. Four Regional Meetings were scheduled from 22 September 2005 to disseminate the guidelines among health workers. Orientation workshops were held in five regional centres to train health workers in the use of these guidelines. WHO and UNFPA supported the Ministry of Gender and Family in the training of enumerators participating in the first ever national survey to assess the problem of domestic violence. In the area of newborn health, one paediatrician and three nurses completed a 3-month training course in intensive neonatal care at AIIMS, New Delhi, India. The Essential Newborn Care training package was introduced in the Maldives in November 2006. One paediatrician and one nurse attended the ToT in Yangon, Myanmar in June 2006. Delivery of food to the affected islands was one of the most pressing concerns in the first days following the tsunami. The most immediate response to the need came from the people themselves, with residents of Malé and other less affected islands buying food and sending it to other islands at their own initiative. This action was mirrored on a national scale by the Government, which sent rice, sugar and flour to the affected islands. Over the next days and weeks, emergency food relief arrived from numerous sources and was distributed either at the expense of the donors or through the Government transportation system. Maternal and child health Nutrition Paper on Water and Sanitation” on sludge management, sea outfalls, septic tanks, ground water quality and biomedical waste. The aim was to ensure long-term sustainable development of resources. To address long-term sustainability of potable water supplies, WHO contracted a geohydrologist to carry out detailed assessments of groundwater resources and existing water supply. MWSA staff was trained in geophysical surveying for ecologically sound management of water resources. The MoH and MWSA also drafted standards for waste water reuse in agriculture. Progress was made on water safety plans (WSPs). In collaboration with the Public Health Laboratory (PHL) and the MoH, MWSA organized training sessions on water quality surveillance and testing for staff based in three atolls in September 2005. The training covered risk management, including the design and implementation of WSPs. Participants included community health workers and family health workers from each hospital, health centre and health post. The objective was to train at least one health worker from each island in water quality testing, monitoring and reporting, and in the design and implementation of WSPs. Other objectives were to set up a water quality surveillance programme for the islands, with a view to long-term, sustainable use of water resources, and to assist island communities in carrying out a survey of rain water harvesting. A survey of water from harvested rain water was also carried out. The findings of this survey were presented at a WHO-sponsored rain water harvesting conference in New Delhi in November 2005. Participants from regional and atoll hospitals attended a 10-day training course on health-care waste management in September 2005, organized by the Department of Community Medicine, MS Ramaiah Medical College, Bangalore, India. Three batches from the Maldives attended this course. Draft guidelines were developed with Hithadhoo Regional Hospital for waste minimization, segregation and placement into containers, storage, transport, treatment and final disposal. The guidelines also covered autoclaving, chemical disinfection, encapsulation and incineration. Guidelines were also drafted on the collection and disposal of health-care liquid wastes from health-care establishments. These guidelines covered the Water and sanitation Health-care waste management F r o m r e l i e f t o r e c o v e r y T h e M a l d i v e s hazards associated with liquid wastes, disposal of organic and inorganic chemicals, as well as waste containing infectious microorganisms. The MoH decided to instal two incinerators and sixteen autoclaves with shredders to improve the safety and handling of health-care waste. This was part of a solid waste plan developed with the Ministry of Environment, Energy and Water. Three thousand drums were procured for collecting hazardous waste from tsunami-affected islands, and 13 health professionals underwent training to develop and implement a national strategy for management of health-care waste. The National Guidelines and Minimum Medical Standards for Family Planning Services developed in 1997 were updated with the technical and financial assistance of WHO and UNFPA in 2005. A chapter on emergency contraception was included, in keeping with the Reproductive Health Strategy 2005–2007. Four Regional Meetings were scheduled from 22 September 2005 to disseminate the guidelines among health workers. Orientation workshops were held in five regional centres to train health workers in the use of these guidelines. WHO and UNFPA supported the Ministry of Gender and Family in the training of enumerators participating in the first ever national survey to assess the problem of domestic violence. In the area of newborn health, one paediatrician and three nurses completed a 3-month training course in intensive neonatal care at AIIMS, New Delhi, India. The Essential Newborn Care training package was introduced in the Maldives in November 2006. One paediatrician and one nurse attended the ToT in Yangon, Myanmar in June 2006. Delivery of food to the affected islands was one of the most pressing concerns in the first days following the tsunami. The most immediate response to the need came from the people themselves, with residents of Malé and other less affected islands buying food and sending it to other islands at their own initiative. This action was mirrored on a national scale by the Government, which sent rice, sugar and flour to the affected islands. Over the next days and weeks, emergency food relief arrived from numerous sources and was distributed either at the expense of the donors or through the Government transportation system. Maternal and child health Nutrition F r o m r e l i e f t o r e c o v e r y A large part of the food requirements was later covered by the UN, specifically UNICEF and the World Food Programme (WFP). The joint WFP–Government programme continued throughout 2005, with the number of targeted people dropping to some 13 000 including IDPs and their host families. This number will reduce further as more IDPs move back into their homes. A national food safety strategy was prepared. It was based on a risk analysis approach in combination with self-regulation by industry, consumer participation and selective enforcement. Twenty-five food inspectors were trained in the strategy. WHO assisted the DPH to identify food safety monitoring tools and facilitate procurement. Training needs were identified and existing guidelines reviewed. Efforts were also made to promote food safety in schools as one more component of the “Healthy school initiatives” launched by the Government, with support from WHO and UNICEF. The government launched a well-organized, community-based programme to provide psychosocial support to disaster-affected persons. A Psychological Unit was formed in the NDMC. This unit mobilized groups of volunteers—all local Maldivians who knew the language and culture, and also had some previous training as counsellors—to reach out to the community. In the immediate aftermath of the tsunami a unit called the “Social Support and Counselling Services” was created within the NDMC with counsellors and volunteers who coordinated psychosocial support activities in the affected islands. Work focused on two major areas. First, counsellors were sent to the worst-affected islands to provide direct psychosocial intervention, and carry out workshops to generate local community volunteers for continuation of psychosocial support activities (known as “emotional support brigades”). The second arm trained teachers in schools all over the country to provide psychosocial support to pupils. The American Red Cross (AmRC) provided psychological first aid training and materials to 70 counsellors involved in psychosocial intervention work. Through this programme, 22 500 people were provided with social support and counselling services. Training was also provided to 321 teachers in 20 atolls covering 226 schools, and to 6 master trainers in Malé. UNFPA and UNICEF provided logistical support to these projects. Training manuals developed earlier in English were translated into the local Dhivehi language. Mental health T h e M a l d i v e s F r o m r e l i e f t o r e c o v e r y A large part of the food requirements was later covered by the UN, specifically UNICEF and the World Food Programme (WFP). The joint WFP–Government programme continued throughout 2005, with the number of targeted people dropping to some 13 000 including IDPs and their host families. This number will reduce further as more IDPs move back into their homes. A national food safety strategy was prepared. It was based on a risk analysis approach in combination with self-regulation by industry, consumer participation and selective enforcement. Twenty-five food inspectors were trained in the strategy. WHO assisted the DPH to identify food safety monitoring tools and facilitate procurement. Training needs were identified and existing guidelines reviewed. Efforts were also made to promote food safety in schools as one more component of the “Healthy school initiatives” launched by the Government, with support from WHO and UNICEF. The government launched a well-organized, community-based programme to provide psychosocial support to disaster-affected persons. A Psychological Unit was formed in the NDMC. This unit mobilized groups of volunteers—all local Maldivians who knew the language and culture, and also had some previous training as counsellors—to reach out to the community. In the immediate aftermath of the tsunami a unit called the “Social Support and Counselling Services” was created within the NDMC with counsellors and volunteers who coordinated psychosocial support activities in the affected islands. Work focused on two major areas. First, counsellors were sent to the worst-affected islands to provide direct psychosocial intervention, and carry out workshops to generate local community volunteers for continuation of psychosocial support activities (known as “emotional support brigades”). The second arm trained teachers in schools all over the country to provide psychosocial support to pupils. The American Red Cross (AmRC) provided psychological first aid training and materials to 70 counsellors involved in psychosocial intervention work. Through this programme, 22 500 people were provided with social support and counselling services. Training was also provided to 321 teachers in 20 atolls covering 226 schools, and to 6 master trainers in Malé. UNFPA and UNICEF provided logistical support to these projects. Training manuals developed earlier in English were translated into the local Dhivehi language. Mental health T h e M a l d i v e s WHO organized a review and evaluation mission to the Maldives and sent a three-member team. The evaluation was based on a structured questionnaire prepared in advance by the SEARO Mental Health Unit. An instrument for assessing the needs of people with psychosocial distress in the tsunami-affected community was field-tested by WHO on Kaafu Guraidhoo island. Cut-off scores were established in order to identify persons needing additional psychosocial support and the instrument was used by the Psychosocial Support Unit of the NDMC. The MoH worked closely with WHO and UNFPA to increase the capacity of island health workers and communities to deal with psychosocial stress. On five atolls, health-care providers were trained in psychosocial and mental health issues; and local “community educators” were given the skills to provide support to these communities as well. A programme by Care Society—one of the largest national NGOs—will be run with the involvement of members of tsunami- affected households in four atolls. The AmRC will be implementing a three-year psychosocial support programme in six atolls, and capacity building at the national level. Training workshops on mental health in the tsunami-affected population were conducted in Naifaru atoll in 2005 for health providers (nurses, community health and family health workers). In addition, selected physicians based in the host island were also given orientation on psychosocial and mental health care. Five training sessions were held on Mental Health, covering all atolls. With facilitation from SEARO, a two-day national workshop on the current status and future preparedness in the psychosocial and mental health aspects of disasters was conducted in September 2005. Senior government staff, the media, NGOs and donor agencies were provided with training on IDP issues. UNFPA was instrumental in ensuring that a module on reproductive health and psychosocial issues is included in the Tsunami Impact Assessment Survey conducted by the Government. WHO and the MoH released a report on the assessment of the mental health system in Maldives using the World Health Organization Assessment Instrument for Mental Health Systems (WHOAIMS). Maldives became the first country in the SEA Region to have completed and approved the WHOAIMS. WHO staff were deployed in the Maldives to assist the MoH with the Communicable diseases F r o m r e l i e f t o r e c o v e r y T h e M a l d i v e s establishment of supplemental surveillance, and early warning alert and response systems (EWARN). The objective was to detect epidemic-prone diseases based on symptomatic diagnosis followed by laboratory confirmation, and to institute necessary interventions to contain further spread of disease. No communicable disease outbreaks were reported. Activities in this area focused on capacity-building. = Extensive training was carried out in the area of field epidemiology for national-level epidemiology staff and community health workers. = Community health workers and vector-borne disease control staff were trained in vector larval surveillance and scrub typhus entomology. = Active surveillance for acute flaccid paralysis was re-established in two major hospitals. = Clinicians were trained in the management of dengue fever and dengue haemorrhagic fever. = A web-based data management system for communicable diseases was introduced to facilitate data collection and analysis throughout the country. = Laboratory equipment was procured for the main national hospital and public health laboratory. = Equipment was procured for public health units in atoll and regional hospitals, health centres and health posts, the port health unit and the vector-borne disease control unit. A total of 2389 cases and 9 deaths were reported from 1 January 2006 to 7 November 2006 (compared with 615 cases reported for the same period in 2005). More than 50% of the cases were in those above 15 years of age; 18% in those between 5 and 9 years and the remaining in those less than 5 years of age. In March 2006, a consultant with the WHO Mediterranean Centre for Vulnerability Reduction (WMC) worked with the DPH to develop a Communication for Behavioural Impact (COMBI) plan to address the dengue fever outbreak and to strengthen the effectiveness of field officers during routine mosquito control activities. DPH/MoH with the support of WHO, UNICEF and UNDP, in coordination with Malé Municipality and other stakeholders supported the costs for an intensive two-day COMBI workshop at which there were 21 participants from partner ministries and UN organizations. With support from WHO, two experts from the WHO Collaborating Centre Dengue WHO organized a review and evaluation mission to the Maldives and sent a three-member team. The evaluation was based on a structured questionnaire prepared in advance by the SEARO Mental Health Unit. An instrument for assessing the needs of people with psychosocial distress in the tsunami-affected community was field-tested by WHO on Kaafu Guraidhoo island. Cut-off scores were established in order to identify persons needing additional psychosocial support and the instrument was used by the Psychosocial Support Unit of the NDMC. The MoH worked closely with WHO and UNFPA to increase the capacity of island health workers and communities to deal with psychosocial stress. On five atolls, health-care providers were trained in psychosocial and mental health issues; and local “community educators” were given the skills to provide support to these communities as well. A programme by Care Society—one of the largest national NGOs—will be run with the involvement of members of tsunami- affected households in four atolls. The AmRC will be implementing a three-year psychosocial support programme in six atolls, and capacity building at the national level. Training workshops on mental health in the tsunami-affected population were conducted in Naifaru atoll in 2005 for health providers (nurses, community health and family health workers). In addition, selected physicians based in the host island were also given orientation on psychosocial and mental health care. Five training sessions were held on Mental Health, covering all atolls. With facilitation from SEARO, a two-day national workshop on the current status and future preparedness in the psychosocial and mental health aspects of disasters was conducted in September 2005. Senior government staff, the media, NGOs and donor agencies were provided with training on IDP issues. UNFPA was instrumental in ensuring that a module on reproductive health and psychosocial issues is included in the Tsunami Impact Assessment Survey conducted by the Government. WHO and the MoH released a report on the assessment of the mental health system in Maldives using the World Health Organization Assessment Instrument for Mental Health Systems (WHOAIMS). Maldives became the first country in the SEA Region to have completed and approved the WHOAIMS. WHO staff were deployed in the Maldives to assist the MoH with the Communicable diseases F r o m r e l i e f t o r e c o v e r y T h e M a l d i v e s establishment of supplemental surveillance, and early warning alert and response systems (EWARN). The objective was to detect epidemic-prone diseases based on symptomatic diagnosis followed by laboratory confirmation, and to institute necessary interventions to contain further spread of disease. No communicable disease outbreaks were reported. Activities in this area focused on capacity-building. = Extensive training was carried out in the area of field epidemiology for national-level epidemiology staff and community health workers. = Community health workers and vector-borne disease control staff were trained in vector larval surveillance and scrub typhus entomology. = Active surveillance for acute flaccid paralysis was re-established in two major hospitals. = Clinicians were trained in the management of dengue fever and dengue haemorrhagic fever. = A web-based data management system for communicable diseases was introduced to facilitate data collection and analysis throughout the country. = Laboratory equipment was procured for the main national hospital and public health laboratory. = Equipment was procured for public health units in atoll and regional hospitals, health centres and health posts, the port health unit and the vector-borne disease control unit. A total of 2389 cases and 9 deaths were reported from 1 January 2006 to 7 November 2006 (compared with 615 cases reported for the same period in 2005). More than 50% of the cases were in those above 15 years of age; 18% in those between 5 and 9 years and the remaining in those less than 5 years of age. In March 2006, a consultant with the WHO Mediterranean Centre for Vulnerability Reduction (WMC) worked with the DPH to develop a Communication for Behavioural Impact (COMBI) plan to address the dengue fever outbreak and to strengthen the effectiveness of field officers during routine mosquito control activities. DPH/MoH with the support of WHO, UNICEF and UNDP, in coordination with Malé Municipality and other stakeholders supported the costs for an intensive two-day COMBI workshop at which there were 21 participants from partner ministries and UN organizations. With support from WHO, two experts from the WHO Collaborating Centre Dengue for Case Management of Dengue/DHF/DSS at Queen Sirikit National Institute of Child Health (Children's Hospital) visited the Maldives in May 2006 to revise protocols and train doctors and nurses on the management of DHF/DSS at Indira Gandhi Memorial Hospital (IGMH) in Malé. They also conducted field visits to Faafu Atoll Health Centre, Dhaal Atoll Hospital and Mulee Regional Hospital. In June 2006, a Dengue week and Malé Clean-up Campaign was organized by the Department of Health, MoH and the Malé Municipality utilizing the COMBI approach (Malé accounted for 75% of the total cases of dengue). This campaign helped to decrease the incidence. The National Preparedness Plan for human pandemic influenza and avian influenza was finalized and uploaded on the website of the MoH and WCO. The main constraint at the moment for the implementation of the National Preparedness Plan is the lack of funds. A UN plan was also drafted and approved by the UNCT and forwarded to the UN HQ in New York. Emergency supplies of antivirals and personal protective equipment (PPE) were procured through WHO and FAO and nationals from the Ministries have been attending meetings and workshops on the topic. One laboratory technologist from IGMH was trained in the laboratory diagnosis of avian influenza at the WHO referral laboratory in Hong Kong in February 2006. Several measles cases were reported. Those in the age group of 10–24 years were the most affected. A measles–rubella (MR) campaign was conducted with 85% coverage of all children between 5 and 15 years of age, and women of childbearing age. Control measures included supplementary immunization activities in areas with localized outbreaks, vitamin A administration, measles vaccination for 6- month-olds (instead of 9-month-olds), WHO provision of laboratory testing kits for confirmation of outbreaks, and raising awareness among health-care professionals. An EPI consultant from SEARO trained 20 health-care workers from 20 atolls at a comprehensive workshop held on 14–16 August 2005 for the MR campaign. Sessions included one on the microplanning process. A national plan was developed in this area. Avian flu and pandemic human influenza Measles F r o m r e l i e f t o r e c o v e r y T h e M a l d i v e s for Case Management of Dengue/DHF/DSS at Queen Sirikit National Institute of Child Health (Children's Hospital) visited the Maldives in May 2006 to revise protocols and train doctors and nurses on the management of DHF/DSS at Indira Gandhi Memorial Hospital (IGMH) in Malé. They also conducted field visits to Faafu Atoll Health Centre, Dhaal Atoll Hospital and Mulee Regional Hospital. In June 2006, a Dengue week and Malé Clean-up Campaign was organized by the Department of Health, MoH and the Malé Municipality utilizing the COMBI approach (Malé accounted for 75% of the total cases of dengue). This campaign helped to decrease the incidence. The National Preparedness Plan for human pandemic influenza and avian influenza was finalized and uploaded on the website of the MoH and WCO. The main constraint at the moment for the implementation of the National Preparedness Plan is the lack of funds. A UN plan was also drafted and approved by the UNCT and forwarded to the UN HQ in New York. Emergency supplies of antivirals and personal protective equipment (PPE) were procured through WHO and FAO and nationals from the Ministries have been attending meetings and workshops on the topic. One laboratory technologist from IGMH was trained in the laboratory diagnosis of avian influenza at the WHO referral laboratory in Hong Kong in February 2006. Several measles cases were reported. Those in the age group of 10–24 years were the most affected. A measles–rubella (MR) campaign was conducted with 85% coverage of all children between 5 and 15 years of age, and women of childbearing age. Control measures included supplementary immunization activities in areas with localized outbreaks, vitamin A administration, measles vaccination for 6- month-olds (instead of 9-month-olds), WHO provision of laboratory testing kits for confirmation of outbreaks, and raising awareness among health-care professionals. An EPI consultant from SEARO trained 20 health-care workers from 20 atolls at a comprehensive workshop held on 14–16 August 2005 for the MR campaign. Sessions included one on the microplanning process. A national plan was developed in this area. Avian flu and pandemic human influenza Measles F r o m r e l i e f t o r e c o v e r y T h e M a l d i v e s F r o m r e l i e f t o r e c o v e r y PHASE III: REVIEW AND CONSOLIDATION ASSESSMENT Health systems For a country with no previous experience of dealing with IDPs, the Maldives responded extremely quickly to ensure that all displaced communities were provided with safe shelter and that problems with overcrowding in host families were addressed. With funding from the IFRC and advice from the Internal Displacement Division of OCHA, the Government rapidly set up temporary housing that met Sphere standards—a set of internationally recognized standards for emergency settlements. At one year, approximately 50% of IDPs were living in temporary family units (for up to 11 people) made of plywood and zinc roofing. Each unit has electricity and consists of two bedrooms, and a bathroom with a flush toilet. The Government has estimated that the cost of infrastructure reconstruction alone over the next three years will be around US$ 390 million. Today, the country faces three major disaster risks: climate change, resulting in rising sea levels; storm surge; and tsunami. It is also exposed to droughts, heavy rains and high waves caused by cyclones in the southern Indian Ocean. The major task ahead for the MoH is the provision of services on an equitable basis to populations that are scattered over many islands. The reorganization of the health system into a five-tier referral system, with the introduction of atoll hospitals and placement of doctors at health centres has enabled increased access to curative services for the island communities. With this reorganization, all curative facilities have been brought under the newly created Department of Medical Services (IGMH being the exception). At present, the DPH is administratively responsible only for the health posts/family health sections in the islands. Curative services earlier provided by the clinics under the DPH, which managed tuberculosis, malaria, filaria and leprosy cases, have been discontinued and these services are now provided by IGMH. This has led to a shift in health services from preventive and public health services to curative services. The logistical problems associated with this provision of services include infrequent transport links and high operational costs. The provision of curative services at island levels has almost doubled the cost of health service delivery. To ensure adequate and appropriate human resources for health, the Health T h e M a l d i v e s F r o m r e l i e f t o r e c o v e r y PHASE III: REVIEW AND CONSOLIDATION ASSESSMENT Health systems For a country with no previous experience of dealing with IDPs, the Maldives responded extremely quickly to ensure that all displaced communities were provided with safe shelter and that problems with overcrowding in host families were addressed. With funding from the IFRC and advice from the Internal Displacement Division of OCHA, the Government rapidly set up temporary housing that met Sphere standards—a set of internationally recognized standards for emergency settlements. At one year, approximately 50% of IDPs were living in temporary family units (for up to 11 people) made of plywood and zinc roofing. Each unit has electricity and consists of two bedrooms, and a bathroom with a flush toilet. The Government has estimated that the cost of infrastructure reconstruction alone over the next three years will be around US$ 390 million. Today, the country faces three major disaster risks: climate change, resulting in rising sea levels; storm surge; and tsunami. It is also exposed to droughts, heavy rains and high waves caused by cyclones in the southern Indian Ocean. The major task ahead for the MoH is the provision of services on an equitable basis to populations that are scattered over many islands. The reorganization of the health system into a five-tier referral system, with the introduction of atoll hospitals and placement of doctors at health centres has enabled increased access to curative services for the island communities. With this reorganization, all curative facilities have been brought under the newly created Department of Medical Services (IGMH being the exception). At present, the DPH is administratively responsible only for the health posts/family health sections in the islands. Curative services earlier provided by the clinics under the DPH, which managed tuberculosis, malaria, filaria and leprosy cases, have been discontinued and these services are now provided by IGMH. This has led to a shift in health services from preventive and public health services to curative services. The logistical problems associated with this provision of services include infrequent transport links and high operational costs. The provision of curative services at island levels has almost doubled the cost of health service delivery. To ensure adequate and appropriate human resources for health, the Health T h e M a l d i v e s F r o m r e l i e f t o r e c o v e r y Master Plan (HMP) 2006–2015 identified targets and strategic actions to achieve this. WHO support has been requested to strengthen training capacity of the Faculty of Health Sciences, improve administration of health facilities by training managers and ensure proper functioning of the Medical Council, Nursing Council and Health Science Board. Decentralization remains a major issue. Policies and regulatory mechanisms need to be developed to promote partnerships with NGOs and international institutions working in the country to ensure that the public and private sectors provide services that complement each other and that these are of good quality. Access to medicines remains a concern as pharmaceutical services in the country are operated on a fully corporate basis by the private sector. Due to the small size and remoteness of the islands, the operation of a pharmacy at island level on a corporate basis is not viable. These constraints have led to a decline in satisfaction of the community with the health services. WHO support to tsunami “recovery plus” in the Maldives led to an assessment of the MoH supply system and the development of a revised structure. The health- care system has now decided to implement a centralized method to replace the previous supply system of departmental procurement. Although the tsunami created a number of specific environmental problems, uncontrolled reconstruction activities will further exacerbate the chronic environmental problems that predate the tsunami including poor waste management and sanitation systems. The rapid environmental assessment that was completed highlighted many unsustainable practices. By building back better and building back greener, the Maldivian Government and its partners have had an opportunity to promote more sustainable practices and strengthen environmental institutions throughout the country. Improved rainwater harvesting and waste management, investment in sustainable sanitation solutions, and exploration of the potential for renewable energies are being undertaken as part of the recovery and development programme. The Government and its partners are also creating the capacity within the Ministry of Environment, Energy and Water to apply environmental impact assessments to future development programmes and to promote sustainable waste management policies and practices. Environmental health and waste management T h e M a l d i v e s Disaster management CHALLENGES The Government's long-term disaster mitigation programme, The Safe Islands programme, builds on its pre-tsunami goal of increased population consolidation. The existing programme has been adapted to accommodate the need for disaster risk management so that “safe” islands will receive greater investment in sea walls, more solidly constructed buildings, buffer zones and drainage systems. Improved standards of housing and infrastructure are also part of the overall plan. The Maldives is unique amongst tsunami-affected countries in terms of the disaster's nationwide economic and social impact. For this reason, the principle of “building back better”, with its focus on quality of outcome, takes on a far greater significance and has wider implications than may be the case in other recovering nations. To ensure a healthier and more prosperous country than existed prior to 26 December 2004 will require more than the rebuilding of houses and infrastructure. Numerous hurdles have yet to be overcome and all partners in the recovery and reconstruction effort must unite to do this. = The biggest challenge for 2006 was attracting donor resources to fill the funding gap of US$ 145 million. = Human capacity constraints in the public health fields is a key challenge, and building capacity at both the central and peripheral levels will require vigorous efforts. = Provision of safe, durable housing, with access to safe water and sanitation for all families continues to be an issue. = The present level of interest and motivation to address disaster management and to have all ministries and departments integrate disaster management into their normal development programme must be sustained. = Each person and family must know and practise personal safety management to increase the confidence and resources of communities to better manage disasters. = Expansion of viable, diversified economic activity with an emphasis on job creation for young people is essential but may prove difficult. = Shifting the focus is required, from simply replacing lost assets to programmes that help all contributors to the economy, including women and vulnerable F r o m r e l i e f t o r e c o v e r y Master Plan (HMP) 2006–2015 identified targets and strategic actions to achieve this. WHO support has been requested to strengthen training capacity of the Faculty of Health Sciences, improve administration of health facilities by training managers and ensure proper functioning of the Medical Council, Nursing Council and Health Science Board. Decentralization remains a major issue. Policies and regulatory mechanisms need to be developed to promote partnerships with NGOs and international institutions working in the country to ensure that the public and private sectors provide services that complement each other and that these are of good quality. Access to medicines remains a concern as pharmaceutical services in the country are operated on a fully corporate basis by the private sector. Due to the small size and remoteness of the islands, the operation of a pharmacy at island level on a corporate basis is not viable. These constraints have led to a decline in satisfaction of the community with the health services. WHO support to tsunami “recovery plus” in the Maldives led to an assessment of the MoH supply system and the development of a revised structure. The health- care system has now decided to implement a centralized method to replace the previous supply system of departmental procurement. Although the tsunami created a number of specific environmental problems, uncontrolled reconstruction activities will further exacerbate the chronic environmental problems that predate the tsunami including poor waste management and sanitation systems. The rapid environmental assessment that was completed highlighted many unsustainable practices. By building back better and building back greener, the Maldivian Government and its partners have had an opportunity to promote more sustainable practices and strengthen environmental institutions throughout the country. Improved rainwater harvesting and waste management, investment in sustainable sanitation solutions, and exploration of the potential for renewable energies are being undertaken as part of the recovery and development programme. The Government and its partners are also creating the capacity within the Ministry of Environment, Energy and Water to apply environmental impact assessments to future development programmes and to promote sustainable waste management policies and practices. Environmental health and waste management T h e M a l d i v e s Disaster management CHALLENGES The Government's long-term disaster mitigation programme, The Safe Islands programme, builds on its pre-tsunami goal of increased population consolidation. The existing programme has been adapted to accommodate the need for disaster risk management so that “safe” islands will receive greater investment in sea walls, more solidly constructed buildings, buffer zones and drainage systems. Improved standards of housing and infrastructure are also part of the overall plan. The Maldives is unique amongst tsunami-affected countries in terms of the disaster's nationwide economic and social impact. For this reason, the principle of “building back better”, with its focus on quality of outcome, takes on a far greater significance and has wider implications than may be the case in other recovering nations. To ensure a healthier and more prosperous country than existed prior to 26 December 2004 will require more than the rebuilding of houses and infrastructure. Numerous hurdles have yet to be overcome and all partners in the recovery and reconstruction effort must unite to do this. = The biggest challenge for 2006 was attracting donor resources to fill the funding gap of US$ 145 million. = Human capacity constraints in the public health fields is a key challenge, and building capacity at both the central and peripheral levels will require vigorous efforts. = Provision of safe, durable housing, with access to safe water and sanitation for all families continues to be an issue. = The present level of interest and motivation to address disaster management and to have all ministries and departments integrate disaster management into their normal development programme must be sustained. = Each person and family must know and practise personal safety management to increase the confidence and resources of communities to better manage disasters. = Expansion of viable, diversified economic activity with an emphasis on job creation for young people is essential but may prove difficult. = Shifting the focus is required, from simply replacing lost assets to programmes that help all contributors to the economy, including women and vulnerable F r o m r e l i e f t o r e c o v e r y T h e M a l d i v e s groups, and also incorporate social welfare and community consultation policies. = Policies within recovery efforts dealing with gender, particularly vulnerability of women and children to increased risk of violence and sexual abuse, require strengthening. = Increased attention must be given to improving communications with the most affected communities and to provide them with regular updates on progress. = The Government embarked on a political and judicial reform programme with greater transparency and accountability. These steps must be supported by the international community as part of the recovery process. = A holistic approach to water conservation and sanitation, waste disposal and renewable energy must be developed. = Due to the reforms in the country, recovery and reconstruction is taking place in a political and social environment which is considerably different from pre- tsunami conditions. This poses unique challenges. = There is a need for nutrition improvement, agricultural diversification and linkage of farmers' production to resorts' demand. The momentum so desperately needed over the coming years must be maintained and full recovery ensured of the Maldives, a nation which, despite disaster, has united to build back better. F r o m r e l i e f t o r e c o v e r y T h e M a l d i v e s groups, and also incorporate social welfare and community consultation policies. = Policies within recovery efforts dealing with gender, particularly vulnerability of women and children to increased risk of violence and sexual abuse, require strengthening. = Increased attention must be given to improving communications with the most affected communities and to provide them with regular updates on progress. = The Government embarked on a political and judicial reform programme with greater transparency and accountability. These steps must be supported by the international community as part of the recovery process. = A holistic approach to water conservation and sanitation, waste disposal and renewable energy must be developed. = Due to the reforms in the country, recovery and reconstruction is taking place in a political and social environment which is considerably different from pre- tsunami conditions. This poses unique challenges. = There is a need for nutrition improvement, agricultural diversification and linkage of farmers' production to resorts' demand. The momentum so desperately needed over the coming years must be maintained and full recovery ensured of the Maldives, a nation which, despite disaster, has united to build back better. PHASE I: EMERGENCY RELIEF ASSESSMENT Affected areas Affected population Taking stock of the situation In India, the tsunami affected nearly 2260 km of the eastern and southern coastline and the relatively less accessible Andaman and Nicobar Islands. The Andaman and Nicobar Islands bore the brunt of the tsunami's fury. Tidal waves 10 metres high moved more than 3 km inland. In the mainland, the southern Indian states of Tamil Nadu, Andhra Pradesh and Kerala were primarily affected, as well as the union territory of Pondicherry. About 3.6 million people were affected; over 12 000 died, with nearly 6000 reported missing and over 7000 injured. Many more women than men were killed. In some places, there were three times as many women as men killed and, in Pachaankuppam village, the dead were only women. The major damage was to the coastal infrastructure such as dwelling units, fisheries, jetties and shipyards. The damage to the health infrastructure was large and included 80 subcentres, 13 primary health centres and seven partially damaged district hospitals. India 12 405 18 405 Country Fatalities Total Source1Missing 1 Some countries have not disaggregated between the deceased and the missing. M AG NI TU DE 5640 Government of India, January 2006 = Number of fatalities: 12 405. (Source: Government of India, Ministry of Home Affairs Report, 25 May 2005) = Number of people missing: 5640. (Source: Situation Report, No.32-5/2004-NDM-Government of India, Ministry of Home Affairs) = Number of people displaced: 647 599. (Source: Situation Report, No.32-5/2004-NDM-Government of India, Ministry of Home Affairs) INDIA PHASE I: EMERGENCY RELIEF ASSESSMENT Affected areas Affected population Taking stock of the situation In India, the tsunami affected nearly 2260 km of the eastern and southern coastline and the relatively less accessible Andaman and Nicobar Islands. The Andaman and Nicobar Islands bore the brunt of the tsunami's fury. Tidal waves 10 metres high moved more than 3 km inland. In the mainland, the southern Indian states of Tamil Nadu, Andhra Pradesh and Kerala were primarily affected, as well as the union territory of Pondicherry. About 3.6 million people were affected; over 12 000 died, with nearly 6000 reported missing and over 7000 injured. Many more women than men were killed. In some places, there were three times as many women as men killed and, in Pachaankuppam village, the dead were only women. The major damage was to the coastal infrastructure such as dwelling units, fisheries, jetties and shipyards. The damage to the health infrastructure was large and included 80 subcentres, 13 primary health centres and seven partially damaged district hospitals. India 12 405 18 405 Country Fatalities Total Source1Missing 1 Some countries have not disaggregated between the deceased and the missing. M AG NI TU DE 5640 Government of India, January 2006 = Number of fatalities: 12 405. (Source: Government of India, Ministry of Home Affairs Report, 25 May 2005) = Number of people missing: 5640. (Source: Situation Report, No.32-5/2004-NDM-Government of India, Ministry of Home Affairs) = Number of people displaced: 647 599. (Source: Situation Report, No.32-5/2004-NDM-Government of India, Ministry of Home Affairs) INDIA F r o m r e l i e f t o r e c o v e r y / An estimated 1089 villages were affected in Andhra Pradesh, Kerala, Tamil Nadu, Pondicherry, and the Andaman and Nicobar Islands. / An estimated 235 377 houses were destroyed. / Approximately 730 000 individuals were forced to leave their homes. / 83 788 boats were damaged or destroyed. / 31 755 livestock were lost. / 39 035 hectares of cropped area was damaged. (Source for all figures: Government of India, Ministry of Home Affairs Report, 25 May 2005) Damages and losses The response The UN system provided immediate support to the affected areas in India. However, India did not request, or require, financial help. India also did not seek external assistance—in fact, it assisted the governments of other tsunami-affected countries. Under operations “Rainbow”, “Castor” and “Gambhir” the Government of India (GoI) supported Sri Lanka, the Maldives and Indonesia, respectively. Political and administrative strength is vital for an effective response. In Tamil Nadu, political will was strong and found expression in the prompt provision of funds and personnel to the affected areas. Teamwork and autonomy in the field were essential for a quick and comprehensive response at the ground level. The district authorities were granted powers to act autonomously and were backed by substantial cash grants. This helped in the immediate purchase of material and in meeting the expenses of housing, feeding and caring for the displaced persons in the / Total estimated value of damages: US$ 2.56 billion / Total estimated needs for long-term recovery: US$ 2.19 billion / Total funds proposed for long-term recovery: US$ 2.65 billion. (The Indian government's portion of these funds amounted to an estimated US$ 1.84 billion. Total international donor pledges to India's recovery amounted to approximately US$ 802.30 million.) (Source: Government of India, June 2005. Includes estimates for the Andaman and Nicobar Islands as well as assistance to the shipping industry) Financial implications I n d i a Assistance provided by India to affected countries / Search and rescue, evacuation / Establishment of mobile hospitals, floating naval hospitals / Provision of medical staff and medical supplies / Establishment of essential services / Composite financial relief F r o m r e l i e f t o r e c o v e r y / An estimated 1089 villages were affected in Andhra Pradesh, Kerala, Tamil Nadu, Pondicherry, and the Andaman and Nicobar Islands. / An estimated 235 377 houses were destroyed. / Approximately 730 000 individuals were forced to leave their homes. / 83 788 boats were damaged or destroyed. / 31 755 livestock were lost. / 39 035 hectares of cropped area was damaged. (Source for all figures: Government of India, Ministry of Home Affairs Report, 25 May 2005) Damages and losses The response The UN system provided immediate support to the affected areas in India. However, India did not request, or require, financial help. India also did not seek external assistance—in fact, it assisted the governments of other tsunami-affected countries. Under operations “Rainbow”, “Castor” and “Gambhir” the Government of India (GoI) supported Sri Lanka, the Maldives and Indonesia, respectively. Political and administrative strength is vital for an effective response. In Tamil Nadu, political will was strong and found expression in the prompt provision of funds and personnel to the affected areas. Teamwork and autonomy in the field were essential for a quick and comprehensive response at the ground level. The district authorities were granted powers to act autonomously and were backed by substantial cash grants. This helped in the immediate purchase of material and in meeting the expenses of housing, feeding and caring for the displaced persons in the / Total estimated value of damages: US$ 2.56 billion / Total estimated needs for long-term recovery: US$ 2.19 billion / Total funds proposed for long-term recovery: US$ 2.65 billion. (The Indian government's portion of these funds amounted to an estimated US$ 1.84 billion. Total international donor pledges to India's recovery amounted to approximately US$ 802.30 million.) (Source: Government of India, June 2005. Includes estimates for the Andaman and Nicobar Islands as well as assistance to the shipping industry) Financial implications I n d i a Assistance provided by India to affected countries / Search and rescue, evacuation / Establishment of mobile hospitals, floating naval hospitals / Provision of medical staff and medical supplies / Establishment of essential services / Composite financial relief camps. There was close planning and coordination between various ministries such as transport, power, police and fire, telephones, roads and Public Works Department, particularly at the district level. This speeded up the process of restoration of services, evacuation of the affected population, transportaton for the injured, retrieval of bodies, and mass burial and cleaning of debris. The UNDP-supported Disaster Management Programme that was already functional since 2003 in Tamil Nadu helped mitigate some of the effects of the tsunami. A month before the tsunami, the district-level health service had conducted a training programme for villagers on what to do in emergencies such as floods and cyclones. This stood them in good stead. The established institutional mechanism at the central, state and district levels was put into practice. The affected coastal areas on the mainland were fairly easily accessible, and relief efforts got under way immediately. India was lucky; only the southeastern coastal strips had been affected. The Andaman and Nicobar Islands, India's worst-hit territory that Sunday morning, is, at the best of times, difficult to reach. The Ministry of Home Affairs (MoHA), the nodal ministry, along with other concerned ministries, worked with the state governments and set up rescue and relief operations. According to Indian Government figures, about 645 000 people were evacuated, 28 734 more rescued, 7400 metric tons of relief material were mobilized and 881 relief camps set up. It was the largest such effort undertaken in India. The challenges were overwhelming, and a mesh of political, administrative and societal factors had to be worked through. The logistical difficulties were almost insurmountable. By 31 December 2004, 856 metric tons of relief material had been mobilized for delivery to the Andaman and Nicobar Islands. These were ferried across by navy boats and ships. By 4 January 2005, 111 stationary and 53 mobile medical teams were functioning in Tamil Nadu and Andhra Pradesh, and 92 additional camps had been set up in Kerala. WHO, together with other UN agencies, initiated several activities in the public health area. The WHO Country Office set up a 24-hour Control Room. A WHO Coordination Unit was established in Chennai to coordinate relief and recovery activities. With the background of WHO's long-established knowledge of prevalent conditions, and partnerships with local and national authorities in disaster management, initial assessments were made and strategies developed. The Response by WHO F r o m r e l i e f t o r e c o v e r y I n d i a camps. There was close planning and coordination between various ministries such as transport, power, police and fire, telephones, roads and Public Works Department, particularly at the district level. This speeded up the process of restoration of services, evacuation of the affected population, transportaton for the injured, retrieval of bodies, and mass burial and cleaning of debris. The UNDP-supported Disaster Management Programme that was already functional since 2003 in Tamil Nadu helped mitigate some of the effects of the tsunami. A month before the tsunami, the district-level health service had conducted a training programme for villagers on what to do in emergencies such as floods and cyclones. This stood them in good stead. The established institutional mechanism at the central, state and district levels was put into practice. The affected coastal areas on the mainland were fairly easily accessible, and relief efforts got under way immediately. India was lucky; only the southeastern coastal strips had been affected. The Andaman and Nicobar Islands, India's worst-hit territory that Sunday morning, is, at the best of times, difficult to reach. The Ministry of Home Affairs (MoHA), the nodal ministry, along with other concerned ministries, worked with the state governments and set up rescue and relief operations. According to Indian Government figures, about 645 000 people were evacuated, 28 734 more rescued, 7400 metric tons of relief material were mobilized and 881 relief camps set up. It was the largest such effort undertaken in India. The challenges were overwhelming, and a mesh of political, administrative and societal factors had to be worked through. The logistical difficulties were almost insurmountable. By 31 December 2004, 856 metric tons of relief material had been mobilized for delivery to the Andaman and Nicobar Islands. These were ferried across by navy boats and ships. By 4 January 2005, 111 stationary and 53 mobile medical teams were functioning in Tamil Nadu and Andhra Pradesh, and 92 additional camps had been set up in Kerala. WHO, together with other UN agencies, initiated several activities in the public health area. The WHO Country Office set up a 24-hour Control Room. A WHO Coordination Unit was established in Chennai to coordinate relief and recovery activities. With the background of WHO's long-established knowledge of prevalent conditions, and partnerships with local and national authorities in disaster management, initial assessments were made and strategies developed. The Response by WHO F r o m r e l i e f t o r e c o v e r y I n d i a preliminary strategy till the end of March 2005 included emergency support to the national health authorities to protect the health of the survivors and those rendered vulnerable by the disaster. The strategy comprised the following: = Monitoring public health to provide early warning of emerging health threats and enable timely organization of any necessary response; = Replacing lost assets, infrastructure and supplies that were crucial to meeting health needs consequent to the disaster, as well as reactivating previously available essential health services; = Providing technical expertise to health authorities to enable key gaps to be filled; = Establishing and sustaining effective regional, national and local health coordination to enable efficient deployment of assistance; = Ensuring that up-to-date communications on the health situation were available to all local and international stakeholders; = Refining health needs assessment for the coming period, and facilitating early recovery and rehabilitation. WHO worked closely with the MoH, maintaining daily communication, and drew upon its reservoir of technical expertise to support the national team. Four national staff and nine consultants from the polio and tuberculosis projects were deployed for field operations in the states of Tamil Nadu, Andhra Pradesh and Kerala. Twenty-eight Technical Guidelines were provided by WHO to the Central Government, state governments and partners. The subjects covered ranged from “Tsunami: anticipated health problems”, “Communicable diseases: early warning system” to “Mortuary service and handling of dead persons”. WHO activities were supported by the expertise available with various WHO Collaborating Centres and other reputed national organizations and institutes. This included the development of strategy, guidelines, training modules and provision of technical assistance in implementing activities in the field. The National Institute of Communicable Diseases (NICD) and National Institute of Epidemiology (NIE) mobilized their staff to work in the affected areas. Epidemiologists from NICD were sent to Nagapattinam and Car Nicobar, while those from NIE were sent to Cuddalore and Kanyakumari. Seven medical colleges provided technical assistance in the areas of epidemiology and laboratory support. Partnerships F r o m r e l i e f t o r e c o v e r y I n d i a These medical colleges were Madras Medical College (Chennai), Madurai Medical College (Madurai), Thanjavur Medical College (Thanjavur), Coimbatore Medical College (Coimbatore), Kanyakumari Medical College (Kanyakumari), Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER, Pondicherry) and St John's Medical College (Bangalore). For psychosocial support, WHO collaborated with the Vidyasagar Institute of Mental Health and Neurosciences (VIMHANS, New Delhi); National Institute of Mental H e a l t h a n d N e u r o S c i e n c e s (NIMHANS, Bangalore); Medical College, Guntur; Medical College, Thiruvananthapuram; JIPMER, Pondicherry; Schizophrenia Research Foundation (SCARF), Chennai; SNEHA and Medical College, Allepey. WHO also collaborated with the State Mental Health Authorities of Kerala, Tamil Nadu and Andhra Pradesh. In the area of maternal and child health, WHO collaborated with the Obstetrics and Gynecology Society of Southern India (OGSSI) and the Indian Academy of Pediatrics (IAP). To strengthen the role of nurses during an emergency, WHO's collaborating partners were the Nursing Council of India and its State branches, All India Institute of Medical Sciences (AIIMS), NIMHANS and Christian Medical College, Vellore, as well as 45 nursing colleges in Tamil Nadu and Kerala. In Nagapattinam, Cuddalore and Karaikal, technical assistance was provided to district authorities for strengthening monitoring of drinking water quality, hygiene education and waste management. For this purpose, WHO collaborated with the Gandhigram Rural Institute, Tamil Nadu, and the Tamil Nadu Water and Drainage Board (TWAD). preliminary strategy till the end of March 2005 included emergency support to the national health authorities to protect the health of the survivors and those rendered vulnerable by the disaster. The strategy comprised the following: = Monitoring public health to provide early warning of emerging health threats and enable timely organization of any necessary response; = Replacing lost assets, infrastructure and supplies that were crucial to meeting health needs consequent to the disaster, as well as reactivating previously available essential health services; = Providing technical expertise to health authorities to enable key gaps to be filled; = Establishing and sustaining effective regional, national and local health coordination to enable efficient deployment of assistance; = Ensuring that up-to-date communications on the health situation were available to all local and international stakeholders; = Refining health needs assessment for the coming period, and facilitating early recovery and rehabilitation. WHO worked closely with the MoH, maintaining daily communication, and drew upon its reservoir of technical expertise to support the national team. Four national staff and nine consultants from the polio and tuberculosis projects were deployed for field operations in the states of Tamil Nadu, Andhra Pradesh and Kerala. Twenty-eight Technical Guidelines were provided by WHO to the Central Government, state governments and partners. The subjects covered ranged from “Tsunami: anticipated health problems”, “Communicable diseases: early warning system” to “Mortuary service and handling of dead persons”. WHO activities were supported by the expertise available with various WHO Collaborating Centres and other reputed national organizations and institutes. This included the development of strategy, guidelines, training modules and provision of technical assistance in implementing activities in the field. The National Institute of Communicable Diseases (NICD) and National Institute of Epidemiology (NIE) mobilized their staff to work in the affected areas. Epidemiologists from NICD were sent to Nagapattinam and Car Nicobar, while those from NIE were sent to Cuddalore and Kanyakumari. Seven medical colleges provided technical assistance in the areas of epidemiology and laboratory support. Partnerships F r o m r e l i e f t o r e c o v e r y I n d i a These medical colleges were Madras Medical College (Chennai), Madurai Medical College (Madurai), Thanjavur Medical College (Thanjavur), Coimbatore Medical College (Coimbatore), Kanyakumari Medical College (Kanyakumari), Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER, Pondicherry) and St John's Medical College (Bangalore). For psychosocial support, WHO collaborated with the Vidyasagar Institute of Mental Health and Neurosciences (VIMHANS, New Delhi); National Institute of Mental H e a l t h a n d N e u r o S c i e n c e s (NIMHANS, Bangalore); Medical College, Guntur; Medical College, Thiruvananthapuram; JIPMER, Pondicherry; Schizophrenia Research Foundation (SCARF), Chennai; SNEHA and Medical College, Allepey. WHO also collaborated with the State Mental Health Authorities of Kerala, Tamil Nadu and Andhra Pradesh. In the area of maternal and child health, WHO collaborated with the Obstetrics and Gynecology Society of Southern India (OGSSI) and the Indian Academy of Pediatrics (IAP). To strengthen the role of nurses during an emergency, WHO's collaborating partners were the Nursing Council of India and its State branches, All India Institute of Medical Sciences (AIIMS), NIMHANS and Christian Medical College, Vellore, as well as 45 nursing colleges in Tamil Nadu and Kerala. In Nagapattinam, Cuddalore and Karaikal, technical assistance was provided to district authorities for strengthening monitoring of drinking water quality, hygiene education and waste management. For this purpose, WHO collaborated with the Gandhigram Rural Institute, Tamil Nadu, and the Tamil Nadu Water and Drainage Board (TWAD). COORDINATION With the Government of India With the State Governments With UN agencies Within WHO GAP-FILLING The MoHA was the nodal ministry for coordinating the relief and rescue response. It functioned round the clock and was in constant touch with all the affected states and union territories, as well as the concerned ministries and the armed forces. A daily situation report was issued by the MoHA during the first month. At the Ministry of Health and Family Welfare (MoHFW), tsunami activities were coordinated by the Emergency Medical Relief (EMR) Cell and NICD. WHO maintained daily contact with the EMR and NICD. WHO coordinated closely with the State Governments of Tamil Nadu, Kerala and Andhra Pradesh, and with senior administrative officers in the union territory of Pondicherry, and the Andaman and Nicobar Islands. The UN Disaster Management Team (UNDMT) had its first meeting on 27 December 2004 to assess the situation. This was followed by daily meetings to review the activities initiated by each UN Agency. In consultation with the UN Country Team, the UN Team for Recovery Support (UN TRS) was set up, which prepared a Tsunami Response Framework. WHO participated in the joint mission and in formulation of the framework. For better coordination, the UN TRS started operating from Chennai. The WHO Coordination Unit at Chennai collaborated closely with the UN TRS. WHO Country Office had a 24-hour functional Control Room for the first few weeks. A tsunami status report was sent regularly to the Regional Office and HQ. The Regional Office facilitated regular teleconferences among WHO Country Offices of the affected countries. To meet the immediate supply requirements, the Regional Office increased the authorization of the WHO Country F r o m r e l i e f t o r e c o v e r y I n d i a COORDINATION With the Government of India With the State Governments With UN agencies Within WHO GAP-FILLING The MoHA was the nodal ministry for coordinating the relief and rescue response. It functioned round the clock and was in constant touch with all the affected states and union territories, as well as the concerned ministries and the armed forces. A daily situation report was issued by the MoHA during the first month. At the Ministry of Health and Family Welfare (MoHFW), tsunami activities were coordinated by the Emergency Medical Relief (EMR) Cell and NICD. WHO maintained daily contact with the EMR and NICD. WHO coordinated closely with the State Governments of Tamil Nadu, Kerala and Andhra Pradesh, and with senior administrative officers in the union territory of Pondicherry, and the Andaman and Nicobar Islands. The UN Disaster Management Team (UNDMT) had its first meeting on 27 December 2004 to assess the situation. This was followed by daily meetings to review the activities initiated by each UN Agency. In consultation with the UN Country Team, the UN Team for Recovery Support (UN TRS) was set up, which prepared a Tsunami Response Framework. WHO participated in the joint mission and in formulation of the framework. For better coordination, the UN TRS started operating from Chennai. The WHO Coordination Unit at Chennai collaborated closely with the UN TRS. WHO Country Office had a 24-hour functional Control Room for the first few weeks. A tsunami status report was sent regularly to the Regional Office and HQ. The Regional Office facilitated regular teleconferences among WHO Country Offices of the affected countries. To meet the immediate supply requirements, the Regional Office increased the authorization of the WHO Country F r o m r e l i e f t o r e c o v e r y I n d i a Office. Round-the-clock availability of staff related to procurement at WHO SEARO and WHO Country Office expedited processes. The following items were supplied to cover immediate needs: = Ten surgical and 24 emergency health kits were provided to the governments of Kerala, Andhra Pradesh and Tamil Nadu. = 20 000 insecticide-treated bed-nets were distributed in Kanyakumari, Cuddalore, Kanchipuram and Nagapattinam districts for the prevention of mosquito-borne diseases. = 1000 chloroscopes were provided to monitor water quality in the affected areas. = 30 tons of stable bleaching powder were provided to the Government of Tamil Nadu for use at Cuddalore district. = Co-trimoxazole tablets and packets of ORS were supplied to the Government of Tamil Nadu for the treatment of acute respiratory infections and diarrhoea in children. = Computers and printers were procured and supplied to strengthen disease surveillance units in Nagapattinam, Kanyakumari, Cuddalore and Kancheepuram districts in Tamil Nadu. As India did not request any external assistance for immediate relief, the support extended by WHO during this period was considered an expansion of the existing WHO–GoI collaborative programme. WHO Country Office obtained additional funding of US$ 1.5 million from the Regional Office for the procurement of immediate supply requirements. These funds were received in four stages (January, February, March and June 2005). A sum of US$ 20 000 was also provided by WHO HQ as initial funds. For long-term rehabilitation, GoI requested external assistance from multilateral agencies, including UN agencies. The Asian Development Bank, UN and World Bank undertook a mission, put together a team and organized visits to the affected areas. An officer from WHO participated in the mission and was made responsible for assessment in the health sector and identification of needs during the rehabilitation phase. The UN Framework for post-tsunami recovery and rehabilitation was formulated, which became the basis of the UN Agencies' work and was also turned into a tool for resource mobilization. Additional funds were raised from UNICEF, USAID and UNFPA to support these activities. RESOURCE MOBILIZATION PHASE II: ACTIVE INTERVENTIONS ASSESSMENT The sudden impact of the tsunami not only killed and injured people, but also caused extensive environmental, social and economic damage. Immediate response was impeded by disruption to vital services such as safe water supply, health and security, as well as key communication and transport systems. The existence of adverse environmental conditions such as poor sanitation, breeding sites for vectors, overcrowding in camps and disruption of normal vector control activities increased the risk of outbreaks of communicable diseases such as acute diarrhoeal diseases (including cholera and dysentery), acute jaundice syndrome, acute respiratory infections, malaria, typhoid, acute encephalitis, measles and acute pyogenic meningitis. F r o m r e l i e f t o r e c o v e r y I n d i a Office. Round-the-clock availability of staff related to procurement at WHO SEARO and WHO Country Office expedited processes. The following items were supplied to cover immediate needs: = Ten surgical and 24 emergency health kits were provided to the governments of Kerala, Andhra Pradesh and Tamil Nadu. = 20 000 insecticide-treated bed-nets were distributed in Kanyakumari, Cuddalore, Kanchipuram and Nagapattinam districts for the prevention of mosquito-borne diseases. = 1000 chloroscopes were provided to monitor water quality in the affected areas. = 30 tons of stable bleaching powder were provided to the Government of Tamil Nadu for use at Cuddalore district. = Co-trimoxazole tablets and packets of ORS were supplied to the Government of Tamil Nadu for the treatment of acute respiratory infections and diarrhoea in children. = Computers and printers were procured and supplied to strengthen disease surveillance units in Nagapattinam, Kanyakumari, Cuddalore and Kancheepuram districts in Tamil Nadu. As India did not request any external assistance for immediate relief, the support extended by WHO during this period was considered an expansion of the existing WHO–GoI collaborative programme. WHO Country Office obtained additional funding of US$ 1.5 million from the Regional Office for the procurement of immediate supply requirements. These funds were received in four stages (January, February, March and June 2005). A sum of US$ 20 000 was also provided by WHO HQ as initial funds. For long-term rehabilitation, GoI requested external assistance from multilateral agencies, including UN agencies. The Asian Development Bank, UN and World Bank undertook a mission, put together a team and organized visits to the affected areas. An officer from WHO participated in the mission and was made responsible for assessment in the health sector and identification of needs during the rehabilitation phase. The UN Framework for post-tsunami recovery and rehabilitation was formulated, which became the basis of the UN Agencies' work and was also turned into a tool for resource mobilization. Additional funds were raised from UNICEF, USAID and UNFPA to support these activities. RESOURCE MOBILIZATION PHASE II: ACTIVE INTERVENTIONS ASSESSMENT The sudden impact of the tsunami not only killed and injured people, but also caused extensive environmental, social and economic damage. Immediate response was impeded by disruption to vital services such as safe water supply, health and security, as well as key communication and transport systems. The existence of adverse environmental conditions such as poor sanitation, breeding sites for vectors, overcrowding in camps and disruption of normal vector control activities increased the risk of outbreaks of communicable diseases such as acute diarrhoeal diseases (including cholera and dysentery), acute jaundice syndrome, acute respiratory infections, malaria, typhoid, acute encephalitis, measles and acute pyogenic meningitis. F r o m r e l i e f t o r e c o v e r y I n d i a COORDINATION, GAP-FILLING AND INTERVENTIONS Emergency preparedness and response Water and sanitation WHO supported the 12 most affected districts on the mainland in disease surveillance. WHO had already been indirectly supporting activities in Port Blair in the Andaman Islands. Two epidemiologists from NICD were supported for deployment in Nagapattinam and the Car Nicobar Islands. In addition, the national programme officer from the Country Office of WHO was stationed at Thiruvananthapuram for three months to oversee disease surveillance and other tsunami-related activities in Kerala. The WHO Coordination Unit in Chennai monitored activities in Tamil Nadu. One consultant was appointed exclusively for this purpose. The seven medical colleges with whom partnerships had been formed, and a few others in the affected states, were approached for providing technical help in the areas of epidemiology and laboratory support. In the second week of January 2005, a joint team from WHO, NICD and NIE visited the relief camps in the affected districts of Tamil Nadu, Pondicherry and Kerala, and carried out a rapid health assessment. Gaps were identified in disease surveillance and recommendations were made on the spot. As the UNDP-supported disaster management programme was already functional in Tamil Nadu, the focus was enlarged to include all districts and train all people in emergency preparedness and response. A need was felt to reduce the vulnerability of the people before the next disaster struck. Water and sanitation were major problems. Environmental sanitation projects—including monitoring of drinking water quality, hygiene education and waste management—were set up in 14 villages in three districts of Tamil Nadu, in collaboration with a local NGO, the Gandhigram Rural Institute. These activities were carried out with WHO Country Office support. Providing outlying areas with safe water facilities was a tougher task. In the states of Tamil Nadu and Andhra Pradesh, the tsunami had affected only the coastal region, and the government had the means and capacity to provide relief from other parts of the state within 48 hours. Water sources along the coast had been contaminated by salt water and waste, but clean drinking water could quickly be provided. The TWAD and NGOs could manage the situation by themselves. WHO therefore supplemented efforts by providing much-needed supplies such as bleaching powder, chlorine tablets and mosquito nets. In the Andaman and Nicobar Islands, however, poor access led to delays in repairing water supply systems. By 8 January 2005, one desalination plant and one brackish water treatment plant had been shipped by the Indian Government to the Andaman and Nicobar Islands. A gigantic 785 metric tons of water had also been airlifted. As the tsunami caused a change in ground water quality, the TWAD initiated a water quality surveillance programme with financial and technical support from WHO Country Office. In all the coastal districts, hundreds of Sintex water tanks were set up in camps and villages, with water lorries driving in twice a day to fill them. UNICEF provided all the Sintex tanks. Simple and practical guidelines were adapted and developed to prevent and control communicable diseases. These were disseminated to all the affected districts. They included fact sheets on priority communicable diseases and laboratory support for post-disaster communicable disease surveillance. The WHO national consultant for laboratories coordinated support to laboratories in the tsunami-affected areas. As equipment and reagents were available, the focus of WHO support was on training, which was conducted on-site. Post-training support was extended till normal laboratory services became operational. Standard operating procedures (SOPs), laboratory consumables, reagents and kits were also supplied. By 10 January 2005, the Indian Government had sent 15 fogging machines to the Communicable diseases F r o m r e l i e f t o r e c o v e r y I n d i a COORDINATION, GAP-FILLING AND INTERVENTIONS Emergency preparedness and response Water and sanitation WHO supported the 12 most affected districts on the mainland in disease surveillance. WHO had already been indirectly supporting activities in Port Blair in the Andaman Islands. Two epidemiologists from NICD were supported for deployment in Nagapattinam and the Car Nicobar Islands. In addition, the national programme officer from the Country Office of WHO was stationed at Thiruvananthapuram for three months to oversee disease surveillance and other tsunami-related activities in Kerala. The WHO Coordination Unit in Chennai monitored activities in Tamil Nadu. One consultant was appointed exclusively for this purpose. The seven medical colleges with whom partnerships had been formed, and a few others in the affected states, were approached for providing technical help in the areas of epidemiology and laboratory support. In the second week of January 2005, a joint team from WHO, NICD and NIE visited the relief camps in the affected districts of Tamil Nadu, Pondicherry and Kerala, and carried out a rapid health assessment. Gaps were identified in disease surveillance and recommendations were made on the spot. As the UNDP-supported disaster management programme was already functional in Tamil Nadu, the focus was enlarged to include all districts and train all people in emergency preparedness and response. A need was felt to reduce the vulnerability of the people before the next disaster struck. Water and sanitation were major problems. Environmental sanitation projects—including monitoring of drinking water quality, hygiene education and waste management—were set up in 14 villages in three districts of Tamil Nadu, in collaboration with a local NGO, the Gandhigram Rural Institute. These activities were carried out with WHO Country Office support. Providing outlying areas with safe water facilities was a tougher task. In the states of Tamil Nadu and Andhra Pradesh, the tsunami had affected only the coastal region, and the government had the means and capacity to provide relief from other parts of the state within 48 hours. Water sources along the coast had been contaminated by salt water and waste, but clean drinking water could quickly be provided. The TWAD and NGOs could manage the situation by themselves. WHO therefore supplemented efforts by providing much-needed supplies such as bleaching powder, chlorine tablets and mosquito nets. In the Andaman and Nicobar Islands, however, poor access led to delays in repairing water supply systems. By 8 January 2005, one desalination plant and one brackish water treatment plant had been shipped by the Indian Government to the Andaman and Nicobar Islands. A gigantic 785 metric tons of water had also been airlifted. As the tsunami caused a change in ground water quality, the TWAD initiated a water quality surveillance programme with financial and technical support from WHO Country Office. In all the coastal districts, hundreds of Sintex water tanks were set up in camps and villages, with water lorries driving in twice a day to fill them. UNICEF provided all the Sintex tanks. Simple and practical guidelines were adapted and developed to prevent and control communicable diseases. These were disseminated to all the affected districts. They included fact sheets on priority communicable diseases and laboratory support for post-disaster communicable disease surveillance. The WHO national consultant for laboratories coordinated support to laboratories in the tsunami-affected areas. As equipment and reagents were available, the focus of WHO support was on training, which was conducted on-site. Post-training support was extended till normal laboratory services became operational. Standard operating procedures (SOPs), laboratory consumables, reagents and kits were also supplied. By 10 January 2005, the Indian Government had sent 15 fogging machines to the Communicable diseases F r o m r e l i e f t o r e c o v e r y I n d i a Andaman and Nicobar Islands. In district after district, the malaria control wing of the local administration meticulously checked wells, stagnant pools of water, as well as water stored in drums for larvae, and provided fumigation services to control adult mosquitoes. Insecticide-treated bed-nets were sent as a protective measure. Immunization against measles is the single most cost-effective public health intervention among children in displaced populations. Immunization activities were initiated within the first week, and were jointly carried out by the GoI, WHO and UNICEF. Auto-disable (AD) syringes were introduced for the first time to carry out immunization in the affected districts. Children residing in the relief shelters were targeted first. WHO supported the MoH in the following activities: = Provision of technical assistance to Tamil Nadu, Kerala, Andhra Pradesh, Pondicherry, and the Andaman and Nicobar Islands for measles and polio vaccination. One dose of measles vaccine and one dose of oral polio vaccine (OPV) were administered to all children in the age group of 6–59 months, irrespective of their previous immunization status. Vitamin A supplementation was also provided for children 6–59 months of age. = Vaccination of 71 338 children was carried out by early February in Tamil Nadu with UNICEF support. = Immunization of children in the temporary shelters and affected villages was done in collaboration with the Integrated Child Development Scheme (ICDS). = Regular immunization coverage was sustained after the campaign. Except for sporadic cases of measles, no outbreak was reported. Coverage of a higher age group (5–14 years) is recommended for future campaigns as 29% of the cases that occurred were in this age group. A rapid household survey was conducted for diarrhoeal diseases. Eighteen cases of diarrhoea were found in the Karaikal district and 83 in the Nagapattinam district. The incidence of diarrhoea was 12% higher than in the unaffected villages. WHO provided technical assistance to strengthen disease surveillance systems in all the affected states. Four Disease Surveillance Units were established and adequately equipped in Tamil Nadu in the worst affected districts of Nagapattinam, Immunization Measles Diarrhoea Surveillance systems F r o m r e l i e f t o r e c o v e r y I n d i a Andaman and Nicobar Islands. In district after district, the malaria control wing of the local administration meticulously checked wells, stagnant pools of water, as well as water stored in drums for larvae, and provided fumigation services to control adult mosquitoes. Insecticide-treated bed-nets were sent as a protective measure. Immunization against measles is the single most cost-effective public health intervention among children in displaced populations. Immunization activities were initiated within the first week, and were jointly carried out by the GoI, WHO and UNICEF. Auto-disable (AD) syringes were introduced for the first time to carry out immunization in the affected districts. Children residing in the relief shelters were targeted first. WHO supported the MoH in the following activities: = Provision of technical assistance to Tamil Nadu, Kerala, Andhra Pradesh, Pondicherry, and the Andaman and Nicobar Islands for measles and polio vaccination. One dose of measles vaccine and one dose of oral polio vaccine (OPV) were administered to all children in the age group of 6–59 months, irrespective of their previous immunization status. Vitamin A supplementation was also provided for children 6–59 months of age. = Vaccination of 71 338 children was carried out by early February in Tamil Nadu with UNICEF support. = Immunization of children in the temporary shelters and affected villages was done in collaboration with the Integrated Child Development Scheme (ICDS). = Regular immunization coverage was sustained after the campaign. Except for sporadic cases of measles, no outbreak was reported. Coverage of a higher age group (5–14 years) is recommended for future campaigns as 29% of the cases that occurred were in this age group. A rapid household survey was conducted for diarrhoeal diseases. Eighteen cases of diarrhoea were found in the Karaikal district and 83 in the Nagapattinam district. The incidence of diarrhoea was 12% higher than in the unaffected villages. WHO provided technical assistance to strengthen disease surveillance systems in all the affected states. Four Disease Surveillance Units were established and adequately equipped in Tamil Nadu in the worst affected districts of Nagapattinam, Immunization Measles Diarrhoea Surveillance systems F r o m r e l i e f t o r e c o v e r y I n d i a Kanyakumari, Cuddalore and Kancheepuram, to report daily on the status of communicable diseases in the affected areas. WHO and NICD provided supportive supervision and training to these Disease Surveillance Units. WHO provided support to the Integrated Disease Surveillance Cell (IDSC) through the supply of computers, and bore the costs of communication, operational expenses and the salary of a data entry operator in each of the 12 most-affected districts on the mainland. Guidelines and reporting formats were provided to these cells and they were asked to send in a daily report during the first month and once- weekly thereafter. The IDSC closely monitored syndromic reporting of outbreak- prone diseases from the relief camps and subcentres to detect early warning signals of impending outbreaks. A need was felt to strengthen and intensify the existing disease surveillance activities and scale them up to the level of post-disaster disease surveillance on the lines of the Integrated Disease Surveillance Programme (IDSP). The IDSP was strengthened with sensitization messages, and post-disaster surveillance workshops were held for medical officers and health-care workers. In the Andaman and Nicobar Islands, training workshops in Post-Disaster Disease Surveillance were started in August 2005 and were completed by October 2005. The data management capacity at the State level was enhanced by strengthening reporting and data analyses from the Comprehensive Emergency Obstetric and Newborn Care (CEmONC) centres, and by establishing a Data Resource Centre, including a data warehouse, at the Directorate of Public Health in Tamil Nadu. In January 2005, WHO supported a project to strengthen outreach services which had been disrupted. Dedicated teams were made available to provide services at the doorstep and to those living in shelters in Nagapattinam and Cuddalore. Each team consisted of a medical officer, paramedical staff, laboratory technician and health educators, along with a vehicle equipped with all the basic facilities, and drugs and vaccines for basic and Reproductive and Child Health (RCH) services. The team staff was deputed by the Government of Tamil Nadu. Fuel for the vehicles, funds for IEC, health education, and organizing health care camps, costs of forms and records, pocket expenses of the team members and funds for the monthly review meetings were provided by WHO. WHO also provided technical assistance to sensitize programme managers to the use of alternative therapies. Health systems and infrastructure Repair and restoration of health facilities would result in the facilities reaching pre-tsunami levels, but not necessarily improve them. The State Health Department viewed this as an opportunity to improve and expand services, with the help of WHO, UNICEF and several NGOs. The State Government laid down norms for these partnerships. A Chennai-based Trust undertook the task of completely rebuilding the GH Nagapattinam. Other NGOs took on the task of rebuilding damaged PHCs or provided equipment for various facilities. Included in the State's plans were phased renovation and upgradation of rural and urban hospitals and centres through the Health System Development and the RCH- II Project. This plan addresses human resource issues such as filling vacancies and capacity building of staff, mobility support and improved communication facilities. The Family and Community Health Cluster of the WHO Country Office planned activities to enhance the capacity of the health systems to respond effectively to the needs of women, children, newborns and adolescents. Immediately after the tsunami, it was estimated that there would be at least 474 births in a month, and more than 5000 pregnant women among the displaced population (3%). Services at the GH Nagapattinam were strengthened; WHO facilitated partnership with OGSSI to ensure the services of skilled personnel at the hospital. With support from UNICEF and UNFPA, equipment for paediatric care was provided. In March 2005, WHO-supported specialists joined the hospital to ease the shortage of paediatricians and gynaecologists. Guidelines were provided for continued breastfeeding during emergencies and outreach activities were strengthened for reproductive, maternal, newborn and child health services. Adolescent-friendly health services were established and nurses trained in managing conditions during emergencies. Child health activities included immunization against measles and polio, and vitamin A supplementation. These were jointly carried out by the GoI, WHO and UNICEF. ORS packets for the treatment of diarrhoea, and co-trimoxazole tablets for the treatment of acute respiratory infections and gastroenteritis were also distributed. Except for sporadic cases of measles, chicken pox and gastroenteritis, no major outbreaks were reported. At the request of the RCH unit, Government of Tamil Nadu, WHO provided technical assistance in establishing a web-based weekly reporting system that would Maternal, newborn, child and adolescent health F r o m r e l i e f t o r e c o v e r y I n d i a Kanyakumari, Cuddalore and Kancheepuram, to report daily on the status of communicable diseases in the affected areas. WHO and NICD provided supportive supervision and training to these Disease Surveillance Units. WHO provided support to the Integrated Disease Surveillance Cell (IDSC) through the supply of computers, and bore the costs of communication, operational expenses and the salary of a data entry operator in each of the 12 most-affected districts on the mainland. Guidelines and reporting formats were provided to these cells and they were asked to send in a daily report during the first month and once- weekly thereafter. The IDSC closely monitored syndromic reporting of outbreak- prone diseases from the relief camps and subcentres to detect early warning signals of impending outbreaks. A need was felt to strengthen and intensify the existing disease surveillance activities and scale them up to the level of post-disaster disease surveillance on the lines of the Integrated Disease Surveillance Programme (IDSP). The IDSP was strengthened with sensitization messages, and post-disaster surveillance workshops were held for medical officers and health-care workers. In the Andaman and Nicobar Islands, training workshops in Post-Disaster Disease Surveillance were started in August 2005 and were completed by October 2005. The data management capacity at the State level was enhanced by strengthening reporting and data analyses from the Comprehensive Emergency Obstetric and Newborn Care (CEmONC) centres, and by establishing a Data Resource Centre, including a data warehouse, at the Directorate of Public Health in Tamil Nadu. In January 2005, WHO supported a project to strengthen outreach services which had been disrupted. Dedicated teams were made available to provide services at the doorstep and to those living in shelters in Nagapattinam and Cuddalore. Each team consisted of a medical officer, paramedical staff, laboratory technician and health educators, along with a vehicle equipped with all the basic facilities, and drugs and vaccines for basic and Reproductive and Child Health (RCH) services. The team staff was deputed by the Government of Tamil Nadu. Fuel for the vehicles, funds for IEC, health education, and organizing health care camps, costs of forms and records, pocket expenses of the team members and funds for the monthly review meetings were provided by WHO. WHO also provided technical assistance to sensitize programme managers to the use of alternative therapies. Health systems and infrastructure Repair and restoration of health facilities would result in the facilities reaching pre-tsunami levels, but not necessarily improve them. The State Health Department viewed this as an opportunity to improve and expand services, with the help of WHO, UNICEF and several NGOs. The State Government laid down norms for these partnerships. A Chennai-based Trust undertook the task of completely rebuilding the GH Nagapattinam. Other NGOs took on the task of rebuilding damaged PHCs or provided equipment for various facilities. Included in the State's plans were phased renovation and upgradation of rural and urban hospitals and centres through the Health System Development and the RCH- II Project. This plan addresses human resource issues such as filling vacancies and capacity building of staff, mobility support and improved communication facilities. The Family and Community Health Cluster of the WHO Country Office planned activities to enhance the capacity of the health systems to respond effectively to the needs of women, children, newborns and adolescents. Immediately after the tsunami, it was estimated that there would be at least 474 births in a month, and more than 5000 pregnant women among the displaced population (3%). Services at the GH Nagapattinam were strengthened; WHO facilitated partnership with OGSSI to ensure the services of skilled personnel at the hospital. With support from UNICEF and UNFPA, equipment for paediatric care was provided. In March 2005, WHO-supported specialists joined the hospital to ease the shortage of paediatricians and gynaecologists. Guidelines were provided for continued breastfeeding during emergencies and outreach activities were strengthened for reproductive, maternal, newborn and child health services. Adolescent-friendly health services were established and nurses trained in managing conditions during emergencies. Child health activities included immunization against measles and polio, and vitamin A supplementation. These were jointly carried out by the GoI, WHO and UNICEF. ORS packets for the treatment of diarrhoea, and co-trimoxazole tablets for the treatment of acute respiratory infections and gastroenteritis were also distributed. Except for sporadic cases of measles, chicken pox and gastroenteritis, no major outbreaks were reported. At the request of the RCH unit, Government of Tamil Nadu, WHO provided technical assistance in establishing a web-based weekly reporting system that would Maternal, newborn, child and adolescent health F r o m r e l i e f t o r e c o v e r y I n d i a connect all 62 CEmONC centres, which would be expanded to all 274 hospitals across the state with WHO Country Office support. This helped in making vital performance indicators available to key stakeholders. Adolescent reproductive and sexual health was included in the national RCH-II Programme, with GH Nagapattinam as the nodal centre for implementation. WHO Country Office carried out training on adolescent-friendly health services in conjunction with IAP (Chennai) and IAP (Delhi). The Mapping Adolescent Programming and Measurement (MAPM) Framework developed by WHO was applied to strengthen action plans. A meeting and planning workshop of the core group for nursing was held in Chennai. The draft module for capacity-building of faculty was reviewed, and tools for rapid assessment of health were revised. More than 45 schools of nursing in Tamil Nadu agreed to adopt villages and/or shelters near their schools for providing first-hand experience of managing health conditions in emergency situations to their students. WHO facilitated the process of developing and revising a module entitled “Reaching out: nursing care in emergencies and facilitators’ guide”. Training of doctors/specialists at First Referral Units (FRUs)/District Hospitals (DHs) in inpatient management of cases of severe infections and malnutrition was carried out in the affected districts. Anganwadi workers (AWWs) were deployed in all the affected villages to monitor nutrition status. Each and every person was psychologically affected by the disaster to some extent. Thus, the magnitude of the problem of psychological trauma was as large as the population itself. Problems ranged from mild distress to a variety of mental disorders, including very severe disorders. The initial efforts of the government focused on relief, followed by rehabilitation. Psychosocial support (PSS) could not be provided in the initial post-disaster phase, but took about a month to commence. WHO worked closely with the government to tackle the problem of PSS. One of the first responses of the WHO mental health team was to provide technical guidelines on topics such as emergency phase, suicide prevention, and child and adolescent health, which were uploaded onto the SEARO website. In late January Nursing services Nutrition Mental health 2005, the WHO National Programme Officer for mental health led a UN Disaster Management Team to Chennai for an assessment and developed a framework for PSS along with UNICEF and other UN agencies (UNDP, UNODC and UNFPA). WHO also initiated contact with and contracted reputed mental health institutes such as NIMHANS, VIMHANS and Medical College Allepey. These agencies provided training to local service providers such as teachers, AWWs and community-level workers (CLWs). They would work within the affected communities using standard manuals. JIPMER, Pondicherry trained 100 teachers and the Schizophrenia Research Foundation (SCARF), Chennai trained 766 people and provided them with printed material in Tamil. NGOs and other community- based organizations provided technical resources and field support. WHO SEARO developed manuals for training CLWs and medical officers, and provided resource persons for the training. These manuals were translated into the local language. The Directorate of Social Welfare, Government of Tamil Nadu was the nodal agency for the organization of PSS activities. The CLWs were assigned 20 families each for whom they were responsible for providing PSS, and acted as a link between the community and various organizations and the government. At the district level, 2813 lay counsellors were trained. They were taught simple techniques of counselling. Those whom the CLWs could not cope with were cared for by trained medical personnel. Complicated cases were referred to psychiatrists. Following the experience of the tsunami in providing PSS, a generic model was suggested, which can be divided into three phases. Phase 1 covers the first six weeks, Phase 2 from six weeks to six months, and Phase 3 from six months to a year. This model was shown to be effective and sustainable. WHO Country Office planned activities to enhance the capacity of the PSS Cell in the Directorate of Social Welfare for monitoring and coordination, supporting the work of CLWs through further training and kits, targeted interventions such as alcohol and substance abuse, and increased focus on vulnerable groups such as adolescents and widows. Immediately following the tsunami, several shelters were put up to house the huge numbers of displaced persons without much thought given to the land they were put up on. Most were on low-lying areas of the sandy belt, and did not provide easy passage for waste water and sewage. Thus, collapsed toilets, blocked drains and waterlogging posed serious threats to the health of the community. WHO Country Office initiated environmental sanitation interventions to tackle Environmental health F r o m r e l i e f t o r e c o v e r y I n d i a connect all 62 CEmONC centres, which would be expanded to all 274 hospitals across the state with WHO Country Office support. This helped in making vital performance indicators available to key stakeholders. Adolescent reproductive and sexual health was included in the national RCH-II Programme, with GH Nagapattinam as the nodal centre for implementation. WHO Country Office carried out training on adolescent-friendly health services in conjunction with IAP (Chennai) and IAP (Delhi). The Mapping Adolescent Programming and Measurement (MAPM) Framework developed by WHO was applied to strengthen action plans. A meeting and planning workshop of the core group for nursing was held in Chennai. The draft module for capacity-building of faculty was reviewed, and tools for rapid assessment of health were revised. More than 45 schools of nursing in Tamil Nadu agreed to adopt villages and/or shelters near their schools for providing first-hand experience of managing health conditions in emergency situations to their students. WHO facilitated the process of developing and revising a module entitled “Reaching out: nursing care in emergencies and facilitators’ guide”. Training of doctors/specialists at First Referral Units (FRUs)/District Hospitals (DHs) in inpatient management of cases of severe infections and malnutrition was carried out in the affected districts. Anganwadi workers (AWWs) were deployed in all the affected villages to monitor nutrition status. Each and every person was psychologically affected by the disaster to some extent. Thus, the magnitude of the problem of psychological trauma was as large as the population itself. Problems ranged from mild distress to a variety of mental disorders, including very severe disorders. The initial efforts of the government focused on relief, followed by rehabilitation. Psychosocial support (PSS) could not be provided in the initial post-disaster phase, but took about a month to commence. WHO worked closely with the government to tackle the problem of PSS. One of the first responses of the WHO mental health team was to provide technical guidelines on topics such as emergency phase, suicide prevention, and child and adolescent health, which were uploaded onto the SEARO website. In late January Nursing services Nutrition Mental health 2005, the WHO National Programme Officer for mental health led a UN Disaster Management Team to Chennai for an assessment and developed a framework for PSS along with UNICEF and other UN agencies (UNDP, UNODC and UNFPA). WHO also initiated contact with and contracted reputed mental health institutes such as NIMHANS, VIMHANS and Medical College Allepey. These agencies provided training to local service providers such as teachers, AWWs and community-level workers (CLWs). They would work within the affected communities using standard manuals. JIPMER, Pondicherry trained 100 teachers and the Schizophrenia Research Foundation (SCARF), Chennai trained 766 people and provided them with printed material in Tamil. NGOs and other community- based organizations provided technical resources and field support. WHO SEARO developed manuals for training CLWs and medical officers, and provided resource persons for the training. These manuals were translated into the local language. The Directorate of Social Welfare, Government of Tamil Nadu was the nodal agency for the organization of PSS activities. The CLWs were assigned 20 families each for whom they were responsible for providing PSS, and acted as a link between the community and various organizations and the government. At the district level, 2813 lay counsellors were trained. They were taught simple techniques of counselling. Those whom the CLWs could not cope with were cared for by trained medical personnel. Complicated cases were referred to psychiatrists. Following the experience of the tsunami in providing PSS, a generic model was suggested, which can be divided into three phases. Phase 1 covers the first six weeks, Phase 2 from six weeks to six months, and Phase 3 from six months to a year. This model was shown to be effective and sustainable. WHO Country Office planned activities to enhance the capacity of the PSS Cell in the Directorate of Social Welfare for monitoring and coordination, supporting the work of CLWs through further training and kits, targeted interventions such as alcohol and substance abuse, and increased focus on vulnerable groups such as adolescents and widows. Immediately following the tsunami, several shelters were put up to house the huge numbers of displaced persons without much thought given to the land they were put up on. Most were on low-lying areas of the sandy belt, and did not provide easy passage for waste water and sewage. Thus, collapsed toilets, blocked drains and waterlogging posed serious threats to the health of the community. WHO Country Office initiated environmental sanitation interventions to tackle Environmental health F r o m r e l i e f t o r e c o v e r y I n d i a the problem, with active community participation. The aim was to provide safe water, sanitation facilities, solid waste management and vector control measures within the temporary shelters. The basic approach was to monitor drinking water quality, rebuild toilets, improve drainage facilities and train the community in the upkeep of these measures. The state health authorities actively supported the programme and provided administrative support. WHO selected the Gandhigram Rural Institute to assist in these activities. The team conducted a rapid assessment in the affected areas. An organizational structure was developed for the project to converge the activities of both governmental and nongovernmental agencies. Solid waste management was given importance and stagnated solid waste removed with the help of local NGOs and the community. Soakage pits and landfills were constructed to handle waste water. For vector control, breeding sites of flies and mosquitoes were tackled. The Gandhigram Rural Institute, with technical support from WHO, developed field-level technical guidelines for water and environmental sanitation facilities for adaptation by community health workers. Medical and paramedical staff were jointly trained by WHO and NICD in integrated disease surveillance (IDS) and response in the 12 affected districts. Draft manuals were adapted, printed and field-tested. A total of 1500 training manuals for medical officers, 7000 for health workers and sufficient quantities of reporting formats were printed and distributed. A training module on IDS was prepared with special emphasis on post-disaster disease surveillance and response. The WHO–NICD team trained 50 medical officers and 50 paramedical workers, and carried out training of trainers (ToT) in each of the 12 districts. These trained medical officers and paramedical workers in turn trained other staff. Thus, 961 medical workers and 4179 health workers were trained. Five medical officers from the tsunami-affected districts were provided with a 3- month fellowship training at NICD, Delhi under the Tenth WHO Fellowship Regional Field Epidemiology Training Programme (FETP). Two paramedical workers from Kerala and the Andaman and Nicobar Islands participated in a one-month WHO Regional Fellowship Training Programme at NICD, Delhi. CAPACITY-BUILDING Training in post-disaster disease surveillance Training in field epidemiology F r o m r e l i e f t o r e c o v e r y I n d i a the problem, with active community participation. The aim was to provide safe water, sanitation facilities, solid waste management and vector control measures within the temporary shelters. The basic approach was to monitor drinking water quality, rebuild toilets, improve drainage facilities and train the community in the upkeep of these measures. The state health authorities actively supported the programme and provided administrative support. WHO selected the Gandhigram Rural Institute to assist in these activities. The team conducted a rapid assessment in the affected areas. An organizational structure was developed for the project to converge the activities of both governmental and nongovernmental agencies. Solid waste management was given importance and stagnated solid waste removed with the help of local NGOs and the community. Soakage pits and landfills were constructed to handle waste water. For vector control, breeding sites of flies and mosquitoes were tackled. The Gandhigram Rural Institute, with technical support from WHO, developed field-level technical guidelines for water and environmental sanitation facilities for adaptation by community health workers. Medical and paramedical staff were jointly trained by WHO and NICD in integrated disease surveillance (IDS) and response in the 12 affected districts. Draft manuals were adapted, printed and field-tested. A total of 1500 training manuals for medical officers, 7000 for health workers and sufficient quantities of reporting formats were printed and distributed. A training module on IDS was prepared with special emphasis on post-disaster disease surveillance and response. The WHO–NICD team trained 50 medical officers and 50 paramedical workers, and carried out training of trainers (ToT) in each of the 12 districts. These trained medical officers and paramedical workers in turn trained other staff. Thus, 961 medical workers and 4179 health workers were trained. Five medical officers from the tsunami-affected districts were provided with a 3- month fellowship training at NICD, Delhi under the Tenth WHO Fellowship Regional Field Epidemiology Training Programme (FETP). Two paramedical workers from Kerala and the Andaman and Nicobar Islands participated in a one-month WHO Regional Fellowship Training Programme at NICD, Delhi. CAPACITY-BUILDING Training in post-disaster disease surveillance Training in field epidemiology F r o m r e l i e f t o r e c o v e r y I n d i a Strengthening health systems Setting up a data resource centre After the tsunami, WHO took steps to improve the quality of health-care services and strengthen the health-care system. After the initial assessment of health infrastructure, a database was developed and GIS mapping carried out of health and education facilities in 373 villages in Andhra Pradesh and Tamil Nadu. This activity was coordinated by WHO Country Office in conjunction with WHO HQ and UNICEF. WHO, along with other agencies and the Government of Tamil Nadu, developed an accreditation system for district hospitals across 10 districts in the state. The tsunami response was documented via a publication entitled Responding to the tsunami: the Tamil Nadu experience, which was brought out by WHO Country Office. WHO facilitated a series of meetings between representatives of the finance department, health department, fisheries and insurance companies to develop an insurance scheme for fisherfolk. The Government of Tamil Nadu, WHO and other organizations formed a partnership to provide protective cover to the poorest sections of the society. A major lacuna identified during the tsunami was the absence of a repository of information on how to deal with various aspects of disaster management, including the availability of guidelines, SOPs, etc. A unified system of data flow was required to provide accurate and timely information to administrators and health staff. Awareness was limited of various reports, surveys, studies and policy documents brought out by diverse departments, institutions, and multilateral and bilateral agencies. There was also no proper office where such data could be accessed. A data resource centre was established at the Directorate of Public Health in Chennai. This would provide information for researchers, programme managers, academicians and the media. The space for this centre was provided by the Directorate of Public Health in Chennai and infrastructure support was provided by WHO. PHASE III: REVIEW AND CONSOLIDATION ASSESSMENT While the overall response and performance of the GoI and Department of Health and Family Welfare of Tamil Nadu was laudable, several gaps were identified. = The Government was not very visible in the relief work. To counter this, banners were printed and pasted on all relief vehicles and ambulances. = Training: The need for training in disaster management was strongly felt by many government service providers, NGOs and the local community. The UNDP Disaster Management Programme has been extended to cover this lacuna. = Distribution of forces: Due to several areas being cut off, they could not be reached early enough. Also, helpers who came in from outside wanted to work in the few areas that had received international focus. Hence, some areas did not receive adequate and timely help. = Mobilization and infrastructure: It was felt that teams from medical colleges were not used to their full potential because of poor coordination. Manpower shortages were serious, especially in Nagapattinam and Kanyakumari. Keeping a permanent staff of ten field health workers would be useful, as staff were constantly on the move from regular duties due to some crisis or the other. A reserve team should be kept ready. = Infrastructure for entomological surveillance was found to be very poor, and laboratory support inadequate. = Administration and coordination: Procedures to be followed for issuing death certificates and identifying dead bodies were not known and took some time to find. While unidentified dead bodies were photographed, they were not fingerprinted, which should have been done. = Coordination was also required to streamline the work of the many agencies who volunteered their services. While their good intent was not in question, they had to be prevented from doing the wrong things. Their work was not constructively channelled, and this resulted in duplication of effort. = Water quality testing was more arbitrary than systematic. In some places, the water was overchlorinated. It took some time to find sources for the supply of bleaching powder. It was felt that a database of suppliers should be kept by the Health Department and Disaster Relief Centre. The water quality was also not suitable for children, and should have been boiled. F r o m r e l i e f t o r e c o v e r y I n d i a Strengthening health systems Setting up a data resource centre After the tsunami, WHO took steps to improve the quality of health-care services and strengthen the health-care system. After the initial assessment of health infrastructure, a database was developed and GIS mapping carried out of health and education facilities in 373 villages in Andhra Pradesh and Tamil Nadu. This activity was coordinated by WHO Country Office in conjunction with WHO HQ and UNICEF. WHO, along with other agencies and the Government of Tamil Nadu, developed an accreditation system for district hospitals across 10 districts in the state. The tsunami response was documented via a publication entitled Responding to the tsunami: the Tamil Nadu experience, which was brought out by WHO Country Office. WHO facilitated a series of meetings between representatives of the finance department, health department, fisheries and insurance companies to develop an insurance scheme for fisherfolk. The Government of Tamil Nadu, WHO and other organizations formed a partnership to provide protective cover to the poorest sections of the society. A major lacuna identified during the tsunami was the absence of a repository of information on how to deal with various aspects of disaster management, including the availability of guidelines, SOPs, etc. A unified system of data flow was required to provide accurate and timely information to administrators and health staff. Awareness was limited of various reports, surveys, studies and policy documents brought out by diverse departments, institutions, and multilateral and bilateral agencies. There was also no proper office where such data could be accessed. A data resource centre was established at the Directorate of Public Health in Chennai. This would provide information for researchers, programme managers, academicians and the media. The space for this centre was provided by the Directorate of Public Health in Chennai and infrastructure support was provided by WHO. PHASE III: REVIEW AND CONSOLIDATION ASSESSMENT While the overall response and performance of the GoI and Department of Health and Family Welfare of Tamil Nadu was laudable, several gaps were identified. = The Government was not very visible in the relief work. To counter this, banners were printed and pasted on all relief vehicles and ambulances. = Training: The need for training in disaster management was strongly felt by many government service providers, NGOs and the local community. The UNDP Disaster Management Programme has been extended to cover this lacuna. = Distribution of forces: Due to several areas being cut off, they could not be reached early enough. Also, helpers who came in from outside wanted to work in the few areas that had received international focus. Hence, some areas did not receive adequate and timely help. = Mobilization and infrastructure: It was felt that teams from medical colleges were not used to their full potential because of poor coordination. Manpower shortages were serious, especially in Nagapattinam and Kanyakumari. Keeping a permanent staff of ten field health workers would be useful, as staff were constantly on the move from regular duties due to some crisis or the other. A reserve team should be kept ready. = Infrastructure for entomological surveillance was found to be very poor, and laboratory support inadequate. = Administration and coordination: Procedures to be followed for issuing death certificates and identifying dead bodies were not known and took some time to find. While unidentified dead bodies were photographed, they were not fingerprinted, which should have been done. = Coordination was also required to streamline the work of the many agencies who volunteered their services. While their good intent was not in question, they had to be prevented from doing the wrong things. Their work was not constructively channelled, and this resulted in duplication of effort. = Water quality testing was more arbitrary than systematic. In some places, the water was overchlorinated. It took some time to find sources for the supply of bleaching powder. It was felt that a database of suppliers should be kept by the Health Department and Disaster Relief Centre. The water quality was also not suitable for children, and should have been boiled. F r o m r e l i e f t o r e c o v e r y I n d i a = Awareness and protection of the environment would help in mitigating the impact of natural hazards. = Disease control: Measles immunization was carried out effectively and covered children up to five years of age. However, measles cases were seen in older children; hence, immunization for measles should cover children up to the age of 14 years. = Disposal of waste: While enormous effort went into maintaining sanitation in the temporary shelters, safe disposal of human waste was a problem. The community did not clean and maintain the toilets that had been made. = Psychosocial care: This was late in coming. It was critically needed in the early days, and not all NGOs were sensitive to this need. More attention should have been given to the care of caregivers, and many of them could not even be provided adequate food. = There is a need to have paradigm shift from “a response-oriented effort” to preparedeness, mitigation response and sustainable development. = Strong coordination is needed at the Centre. = Legislative back-up to implement decisions must be put in place. = The ingress of a multitude of agencies called for monitoring and control for efficient functioning and avoiding duplication of effort. = Primary health-care infrastructure should be oriented to community needs. = The response to trauma needs to be more rapid. = The disease surveillance system requires strengthening. = National Disaster Management Authority = National Disaster Management Bill = Responsive institutional mechanism at all administrative levels = Specialized force for search and rescue = Capacity building for community resilience The following initiatives were identified for better preparedness in emergencies and disasters: LESSONS LEARNT Health sector National initiatives for a disaster-free India National initiatives in the health sector = National Rural Health Mission should focus on strengthening primary health care including community hospitals. = Mobile hospital systems should be set up for a quick response to manage trauma victims. = Trauma care services should be established. = The Integrated Disease Surveillance Programme should be strengthened. F r o m r e l i e f t o r e c o v e r y I n d i a = Awareness and protection of the environment would help in mitigating the impact of natural hazards. = Disease control: Measles immunization was carried out effectively and covered children up to five years of age. However, measles cases were seen in older children; hence, immunization for measles should cover children up to the age of 14 years. = Disposal of waste: While enormous effort went into maintaining sanitation in the temporary shelters, safe disposal of human waste was a problem. The community did not clean and maintain the toilets that had been made. = Psychosocial care: This was late in coming. It was critically needed in the early days, and not all NGOs were sensitive to this need. More attention should have been given to the care of caregivers, and many of them could not even be provided adequate food. = There is a need to have paradigm shift from “a response-oriented effort” to preparedeness, mitigation response and sustainable development. = Strong coordination is needed at the Centre. = Legislative back-up to implement decisions must be put in place. = The ingress of a multitude of agencies called for monitoring and control for efficient functioning and avoiding duplication of effort. = Primary health-care infrastructure should be oriented to community needs. = The response to trauma needs to be more rapid. = The disease surveillance system requires strengthening. = National Disaster Management Authority = National Disaster Management Bill = Responsive institutional mechanism at all administrative levels = Specialized force for search and rescue = Capacity building for community resilience The following initiatives were identified for better preparedness in emergencies and disasters: LESSONS LEARNT Health sector National initiatives for a disaster-free India National initiatives in the health sector = National Rural Health Mission should focus on strengthening primary health care including community hospitals. = Mobile hospital systems should be set up for a quick response to manage trauma victims. = Trauma care services should be established. = The Integrated Disease Surveillance Programme should be strengthened. F r o m r e l i e f t o r e c o v e r y I n d i a 2Thailand 8212 8212 Country Fatalities Total Source1Missing 1. Some countries have not disaggregated between the deceased and the missing 2. In Thailand, fatalities include 2448 foreign tourists from 37 other countries. M AG NI TU DE = Number of fatalities: 8212. (Source: Government of Thailand. Note that this figure includes 2448 non-Thai people from 37 other countries.) = Number of people missing: 2817. (Source: UN Resident Coordinator, Thailand) = Number of people displaced: 6000. (Source: UN Development Program [UNDP], Six Month Cumulative Totals, June 2005) Department of Disaster Prevention and Mitigation, Ministry of Interior, October 2005 PHASE I: EMERGENCY RELIEF ASSESSMENT Affected areas Affected population In Thailand, six provinces in the southern region were the most affected. These were popular international tourist destinations such as Phuket, Ranong, Satun and Trang, Krabi and Phang Nga. A total of 25 districts, 95 tambons and 407 villages were affected; 47 villages were almost completely destroyed. Phang Nga, Phuket and Krabi districts accounted for 97% of all deaths, a considerable number of which comprised tourists from 37 countries. There was minimal damage to the health and transport/logistics infrastructure, and the geographical extent of the damage was relatively limited. The tsunami affected 66 600 people. More than 17 000 had injuries of varying degrees, according to the Thai Ministry of Public Health (MoPH). Over 8000 people were in urgent need of medical attention. The communication and THAILAND 2Thailand 8212 8212 Country Fatalities Total Source1Missing 1. Some countries have not disaggregated between the deceased and the missing 2. In Thailand, fatalities include 2448 foreign tourists from 37 other countries. M AG NI TU DE = Number of fatalities: 8212. (Source: Government of Thailand. Note that this figure includes 2448 non-Thai people from 37 other countries.) = Number of people missing: 2817. (Source: UN Resident Coordinator, Thailand) = Number of people displaced: 6000. (Source: UN Development Program [UNDP], Six Month Cumulative Totals, June 2005) Department of Disaster Prevention and Mitigation, Ministry of Interior, October 2005 PHASE I: EMERGENCY RELIEF ASSESSMENT Affected areas Affected population In Thailand, six provinces in the southern region were the most affected. These were popular international tourist destinations such as Phuket, Ranong, Satun and Trang, Krabi and Phang Nga. A total of 25 districts, 95 tambons and 407 villages were affected; 47 villages were almost completely destroyed. Phang Nga, Phuket and Krabi districts accounted for 97% of all deaths, a considerable number of which comprised tourists from 37 countries. There was minimal damage to the health and transport/logistics infrastructure, and the geographical extent of the damage was relatively limited. The tsunami affected 66 600 people. More than 17 000 had injuries of varying degrees, according to the Thai Ministry of Public Health (MoPH). Over 8000 people were in urgent need of medical attention. The communication and THAILAND F r o m r e l i e f t o r e c o v e r y information system had broken down, and accurate information was lacking. Subjective assessments were made through the regional offices of the Department of Health (DoH). / An estimated 50 000 children were affected by the tsunami and, according to the Ministry of Education, an estimated 1480 children lost one or both parents. (Source: UN Resident Coordinator, Thailand, Situation Report No. 19, October 2005) / More women than men were killed in the tsunami. The UN Children's Fund (UNICEF) warned that this may render children more vulnerable to forms of abuse, including sexual exploitation. (Source: UN Resident Coordinator, Thailand, 13 May 2005) Impact on vulnerable populations / Six southern provinces along the Andaman coastline were severely impacted. / Over 120 000 individuals working in the tourism sector lost their jobs. An additional 30 000 individuals employed in the fisheries sector lost their sources of livelihood. (Source: UN Resident Coordinator, Thailand, Six Month Report) / A total of 4806 houses were affected. Of these, 3302 were completely destroyed, and 1504 were partially damaged. (Source: UN Resident Coordinator, Thailand, Situation Report No. 11, 1 April 2005) / Approximately 5000 boats were lost or damaged. (Source: UN Resident Country Team Thailand, November 2005) / 2000 hectares of agricultural land were destroyed. (Source: UN Country Team Thailand, November 2005) / A total of 305 acres of mangroves, 3600 acres of coral, and 400 seagrass beds were impacted. (Source: UN Country Team Thailand, November 2005) / 102 large ponds, 2321 wells, and two ground wells were contaminated. (Source: UN Country Team Thailand, November 2005) / The loss of income in the tourist industry was estimated to be US$ 25 million monthly. (Source: Thailand Development Research Institute, Department of Disaster Prevention and Mitigation, 7 July 2005) / The Thai Hotels Association estimated that hotel occupancy fell by 20% in 2005. Current Thailand Tourism Authority figures suggest that Andaman region arrivals are down by 30%. (Source: UN Resident Coordinator Thailand) Damages and losses T h a i l a n d The response The Thailand disaster was the first to draw international attention because of media coverage. Pre-existing systems capacity in the health sector was strong, due to Thailand’s prior experience with epidemics of sudden acute respiratory syndrome (SARS) and avian influenza. There was a rapid social response from the local community and formal sectors. The first task during the initial 24 hours was the rescue and treatment of survivors. Those with severe injuries were evacuated to the cities, mostly Bangkok. The mortality rate of those patients who reached hospitals was only 0.3%. The MoPH rapidly activated mass casualty plans and mobilized over 200 doctors and nurses to the affected areas. On 26 December 2004, a central command centre was set up in Bangkok. Each of the affected provinces was equipped with similar centres. More than 100 teams were deployed to provide emergency medical care, while 12 other teams provided technical support and health education. The first team from Bangkok reached the field six hours after the tsunami struck. The Government did not make an appeal for aid, but welcomed technical support. The MoPH deployed surveillance and rapid response teams (SRRT) and, within a week, emergency disease surveillance systems were also functioning in the affected areas. Two Dead Victims Identification (DVI) centres were set up in Phang Nga, one for foreigners and the other for the local people. Temples made their land available for / Losses were estimated at US$ 1.6 billion and costs of repairing damage at US$ 482 million. (Source: UN Country Team Thailand, November 2005) / A total of US$ 21.4 million was requested in humanitarian assistance through the Flash Appeal. Of that, Thailand received US$ 18 million, of which US$ 7.5 million was spent as of November 2005. (Source: UN Office for the Coordination of Humanitarian Affairs [OCHA] Expenditure Tracking System). A further US$ 38.3 million was delivered in mid- to long-term recovery programming for 2005–06. (Source: UN Resident Coordinator, Thailand, 21 June 2005) Financial implications F r o m r e l i e f t o r e c o v e r y information system had broken down, and accurate information was lacking. Subjective assessments were made through the regional offices of the Department of Health (DoH). / An estimated 50 000 children were affected by the tsunami and, according to the Ministry of Education, an estimated 1480 children lost one or both parents. (Source: UN Resident Coordinator, Thailand, Situation Report No. 19, October 2005) / More women than men were killed in the tsunami. The UN Children's Fund (UNICEF) warned that this may render children more vulnerable to forms of abuse, including sexual exploitation. (Source: UN Resident Coordinator, Thailand, 13 May 2005) Impact on vulnerable populations / Six southern provinces along the Andaman coastline were severely impacted. / Over 120 000 individuals working in the tourism sector lost their jobs. An additional 30 000 individuals employed in the fisheries sector lost their sources of livelihood. (Source: UN Resident Coordinator, Thailand, Six Month Report) / A total of 4806 houses were affected. Of these, 3302 were completely destroyed, and 1504 were partially damaged. (Source: UN Resident Coordinator, Thailand, Situation Report No. 11, 1 April 2005) / Approximately 5000 boats were lost or damaged. (Source: UN Resident Country Team Thailand, November 2005) / 2000 hectares of agricultural land were destroyed. (Source: UN Country Team Thailand, November 2005) / A total of 305 acres of mangroves, 3600 acres of coral, and 400 seagrass beds were impacted. (Source: UN Country Team Thailand, November 2005) / 102 large ponds, 2321 wells, and two ground wells were contaminated. (Source: UN Country Team Thailand, November 2005) / The loss of income in the tourist industry was estimated to be US$ 25 million monthly. (Source: Thailand Development Research Institute, Department of Disaster Prevention and Mitigation, 7 July 2005) / The Thai Hotels Association estimated that hotel occupancy fell by 20% in 2005. Current Thailand Tourism Authority figures suggest that Andaman region arrivals are down by 30%. (Source: UN Resident Coordinator Thailand) Damages and losses T h a i l a n d The response The Thailand disaster was the first to draw international attention because of media coverage. Pre-existing systems capacity in the health sector was strong, due to Thailand’s prior experience with epidemics of sudden acute respiratory syndrome (SARS) and avian influenza. There was a rapid social response from the local community and formal sectors. The first task during the initial 24 hours was the rescue and treatment of survivors. Those with severe injuries were evacuated to the cities, mostly Bangkok. The mortality rate of those patients who reached hospitals was only 0.3%. The MoPH rapidly activated mass casualty plans and mobilized over 200 doctors and nurses to the affected areas. On 26 December 2004, a central command centre was set up in Bangkok. Each of the affected provinces was equipped with similar centres. More than 100 teams were deployed to provide emergency medical care, while 12 other teams provided technical support and health education. The first team from Bangkok reached the field six hours after the tsunami struck. The Government did not make an appeal for aid, but welcomed technical support. The MoPH deployed surveillance and rapid response teams (SRRT) and, within a week, emergency disease surveillance systems were also functioning in the affected areas. Two Dead Victims Identification (DVI) centres were set up in Phang Nga, one for foreigners and the other for the local people. Temples made their land available for / Losses were estimated at US$ 1.6 billion and costs of repairing damage at US$ 482 million. (Source: UN Country Team Thailand, November 2005) / A total of US$ 21.4 million was requested in humanitarian assistance through the Flash Appeal. Of that, Thailand received US$ 18 million, of which US$ 7.5 million was spent as of November 2005. (Source: UN Office for the Coordination of Humanitarian Affairs [OCHA] Expenditure Tracking System). A further US$ 38.3 million was delivered in mid- to long-term recovery programming for 2005–06. (Source: UN Resident Coordinator, Thailand, 21 June 2005) Financial implications F r o m r e l i e f t o r e c o v e r y this purpose, in keeping with the Thai culture. Several foreign teams and forensic experts assisted the government with identification of bodies and legal aspects. Immediately after the tsunami struck, the WHO Country Office got in touch with the MoPH. The WHO representative travelled to Southern Thailand to assist the Government in its needs assessment. SEARO set up a coordination centre in the UN Building (Bangkok) called the WHO Inter-country Crisis Support Unit (ICSU) for Tsunami Response. Within 72 hours, a UN Disaster and Assessment Coordination (UNDAC) mission from OCHA, Geneva was in Phuket. The UNDAC team assisted local authorities in the coordination of international support, provided an informal clearing house function for international partners, undertook initial needs assessments, and provided daily status reports to the UNCT and OCHA. WHO officials formed a part of the OCHA team. A UN country meeting was held in early January 2005 with representatives of diplomatic missions and donor agencies. UN agencies, donors and representatives of embassies identified areas of support. To ensure a coordinated and joint response by the UN agencies in Thailand, the UN Humanitarian Coordinator immediately set up a Disaster Management Team (DMT), bringing together the Heads of UNCT agencies to meet on a regular basis to coordinate support to Thailand. WHO supported existing MoPH programmes and initiatives, and provided a link to international partners such as the Centers for Disease Control (CDC), Atlanta; New York City Department of Health; bilateral donors and other UN agencies. The disposal of countless corpses was the most pressing task at hand in the early days. Many of those who had died did not have a family claimant. Several were foreign nationals and identifying the bodies was a problem. The government and health agencies were worried about the possible threat to health and the environment from the multitude of bodies. Sensitivity to cultural needs was required while disposing of dead bodies. WHO provided health education through WHO’s guidelines on appropriate Partnerships Taking stock of the situation Health priorities for WHO T h a i l a n d F r o m r e l i e f t o r e c o v e r y this purpose, in keeping with the Thai culture. Several foreign teams and forensic experts assisted the government with identification of bodies and legal aspects. Immediately after the tsunami struck, the WHO Country Office got in touch with the MoPH. The WHO representative travelled to Southern Thailand to assist the Government in its needs assessment. SEARO set up a coordination centre in the UN Building (Bangkok) called the WHO Inter-country Crisis Support Unit (ICSU) for Tsunami Response. Within 72 hours, a UN Disaster and Assessment Coordination (UNDAC) mission from OCHA, Geneva was in Phuket. The UNDAC team assisted local authorities in the coordination of international support, provided an informal clearing house function for international partners, undertook initial needs assessments, and provided daily status reports to the UNCT and OCHA. WHO officials formed a part of the OCHA team. A UN country meeting was held in early January 2005 with representatives of diplomatic missions and donor agencies. UN agencies, donors and representatives of embassies identified areas of support. To ensure a coordinated and joint response by the UN agencies in Thailand, the UN Humanitarian Coordinator immediately set up a Disaster Management Team (DMT), bringing together the Heads of UNCT agencies to meet on a regular basis to coordinate support to Thailand. WHO supported existing MoPH programmes and initiatives, and provided a link to international partners such as the Centers for Disease Control (CDC), Atlanta; New York City Department of Health; bilateral donors and other UN agencies. The disposal of countless corpses was the most pressing task at hand in the early days. Many of those who had died did not have a family claimant. Several were foreign nationals and identifying the bodies was a problem. The government and health agencies were worried about the possible threat to health and the environment from the multitude of bodies. Sensitivity to cultural needs was required while disposing of dead bodies. WHO provided health education through WHO’s guidelines on appropriate Partnerships Taking stock of the situation Health priorities for WHO T h a i l a n d F r o m r e l i e f t o r e c o v e r y T h a i l a n d management of dead bodies, and explained that corpses did not pose a disease threat, but advised workers handling corpses to use protective clothing, masks and gloves. In addition, the Organization facilitated the availability of forensic experts to help in identification of the dead. The Thai government also requested WHO's help in the area of mental health. Children, migrant workers and their families were deeply traumatized mentally. The MoPH surveyed over 10 000 people in the first two weeks of the disaster and treated many of the affected survivors for mental stress. Within a week, the MoPH also introduced a disease surveillance system to detect diarrhoea, food poisoning, and respiratory and wound infections. SRRT were deployed to four of the six provinces most severely affected—Phuket, Phang Nga, Krabi and Ranong. The role of the SRRT was to assess health needs and risk of outbreaks, and set up surveillance systems. In case of a suspected outbreak, appropriate investigations were carried out and disease control measures initiated. The teams also assessed the response to these measures. The information obtained from the SSRT was shared with WHO on a routine basis. The government was in control of the situation from the beginning and established a coordinative structure. Various ministries handled various aspects: = Ministry of Interior: Responsible for overall coordination = Ministry of Public Health: Situation in hospitals, disease surveillance and control, mental health, environmental health, sanitation = Ministry of Foreign Affairs: International community = Army: Coordination and rescue = Police and Ministry of Justice: Forensic (in addition, there were 31 international forensic teams active in the affected areas) = Ministry of Social Welfare and Human Security: Initial compensation The Thai government requested technical support from WHO and its partners. Health situation COORDINATION GAP-FILLING AND CAPACITY-BUILDING F r o m r e l i e f t o r e c o v e r y T h a i l a n d management of dead bodies, and explained that corpses did not pose a disease threat, but advised workers handling corpses to use protective clothing, masks and gloves. In addition, the Organization facilitated the availability of forensic experts to help in identification of the dead. The Thai government also requested WHO's help in the area of mental health. Children, migrant workers and their families were deeply traumatized mentally. The MoPH surveyed over 10 000 people in the first two weeks of the disaster and treated many of the affected survivors for mental stress. Within a week, the MoPH also introduced a disease surveillance system to detect diarrhoea, food poisoning, and respiratory and wound infections. SRRT were deployed to four of the six provinces most severely affected—Phuket, Phang Nga, Krabi and Ranong. The role of the SRRT was to assess health needs and risk of outbreaks, and set up surveillance systems. In case of a suspected outbreak, appropriate investigations were carried out and disease control measures initiated. The teams also assessed the response to these measures. The information obtained from the SSRT was shared with WHO on a routine basis. The government was in control of the situation from the beginning and established a coordinative structure. Various ministries handled various aspects: = Ministry of Interior: Responsible for overall coordination = Ministry of Public Health: Situation in hospitals, disease surveillance and control, mental health, environmental health, sanitation = Ministry of Foreign Affairs: International community = Army: Coordination and rescue = Police and Ministry of Justice: Forensic (in addition, there were 31 international forensic teams active in the affected areas) = Ministry of Social Welfare and Human Security: Initial compensation The Thai government requested technical support from WHO and its partners. Health situation COORDINATION GAP-FILLING AND CAPACITY-BUILDING F r o m r e l i e f t o r e c o v e r y PHASE II: ACTIVE INTERVENTIONS ASSESSMENTS AND MONITORING All basic urgent needs had been dealt with in the emergency phase. Schools had resumed within two weeks despite ongoing repair work. Debris was being removed. Health assessments were conducted rapidly by the command centres set up in each province. Immediate health needs were identified and public health interventions prioritized. To meet these needs, the MoPH rapidly activated mass casualty plans and deployed personnel and resources. Five teams conducted active surveillance and investigated potential outbreaks. Regional teams were sent to the six affected provinces. The surveillance system used to track and respond to the SARS outbreak was built upon, so that risks of outbreak could be rapidly assessed and addressed. Sanitation, environmental and community mental health needs were also assessed. T h a i l a n d Laboratories were supplemented with additional staff and equipment. Data collection was done on a daily basis from all hospital and health units using a WHO rapid assessment tool. Monitoring was done for diseases with epidemic potential through the data collected by the SRRT. The diseases that were mostly found included diarrhoea, infected wounds and atypical pneumonia. Dengue, malaria, jaundice, conjunctivitis, chicken pox and mumps were also reported. However, the incidence of these diseases was no higher than that reported in previous years. The Thai Government requested WHO's assistance in conducting rapid health and needs assessment, and monitoring and reporting communicable disease outbreaks. WHO also provided technical information and guidelines for forensic operations and psychological and mental health, sanitation and water safety, and health promotion. Medical and rehabilitation care of elderly patients was also supported by WHO. WHO’s biggest contribution was the training and strengthening of the public health infrastructure that it had been providing in the past. The most important aspect was the training of field epidemiologists under the Field Epidemiology Training Programme (FETP) and capacity-building in the area of disaster preparedness. Infrastructure, staffing and funding support was provided for forensic operations and psychosocial trauma. Capacity-strengthening was done for active disease surveillance and environmental health in emergencies. WHO provided laboratory support to the Department of Medical Science. WHO funded over 30 projects, including: = Strengthening expertise in disaster preparedness including engineering aspects for building hospitals and health settings = Strengthening disease surveillance and response = Providing psychological care and mental health support (particularly in the area of long-term psychological effects of the disaster on children) = Development of environmental health, health promotion, care and treatment services = Documentation and sharing of experiences. Role of WHO COORDINATION AND GAP-FILLING F r o m r e l i e f t o r e c o v e r y PHASE II: ACTIVE INTERVENTIONS ASSESSMENTS AND MONITORING All basic urgent needs had been dealt with in the emergency phase. Schools had resumed within two weeks despite ongoing repair work. Debris was being removed. Health assessments were conducted rapidly by the command centres set up in each province. Immediate health needs were identified and public health interventions prioritized. To meet these needs, the MoPH rapidly activated mass casualty plans and deployed personnel and resources. Five teams conducted active surveillance and investigated potential outbreaks. Regional teams were sent to the six affected provinces. The surveillance system used to track and respond to the SARS outbreak was built upon, so that risks of outbreak could be rapidly assessed and addressed. Sanitation, environmental and community mental health needs were also assessed. T h a i l a n d Laboratories were supplemented with additional staff and equipment. Data collection was done on a daily basis from all hospital and health units using a WHO rapid assessment tool. Monitoring was done for diseases with epidemic potential through the data collected by the SRRT. The diseases that were mostly found included diarrhoea, infected wounds and atypical pneumonia. Dengue, malaria, jaundice, conjunctivitis, chicken pox and mumps were also reported. However, the incidence of these diseases was no higher than that reported in previous years. The Thai Government requested WHO's assistance in conducting rapid health and needs assessment, and monitoring and reporting communicable disease outbreaks. WHO also provided technical information and guidelines for forensic operations and psychological and mental health, sanitation and water safety, and health promotion. Medical and rehabilitation care of elderly patients was also supported by WHO. WHO’s biggest contribution was the training and strengthening of the public health infrastructure that it had been providing in the past. The most important aspect was the training of field epidemiologists under the Field Epidemiology Training Programme (FETP) and capacity-building in the area of disaster preparedness. Infrastructure, staffing and funding support was provided for forensic operations and psychosocial trauma. Capacity-strengthening was done for active disease surveillance and environmental health in emergencies. WHO provided laboratory support to the Department of Medical Science. WHO funded over 30 projects, including: = Strengthening expertise in disaster preparedness including engineering aspects for building hospitals and health settings = Strengthening disease surveillance and response = Providing psychological care and mental health support (particularly in the area of long-term psychological effects of the disaster on children) = Development of environmental health, health promotion, care and treatment services = Documentation and sharing of experiences. Role of WHO COORDINATION AND GAP-FILLING F r o m r e l i e f t o r e c o v e r y Health systems and infrastructure Water and sanitation A Central Operation Centre was established in Phuket and a high-ranking health administrator was appointed the health commander in each province. Local health offices were also set up. A Health Rehabilitation Centre was established in the affected provinces to oversee work done at the district level. In addition to teams at the local level, the Thai Government mobilized about 80 doctors. Sanitation teams were assembled from the field operation teams of the DoH's Regional Centres, and worked with over 2000 volunteers. Their role was to improve sanitation at the affected sites, and ensure safe water supply through water treatment. The Department of Medical Science provided laboratory support. WHO assisted in sanitation improvement at the affected sites, and in water quality monitoring. T h a i l a n d Surveillance was also done for food safety and improvement, and for disposal of garbage and waste management. Surveillance and Rapid Response Teams set up surveillance measures, conducted outbreak investigations, initiated and coordinated disease prevention and control, and assessed the response to control measures implemented. The MoPH implemented active surveillance for 20 diseases, as well as for wound infection and electric shock in all the affected districts. Vector conrol teams sprayed insecticides and provided health education. Spraying was carried out at the affected sites, corpse collection areas and around the shelters. Active surveillance, and prevention and control of vector-borne diseases were carried out by these teams. Data were collected from all medical facilities (77 health centres, 22 public hospitals and four private hospitals), two shelters for displaced people and the two forensic identification centres. Surveillance team members visited 119 sites daily, and collected data on the syndromic reporting of epidemic-prone diseases by age, sex and nationality from local hospitals and health centres, private hospitals and clinics, rescue and relief centres, and first-aid units. Daily summary reports for the 20 diseases were prepared and the information was analysed, with the population data for 2004 used as a baseline reference for incidences. The expertise of the field epidemiologists trained by WHO and US/CDC under the FETP was fully utilized. Official records indicated that there were 928 orphans who had lost both parents. Of these, only two were in a situation where they could not be cared for by relatives, highlighting the extended family concept which is a part of Thai culture. No specific child-focused mental health interventions could be provided for affected children and adolescents, but a symptom checklist was developed. Problems among school-age children were addressed through the previously established School Advisory Programme, which was in place in all schools. This was used to identify “high-risk” children. Almost all schools had a guidance teacher trained by child psychiatrists from the DoPH, who identified problems and provided group therapy. Children were also provided routine health-care services through the Surveillance systems Child and adolescent health F r o m r e l i e f t o r e c o v e r y Health systems and infrastructure Water and sanitation A Central Operation Centre was established in Phuket and a high-ranking health administrator was appointed the health commander in each province. Local health offices were also set up. A Health Rehabilitation Centre was established in the affected provinces to oversee work done at the district level. In addition to teams at the local level, the Thai Government mobilized about 80 doctors. Sanitation teams were assembled from the field operation teams of the DoH's Regional Centres, and worked with over 2000 volunteers. Their role was to improve sanitation at the affected sites, and ensure safe water supply through water treatment. The Department of Medical Science provided laboratory support. WHO assisted in sanitation improvement at the affected sites, and in water quality monitoring. T h a i l a n d Surveillance was also done for food safety and improvement, and for disposal of garbage and waste management. Surveillance and Rapid Response Teams set up surveillance measures, conducted outbreak investigations, initiated and coordinated disease prevention and control, and assessed the response to control measures implemented. The MoPH implemented active surveillance for 20 diseases, as well as for wound infection and electric shock in all the affected districts. Vector conrol teams sprayed insecticides and provided health education. Spraying was carried out at the affected sites, corpse collection areas and around the shelters. Active surveillance, and prevention and control of vector-borne diseases were carried out by these teams. Data were collected from all medical facilities (77 health centres, 22 public hospitals and four private hospitals), two shelters for displaced people and the two forensic identification centres. Surveillance team members visited 119 sites daily, and collected data on the syndromic reporting of epidemic-prone diseases by age, sex and nationality from local hospitals and health centres, private hospitals and clinics, rescue and relief centres, and first-aid units. Daily summary reports for the 20 diseases were prepared and the information was analysed, with the population data for 2004 used as a baseline reference for incidences. The expertise of the field epidemiologists trained by WHO and US/CDC under the FETP was fully utilized. Official records indicated that there were 928 orphans who had lost both parents. Of these, only two were in a situation where they could not be cared for by relatives, highlighting the extended family concept which is a part of Thai culture. No specific child-focused mental health interventions could be provided for affected children and adolescents, but a symptom checklist was developed. Problems among school-age children were addressed through the previously established School Advisory Programme, which was in place in all schools. This was used to identify “high-risk” children. Almost all schools had a guidance teacher trained by child psychiatrists from the DoPH, who identified problems and provided group therapy. Children were also provided routine health-care services through the Surveillance systems Child and adolescent health F r o m r e l i e f t o r e c o v e r y community clinic system. The Mental Health Recovery Centre (MHRC) of the DMH implemented child recovery activities and supported UNICEF, the Adventist Development and Relief Agency (ADRA) and World Vision in these activities. The Thai Government mobilized its own resources. The first mobile mental health team visited the affected community on 29 December 2004. Six mobile teams of mental health specialists, one for each affected Province, assisted the population. The DMH opened the MHRC in Phang Nga Province with a psychiatrist and part- time mobile support teams from Surat Thani Psychiatric Hospital. This programme will run for three years. The country's system of village health volunteers (VHVs) served as a model for the provision of psychosocial support to the tsunami-affected people. More than 700 000 VHVs were mobilized for community-based psychosocial support. The Thai Red Cross mobilized thousands of volunteer workers from all over Thailand to give assistance and support. Locals who needed in-depth mental health support were sent to Surat Thani Psychiatric Hospital and foreigners were sent to Phang Nga General Province Hospital. As of 19 January 2005, a total of 7423 survivors had sought psychiatric help (MOPH unpublished data, 2005). Community health centre staff visited every affected family and if any of them had symptoms related to mental health, the WHO GHQ-12 was administered. Based on the score, affected persons were referred to the mobile mental health team for assessment and appropriate care. Repeated administration of the questionnaire to the same people showed that the level of psychological distress diminished over time, indicating a positive response to the interventions. Thailand was the only country that carried out a structured, quantitative assessment of psychological distress in the community. This information was used during the emergency phase for evidence-based psychological support and to measure the outcome of the relief efforts. WHO SEARO assembled a team of mental health experts who visited Thailand; they assessed that the work done by the volunteers was outstanding. Teachers, monks and other partners supplemented the efforts of the volunteers. The DMH produced information to be used by lay people specifically for the support of survivors (one specifically for use by monks). However, further mental health interventions will be needed for residents of coastal communities. Mental health T h a i l a n d Communicable diseases CAPACITY-BUILDING By 9 January 2005, the MoPH had mobilized a team of 200 surveillance and response officials to investigate disease outbreaks in the four provinces that suffered the most casualties from the tsunami. Since 1970, the MoPH had been operating a national surveillance system for infectious diseases by using a standard reporting form, which had 68 diseases under surveillance by 2000. The MoPH implemented active surveillance for 20 diseases, based on the national passive surveillance system for infectious diseases. No outbreaks of communicable diseases were reported. UN agencies = WHO set up operations centres at country and subregional levels to coordinate activities with UN and government counterparts. = UNICEF expressed concern on the protection of children in open camps. In Phang Nga, systems were not in place, and there were rumours of children, particularly orphans, being kidnapped. There was also the danger of sexual abuse. Training in psychosocial rehabilitation was held for teachers in all schools in Phang Nga Province. = FAO jointly with the Ministry of Agriculture conducted technical assessments. = UNHCR sought information on the number of displaced migrant workers (registered and illegal). = WFP assessed the food situation and declared that there was no immediate need for food. F r o m r e l i e f t o r e c o v e r y community clinic system. The Mental Health Recovery Centre (MHRC) of the DMH implemented child recovery activities and supported UNICEF, the Adventist Development and Relief Agency (ADRA) and World Vision in these activities. The Thai Government mobilized its own resources. The first mobile mental health team visited the affected community on 29 December 2004. Six mobile teams of mental health specialists, one for each affected Province, assisted the population. The DMH opened the MHRC in Phang Nga Province with a psychiatrist and part- time mobile support teams from Surat Thani Psychiatric Hospital. This programme will run for three years. The country's system of village health volunteers (VHVs) served as a model for the provision of psychosocial support to the tsunami-affected people. More than 700 000 VHVs were mobilized for community-based psychosocial support. The Thai Red Cross mobilized thousands of volunteer workers from all over Thailand to give assistance and support. Locals who needed in-depth mental health support were sent to Surat Thani Psychiatric Hospital and foreigners were sent to Phang Nga General Province Hospital. As of 19 January 2005, a total of 7423 survivors had sought psychiatric help (MOPH unpublished data, 2005). Community health centre staff visited every affected family and if any of them had symptoms related to mental health, the WHO GHQ-12 was administered. Based on the score, affected persons were referred to the mobile mental health team for assessment and appropriate care. Repeated administration of the questionnaire to the same people showed that the level of psychological distress diminished over time, indicating a positive response to the interventions. Thailand was the only country that carried out a structured, quantitative assessment of psychological distress in the community. This information was used during the emergency phase for evidence-based psychological support and to measure the outcome of the relief efforts. WHO SEARO assembled a team of mental health experts who visited Thailand; they assessed that the work done by the volunteers was outstanding. Teachers, monks and other partners supplemented the efforts of the volunteers. The DMH produced information to be used by lay people specifically for the support of survivors (one specifically for use by monks). However, further mental health interventions will be needed for residents of coastal communities. Mental health T h a i l a n d Communicable diseases CAPACITY-BUILDING By 9 January 2005, the MoPH had mobilized a team of 200 surveillance and response officials to investigate disease outbreaks in the four provinces that suffered the most casualties from the tsunami. Since 1970, the MoPH had been operating a national surveillance system for infectious diseases by using a standard reporting form, which had 68 diseases under surveillance by 2000. The MoPH implemented active surveillance for 20 diseases, based on the national passive surveillance system for infectious diseases. No outbreaks of communicable diseases were reported. UN agencies = WHO set up operations centres at country and subregional levels to coordinate activities with UN and government counterparts. = UNICEF expressed concern on the protection of children in open camps. In Phang Nga, systems were not in place, and there were rumours of children, particularly orphans, being kidnapped. There was also the danger of sexual abuse. Training in psychosocial rehabilitation was held for teachers in all schools in Phang Nga Province. = FAO jointly with the Ministry of Agriculture conducted technical assessments. = UNHCR sought information on the number of displaced migrant workers (registered and illegal). = WFP assessed the food situation and declared that there was no immediate need for food. F r o m r e l i e f t o r e c o v e r y T h a i l a n d PHASE III: REVIEW AND CONSOLIDATION ASSESSMENTS AND MONITORING COORDINATION AND GAP-FILLING The tsunami was a disaster of great magnitude such that systems in place for preparedness were tested to the maximum. Indeed, strengthening and more exercises and training were needed to ensure emergency preparedness. Essential items (including vaccines and medicines) needed to be stockpiled adequately in case of emergencies, which were found lacking during the tsunami disaster. Communication systems also needed enhancement. Restructuring of the MoPH was required for disaster management, with staff trained for the purpose. A pre-planned coordination and command system needed to be put in place. Thailand’s capacity for international coordination was also limited. A joint mission (UNDP, FAO, World Bank) looked into the medium- and long- term recovery phase. The mission assessed livelihood recovery and environmental rehabilitation. The experiences in Thailand underscored the value of written and rehearsed disaster plans, capacity for rapid mobilization, local coordination of relief activities and active public health surveillance. In the area of mental health, although the infrastructure was in place, Thailand’s mental health services were understaffed at all levels, in particular at the level of community-based care and services. The DMH is working with the Medical Council for solutions; developing specialist psychiatric nursing, increasing medical practitioner skills, scholarships and the number of psychiatric residencies. The DMH “National Guidelines for Mental Health Interventions in Natural Disasters” was found to be comprehensive but did not go far enough. At the community level it did not cover planning for preparedness in emergency. The MoPH was assisted by WHO in over 30 projects, including forensic science, the architectural engineering aspects of building hospitals and other public health infrastructure in disaster-prone areas, mental health, and capacity-building in disease surveillance as well as the development of mobile emergency response units. The communication team at SEARO was strengthened with additional staff and professional communication officers were in place in Thailand and in the Regional Office for the longer term. F r o m r e l i e f t o r e c o v e r y T h a i l a n d PHASE III: REVIEW AND CONSOLIDATION ASSESSMENTS AND MONITORING COORDINATION AND GAP-FILLING The tsunami was a disaster of great magnitude such that systems in place for preparedness were tested to the maximum. Indeed, strengthening and more exercises and training were needed to ensure emergency preparedness. Essential items (including vaccines and medicines) needed to be stockpiled adequately in case of emergencies, which were found lacking during the tsunami disaster. Communication systems also needed enhancement. Restructuring of the MoPH was required for disaster management, with staff trained for the purpose. A pre-planned coordination and command system needed to be put in place. Thailand’s capacity for international coordination was also limited. A joint mission (UNDP, FAO, World Bank) looked into the medium- and long- term recovery phase. The mission assessed livelihood recovery and environmental rehabilitation. The experiences in Thailand underscored the value of written and rehearsed disaster plans, capacity for rapid mobilization, local coordination of relief activities and active public health surveillance. In the area of mental health, although the infrastructure was in place, Thailand’s mental health services were understaffed at all levels, in particular at the level of community-based care and services. The DMH is working with the Medical Council for solutions; developing specialist psychiatric nursing, increasing medical practitioner skills, scholarships and the number of psychiatric residencies. The DMH “National Guidelines for Mental Health Interventions in Natural Disasters” was found to be comprehensive but did not go far enough. At the community level it did not cover planning for preparedness in emergency. The MoPH was assisted by WHO in over 30 projects, including forensic science, the architectural engineering aspects of building hospitals and other public health infrastructure in disaster-prone areas, mental health, and capacity-building in disease surveillance as well as the development of mobile emergency response units. The communication team at SEARO was strengthened with additional staff and professional communication officers were in place in Thailand and in the Regional Office for the longer term. F r o m r e l i e f t o r e c o v e r y T h a i l a n d WHO played a supporting role, enabling the government to further strengthen the national capacity and quality of the health force. The project on management of dead bodies (including forensic identification of dead bodies) contributed to building capacity at the Regional level. WHO Thailand has since worked closely with the MoPH on the development, implementation, monitoring and coordination of disaster relief from the emergency phase to the rehabilitation phase. One of WHO’s most important roles was assisting the health authorities in coordinating the work of hundreds of health agencies and NGOs involved in tsunami relief activities. The main thrust for mobilization of multisectoral cooperation and national resources was given by the leadership of the Government and MoPH administrators. = The field coordination and command system worked, although it took time to establish, and contributed to the success of disease control and fast recovery of local systems. = There were no disease epidemics. = A Mental Health Centre was established and training programmes for health volunteers conducted. = Guidelines were revised for emergency health management and preparedness. = Public health infrastructure was strengthened. = Information and communication systems were improved. = Technical specialists were trained in all facets of emergency preparedness. = Technical capacity was built in the areas of forensic medicine, psychosocial care, epidemiology, migrant health, and disaster preparedness and response. = Re-establish the standing office at the MoPH to coordinate preparedness and response during public health emergencies. = Assign and train persons responsible for coordination of public health emergencies at the provincial and local levels. = Further develop preparedness plans for disaster management at the national and local levels, and exercise the plans. ACHIEVEMENTS CHALLENGES AHEAD To do better at the national level, Thailand needs to undertake the following: = Build capacity for surveillance and disease control such as training staff and strengthening the surveillance network. = Provide further mental health interventions for tsunami-affected residents of coastal communities. = Improve the infrastructure for and quality control of water and sanitation. = Further train laboratory staff and improve laboratory facilities. = Improve systems for procurement, stockpiling, monitoring and supply of essential items for a public health emergency response. = Promote public education and communication on the prevention as well as reduction of public health risks. = Collaborate to develop a regional/international early warning system for public health threats and disasters. = Advocate and cooperate in the establishment of international stockpiles (e.g. vaccines, medicines), urging WHO to take lead in the development of such stockpiles. = Improve organizational capacity for international communication and coordination. To do better at the international level, the following issues were identified: F r o m r e l i e f t o r e c o v e r y T h a i l a n d WHO played a supporting role, enabling the government to further strengthen the national capacity and quality of the health force. The project on management of dead bodies (including forensic identification of dead bodies) contributed to building capacity at the Regional level. WHO Thailand has since worked closely with the MoPH on the development, implementation, monitoring and coordination of disaster relief from the emergency phase to the rehabilitation phase. One of WHO’s most important roles was assisting the health authorities in coordinating the work of hundreds of health agencies and NGOs involved in tsunami relief activities. The main thrust for mobilization of multisectoral cooperation and national resources was given by the leadership of the Government and MoPH administrators. = The field coordination and command system worked, although it took time to establish, and contributed to the success of disease control and fast recovery of local systems. = There were no disease epidemics. = A Mental Health Centre was established and training programmes for health volunteers conducted. = Guidelines were revised for emergency health management and preparedness. = Public health infrastructure was strengthened. = Information and communication systems were improved. = Technical specialists were trained in all facets of emergency preparedness. = Technical capacity was built in the areas of forensic medicine, psychosocial care, epidemiology, migrant health, and disaster preparedness and response. = Re-establish the standing office at the MoPH to coordinate preparedness and response during public health emergencies. = Assign and train persons responsible for coordination of public health emergencies at the provincial and local levels. = Further develop preparedness plans for disaster management at the national and local levels, and exercise the plans. ACHIEVEMENTS CHALLENGES AHEAD To do better at the national level, Thailand needs to undertake the following: = Build capacity for surveillance and disease control such as training staff and strengthening the surveillance network. = Provide further mental health interventions for tsunami-affected residents of coastal communities. = Improve the infrastructure for and quality control of water and sanitation. = Further train laboratory staff and improve laboratory facilities. = Improve systems for procurement, stockpiling, monitoring and supply of essential items for a public health emergency response. = Promote public education and communication on the prevention as well as reduction of public health risks. = Collaborate to develop a regional/international early warning system for public health threats and disasters. = Advocate and cooperate in the establishment of international stockpiles (e.g. vaccines, medicines), urging WHO to take lead in the development of such stockpiles. = Improve organizational capacity for international communication and coordination. To do better at the international level, the following issues were identified: PHASE I: EMERGENCY RELIEF ASSESSMENT Affected areas The tsunami affected limited areas in the Ayeyarwaddy Division, Tanantharyi Division, Yangon Division and Rakhine State. In Ayeyarwaddy Division, Nguputaw, Labutta and Bogale townships were affected. In Yangon Division, Cocogyun was slightly affected. In Rakkhine State, Sittwe, Manaung, Thandwe, Ramree, Myebon, Kyaukpyu, Gwa and Taungup townships were affected. In Tanitharyi Division, Kawthaung district was affected. Myanmar was less affected due to a number of factors. There is a high underwater range of mountains underneath the Andaman and Nicobar Islands. The south is protected by numerous offshore islands (Myeik archipelago). Traditional and local customs also played a part. There was a full moon on 26 December; most people do not go out to sea for fishing during a full moon. In addition, it was low tide at the time of the tsunami. Fortunately, the population density in the affected areas is low. Myanmar 61 61 UN Office for the Coordination of Humanitarian Affairs (OCHA)–UNDP, Brief on Tsunami Response in Six Less Affected Countries, November 2005. Country Fatalities Total Source 1Missing 1 Some countries have not disaggregated between the deceased and the missing.M AG NI TU DE MYANMAR PHASE I: EMERGENCY RELIEF ASSESSMENT Affected areas The tsunami affected limited areas in the Ayeyarwaddy Division, Tanantharyi Division, Yangon Division and Rakhine State. In Ayeyarwaddy Division, Nguputaw, Labutta and Bogale townships were affected. In Yangon Division, Cocogyun was slightly affected. In Rakkhine State, Sittwe, Manaung, Thandwe, Ramree, Myebon, Kyaukpyu, Gwa and Taungup townships were affected. In Tanitharyi Division, Kawthaung district was affected. Myanmar was less affected due to a number of factors. There is a high underwater range of mountains underneath the Andaman and Nicobar Islands. The south is protected by numerous offshore islands (Myeik archipelago). Traditional and local customs also played a part. There was a full moon on 26 December; most people do not go out to sea for fishing during a full moon. In addition, it was low tide at the time of the tsunami. Fortunately, the population density in the affected areas is low. Myanmar 61 61 UN Office for the Coordination of Humanitarian Affairs (OCHA)–UNDP, Brief on Tsunami Response in Six Less Affected Countries, November 2005. Country Fatalities Total Source 1Missing 1 Some countries have not disaggregated between the deceased and the missing.M AG NI TU DE MYANMAR F r o m r e l i e f t o r e c o v e r y Affected population The response Partnerships CAPACITY-BUILDING People along the southern coast were affected; 61 died and 43 were injured. Damage to public health infrastructure was minimal. In 17 villages, 601 houses were destroyed and 2592 were homeless. The total loss to property was valued at 1585.6 million kyats. The Government set up temporary shelters/distribution points and distributed essential items to households. The MoH provided emergency medical care, established an early warning surveillance system, ensured safe water and sanitation and food, instituted vector control measures, and provided immunization, health education and social mobilization immediately. All dead bodies were managed by the local people in the traditional manner. WHO's response was closely coordinated with the UN disaster preparedness and management group and with international NGOs, through the Red Cross-led Tsunami Assistance Coordination Group. WHO's primary role was that of providing technical support to the MoH. WHO technical guidelines for emergencies were disseminated. Regular updates to the diplomatic and international community were organized through distribution of situation reports and WHO press releases. WHO focused on reducing the risk of disease outbreaks and morbidity by supporting disease surveillance and providing emergency medical supplies as requested by the MoH. WHO's response during the emergency phase was closely coordinated with the UN disaster preparedness and management group, and international and national NGOs. WHO's primary role of providing technical support to the MoH was maintained throughout this phase. Five sets of new emergency health kits were handed over to the Ministry, along with 22 680 treatment courses of antimalarial drugs (CoArtem), donated by a major pharmaceutical company to address the potential risk of a malaria outbreak in coastal areas. PHASE II: ACTIVE INTERVENTIONS ASSESSMENTS AND MONITORING COORDINATION AND GAP-FILLING WHO support Rehabilitation of those directly affected and rebuilding basic health facilities were the short-term needs. The limited impact of the tsunami in Myanmar resulted in limited fund-raising, and available funds were used to strengthen national and local capacities for disaster preparedness and response. A work-plan was made for technical assistance, development of a system for early warning and timely response, post- disaster health needs assessment, replacement of lost a s s e t s , and e f f e c t i v e coord ina t ion and communication. The MoH put together a proposal for disaster preparedness and response, for which SEARO allotted funds and UN OCHA (Turkey) supported the recruitment of an international consultant. Priorities included the provision of supplies and equipment, strengthening disease surveillance, setting up operation rooms at the MoH and the WHO Country Office, along with other measures to strengthen national capacity in order to respond to any major incident. Activities included: = Renovation of affected health infrastructure = Development of a National Disaster Preparedness Plan = Production of information, education and communication (IEC) materials for basic health staff and the community = Procurement of personal protective equipment = Procurement of rapid test kits and other laboratory items = Operations room support for the Department of Health M y a n m a r F r o m r e l i e f t o r e c o v e r y Affected population The response Partnerships CAPACITY-BUILDING People along the southern coast were affected; 61 died and 43 were injured. Damage to public health infrastructure was minimal. In 17 villages, 601 houses were destroyed and 2592 were homeless. The total loss to property was valued at 1585.6 million kyats. The Government set up temporary shelters/distribution points and distributed essential items to households. The MoH provided emergency medical care, established an early warning surveillance system, ensured safe water and sanitation and food, instituted vector control measures, and provided immunization, health education and social mobilization immediately. All dead bodies were managed by the local people in the traditional manner. WHO's response was closely coordinated with the UN disaster preparedness and management group and with international NGOs, through the Red Cross-led Tsunami Assistance Coordination Group. WHO's primary role was that of providing technical support to the MoH. WHO technical guidelines for emergencies were disseminated. Regular updates to the diplomatic and international community were organized through distribution of situation reports and WHO press releases. WHO focused on reducing the risk of disease outbreaks and morbidity by supporting disease surveillance and providing emergency medical supplies as requested by the MoH. WHO's response during the emergency phase was closely coordinated with the UN disaster preparedness and management group, and international and national NGOs. WHO's primary role of providing technical support to the MoH was maintained throughout this phase. Five sets of new emergency health kits were handed over to the Ministry, along with 22 680 treatment courses of antimalarial drugs (CoArtem), donated by a major pharmaceutical company to address the potential risk of a malaria outbreak in coastal areas. PHASE II: ACTIVE INTERVENTIONS ASSESSMENTS AND MONITORING COORDINATION AND GAP-FILLING WHO support Rehabilitation of those directly affected and rebuilding basic health facilities were the short-term needs. The limited impact of the tsunami in Myanmar resulted in limited fund-raising, and available funds were used to strengthen national and local capacities for disaster preparedness and response. A work-plan was made for technical assistance, development of a system for early warning and timely response, post- disaster health needs assessment, replacement of lost a s s e t s , and e f f e c t i v e coord ina t ion and communication. The MoH put together a proposal for disaster preparedness and response, for which SEARO allotted funds and UN OCHA (Turkey) supported the recruitment of an international consultant. Priorities included the provision of supplies and equipment, strengthening disease surveillance, setting up operation rooms at the MoH and the WHO Country Office, along with other measures to strengthen national capacity in order to respond to any major incident. Activities included: = Renovation of affected health infrastructure = Development of a National Disaster Preparedness Plan = Production of information, education and communication (IEC) materials for basic health staff and the community = Procurement of personal protective equipment = Procurement of rapid test kits and other laboratory items = Operations room support for the Department of Health M y a n m a r F r o m r e l i e f t o r e c o v e r y M y a n m a r = Provision of basic units of new emergency health kits (NEHK) and supplementary kits = Provision of drugs, insecticides, bed-nets, fogging machines and rapid diagnostic tests for malaria control. The WHO Country Office designated a focal person and formed a Tsunami Response Group. The overall purpose of the MoH was to protect the health of the survivors and others affected by the tsunami. To this end, the MoH took care of water and sanitation needs, immunization of vulnerable populations, vector control by spraying insecticides, and health education and social mobilization. The MoH established a disease surveillance system to provide early warning of emerging health threats, so that a timely response could be initiated. This facilitated early recovery and rehabilitation. Surveillance data were compiled and used to signal any likely disease outbreak or unusual health event. Regular communication was maintained at all levels and daily situation reports were compiled. No outbreaks were reported. The tsunami caused limited damage in Myanmar, but provided the opportunity for the country to strengthen and update the National Disaster Management and Preparedness Plan. Surveillance systems are in place but may need to be strengthened for the surveillance of risk factors, disease identification and response. An early warning system, and an advocacy and awareness system are in place. Disaster-prone areas have been mapped. Capacity-building and logistics support are areas that need strengthening. Emergency supplies and buffer stocks need to be available at all times, and delivery mechanisms of these streamlined. Community empowerment has been strengthened, which is crucial for effective response in emergencies. Health systems and infrastructure Surveillance systems PHASE III: REVIEW AND CONSOLIDATION Health protection and disease prevention Health service delivery enhancement Health policy and coordination Support expected from WHO The Central Committee for National Disaster Prevention was formed. The disaster management and response programme is in place with Central, State/Division, township, villager tract/ward and village-level working committees. A disaster preparedness and response plan of the Department of Health is in place with the Central, State and Division Health Departments. The roles and responsibilities of each is clearly defined. The areas identified for support include training, logistics support, technical assistance, and information, education and communication (IEC). For infrastructure development, Myanmar requires laboratory equipment and supplies for the surveillance of communicable diseases following a disaster. Transport and communication equipment are other needs. F r o m r e l i e f t o r e c o v e r y M y a n m a r = Provision of basic units of new emergency health kits (NEHK) and supplementary kits = Provision of drugs, insecticides, bed-nets, fogging machines and rapid diagnostic tests for malaria control. The WHO Country Office designated a focal person and formed a Tsunami Response Group. The overall purpose of the MoH was to protect the health of the survivors and others affected by the tsunami. To this end, the MoH took care of water and sanitation needs, immunization of vulnerable populations, vector control by spraying insecticides, and health education and social mobilization. The MoH established a disease surveillance system to provide early warning of emerging health threats, so that a timely response could be initiated. This facilitated early recovery and rehabilitation. Surveillance data were compiled and used to signal any likely disease outbreak or unusual health event. Regular communication was maintained at all levels and daily situation reports were compiled. No outbreaks were reported. The tsunami caused limited damage in Myanmar, but provided the opportunity for the country to strengthen and update the National Disaster Management and Preparedness Plan. Surveillance systems are in place but may need to be strengthened for the surveillance of risk factors, disease identification and response. An early warning system, and an advocacy and awareness system are in place. Disaster-prone areas have been mapped. Capacity-building and logistics support are areas that need strengthening. Emergency supplies and buffer stocks need to be available at all times, and delivery mechanisms of these streamlined. Community empowerment has been strengthened, which is crucial for effective response in emergencies. Health systems and infrastructure Surveillance systems PHASE III: REVIEW AND CONSOLIDATION Health protection and disease prevention Health service delivery enhancement Health policy and coordination Support expected from WHO The Central Committee for National Disaster Prevention was formed. The disaster management and response programme is in place with Central, State/Division, township, villager tract/ward and village-level working committees. A disaster preparedness and response plan of the Department of Health is in place with the Central, State and Division Health Departments. The roles and responsibilities of each is clearly defined. The areas identified for support include training, logistics support, technical assistance, and information, education and communication (IEC). For infrastructure development, Myanmar requires laboratory equipment and supplies for the surveillance of communicable diseases following a disaster. Transport and communication equipment are other needs. Looking to the future BACKGROUND EVALUATION OF THE SEARO RESPONSE RECOMMENDATIONS All countries and several agencies, both national and regional, have conducted lessons learnt exercises and taken steps to address the issues identified. From these evaluations and learning events, Member States and WHO will take their cue for steps in the future. Several initiatives have come forth from the tsunami that have provided the impetus for reform in national governments and the UN itself, which is taking concrete steps in the humanitarian reform process. This chapter outlines how these lessons are shaping the future for better preparedness and risk reduction. As a lessons learnt exercise, a comprehensive evaluation was carried out of the WHO SEARO response to the tsunami by an independent team of consultants. The team comprised Manuel Carballo of the International Centre for Migration, Geneva, and Nuntavarn Vichit-Vadakan and Marc Ven der Putten of the Thammasat University, Thailand. The team made the following recommendations. 1. SEARO should allocate greater priority to disaster preparedness and response and gear up its structures and functions accordingly. 2. SEARO should prepare a five-year plan of work with all technical and administrative units showing how they will work with, and to, EHA in disasters and how they will relate to HAC/HQ. 3. SEARO should seek a regional partner or partners that can assist with procurement, warehousing and deployment of supplies in disasters 4. SEARO should urgently build up its resource mobilization capacity for disasters including training of staff and country personnel in the process of the Flash Appeal and donor relations. 5. SEARO should quickly develop standard operating procedures that address the organizational needs which emerged in the wake of tsunami, and in collaboration with HAC/HQ. 6. SEARO should begin a major training and simulation programme with its Member States and with others in the area of disaster preparedness and response, always emphasizing links between disaster preparedness and response, and development in general. Looking to the future BACKGROUND EVALUATION OF THE SEARO RESPONSE RECOMMENDATIONS All countries and several agencies, both national and regional, have conducted lessons learnt exercises and taken steps to address the issues identified. From these evaluations and learning events, Member States and WHO will take their cue for steps in the future. Several initiatives have come forth from the tsunami that have provided the impetus for reform in national governments and the UN itself, which is taking concrete steps in the humanitarian reform process. This chapter outlines how these lessons are shaping the future for better preparedness and risk reduction. As a lessons learnt exercise, a comprehensive evaluation was carried out of the WHO SEARO response to the tsunami by an independent team of consultants. The team comprised Manuel Carballo of the International Centre for Migration, Geneva, and Nuntavarn Vichit-Vadakan and Marc Ven der Putten of the Thammasat University, Thailand. The team made the following recommendations. 1. SEARO should allocate greater priority to disaster preparedness and response and gear up its structures and functions accordingly. 2. SEARO should prepare a five-year plan of work with all technical and administrative units showing how they will work with, and to, EHA in disasters and how they will relate to HAC/HQ. 3. SEARO should seek a regional partner or partners that can assist with procurement, warehousing and deployment of supplies in disasters 4. SEARO should urgently build up its resource mobilization capacity for disasters including training of staff and country personnel in the process of the Flash Appeal and donor relations. 5. SEARO should quickly develop standard operating procedures that address the organizational needs which emerged in the wake of tsunami, and in collaboration with HAC/HQ. 6. SEARO should begin a major training and simulation programme with its Member States and with others in the area of disaster preparedness and response, always emphasizing links between disaster preparedness and response, and development in general. L o o k i n g t o t h e f u t u r eF r o m r e l i e f t o r e c o v e r y populations in assessing and monitoring the rate and direction of recovery over the next four to five years. TRIAMS also builds in accountability for the results of efforts by governments, aid agencies and donors. A set of indicators has been drawn up to measure results. The core indicators cover four key areas of recovery: vital needs, basic social services, infrastructure and livelihoods. These indicators will yield valuable information on a range of issues, from coverage of safe water supply and basic sanitation, the rate of housing reconstruction to the nutritional status of children and households’ economic recovery. Relevant country-specific indicators were also identified. Preliminary country action plans for the implementation of TRIAMS were prepared, specifying the information sources and the frequency of data collection for both core and country-specific indicators. The plans include proposals for qualitative approaches to complement the analysis of the quantitative results. Government participants reiterated the need to use planned household surveys and existing routine information systems as much as possible in the TRIAMS process, but also highlighted gaps and areas where they would need specific support for additional data-collection processes. Beneficiaries’ perceptions of the ongoing recovery interventions also needed to be regularly assessed. The ultimate aim of the TRIAMS process is to provide evidence of the changes effected by recovery interventions on beneficiaries’ lives; it should regularly inform stakeholders of unmet needs and influence the re-planning process, so that resources still available can be directed where they are most needed. Countries will be providing reports on the proposed set of core TRIAMS indicators regularly. The TRIAMS process is scheduled to run until 2010. The International Federation and WHO, with the support of the OSE, will work with countries to finalize detailed country action plans, identify technical assistance needs at the country as well as at the regional level and, with other stakeholders, mobilize the additional resources that will eventually be needed for the full implementation of TRIAMS. The core components of the TRIAMS process include: = output and impact indicators across the primary sectors of recovery; = both quantitative and qualitative data on beneficiary perspectives; and = additional qualitative data to help explain the findings of key output and outcome indicators. Some countries have taken important decisions that would create an enabling environment for the TRIAMS process. These include plans to modify national household surveys to enable reporting on some of the proposed indicators and, in the 7. SEARO should develop a database on the tsunami including the good practices that emerged and promote more research in this area to assess how the response to the tsunami affected longer-term public health and health systems in the affected countries. 8. SEARO should strengthen its use of information technology in the area of disaster preparedness, response and training, and coordinate this with WHO/HAC and other WHO regional offices. 9. SEARO should develop plans with, and training of, military sector staff and other sectors, including the religious sector, so as to maximize the input they can provide in the disaster response processes. 10. SEARO should link with all the WHO regional offices and HAC to discuss how best to coordinate and make the most of the characteristics and skills of each regional office in preparing for and responding to disasters and in post-disaster reconstruction. A need was felt to have a common system for tracking recovery efforts and assessing the impact of the overall response. This would enable government authorities to perform a gap analysis at subdistrict and community levels. Any pockets not covered by existing recovery programmes would be identified and unmet needs addressed. Inequities created in the allocation of tsunami-related resources could also be identified and taken care of. Through the Office of the Special Envoy (OSE) for Tsunami Recovery, WHO and the IFRC; the Tsunami Recovery Impact Assessment and Monitoring System (TRIAMS) was developed to address this need. It was elaborated in consultation with the five countries most affected by the tsunami—India, Indonesia, the Maldives, Sri Lanka and Thailand, and with partner international and local aid agencies. The concept of TRIAMS was further fleshed out in consultation with the governments and their key implementing partners in these five most-affected countries. A workshop was held from 3 to 5 May 2006 in Bangkok, Thailand to refine the TRIAMS concept and achieve consensus among the countries concerned and other partners on the process to assess the impact of the response and monitor ongoing recovery efforts. The TRIAMS initiative will assist governments, aid agencies and affected TRIAMS, 2006–2010 Tsunami Recovery Impact Assessment and Monitoring System L o o k i n g t o t h e f u t u r eF r o m r e l i e f t o r e c o v e r y populations in assessing and monitoring the rate and direction of recovery over the next four to five years. TRIAMS also builds in accountability for the results of efforts by governments, aid agencies and donors. A set of indicators has been drawn up to measure results. The core indicators cover four key areas of recovery: vital needs, basic social services, infrastructure and livelihoods. These indicators will yield valuable information on a range of issues, from coverage of safe water supply and basic sanitation, the rate of housing reconstruction to the nutritional status of children and households’ economic recovery. Relevant country-specific indicators were also identified. Preliminary country action plans for the implementation of TRIAMS were prepared, specifying the information sources and the frequency of data collection for both core and country-specific indicators. The plans include proposals for qualitative approaches to complement the analysis of the quantitative results. Government participants reiterated the need to use planned household surveys and existing routine information systems as much as possible in the TRIAMS process, but also highlighted gaps and areas where they would need specific support for additional data-collection processes. Beneficiaries’ perceptions of the ongoing recovery interventions also needed to be regularly assessed. The ultimate aim of the TRIAMS process is to provide evidence of the changes effected by recovery interventions on beneficiaries’ lives; it should regularly inform stakeholders of unmet needs and influence the re-planning process, so that resources still available can be directed where they are most needed. Countries will be providing reports on the proposed set of core TRIAMS indicators regularly. The TRIAMS process is scheduled to run until 2010. The International Federation and WHO, with the support of the OSE, will work with countries to finalize detailed country action plans, identify technical assistance needs at the country as well as at the regional level and, with other stakeholders, mobilize the additional resources that will eventually be needed for the full implementation of TRIAMS. The core components of the TRIAMS process include: = output and impact indicators across the primary sectors of recovery; = both quantitative and qualitative data on beneficiary perspectives; and = additional qualitative data to help explain the findings of key output and outcome indicators. Some countries have taken important decisions that would create an enabling environment for the TRIAMS process. These include plans to modify national household surveys to enable reporting on some of the proposed indicators and, in the 7. SEARO should develop a database on the tsunami including the good practices that emerged and promote more research in this area to assess how the response to the tsunami affected longer-term public health and health systems in the affected countries. 8. SEARO should strengthen its use of information technology in the area of disaster preparedness, response and training, and coordinate this with WHO/HAC and other WHO regional offices. 9. SEARO should develop plans with, and training of, military sector staff and other sectors, including the religious sector, so as to maximize the input they can provide in the disaster response processes. 10. SEARO should link with all the WHO regional offices and HAC to discuss how best to coordinate and make the most of the characteristics and skills of each regional office in preparing for and responding to disasters and in post-disaster reconstruction. A need was felt to have a common system for tracking recovery efforts and assessing the impact of the overall response. This would enable government authorities to perform a gap analysis at subdistrict and community levels. Any pockets not covered by existing recovery programmes would be identified and unmet needs addressed. Inequities created in the allocation of tsunami-related resources could also be identified and taken care of. Through the Office of the Special Envoy (OSE) for Tsunami Recovery, WHO and the IFRC; the Tsunami Recovery Impact Assessment and Monitoring System (TRIAMS) was developed to address this need. It was elaborated in consultation with the five countries most affected by the tsunami—India, Indonesia, the Maldives, Sri Lanka and Thailand, and with partner international and local aid agencies. The concept of TRIAMS was further fleshed out in consultation with the governments and their key implementing partners in these five most-affected countries. A workshop was held from 3 to 5 May 2006 in Bangkok, Thailand to refine the TRIAMS concept and achieve consensus among the countries concerned and other partners on the process to assess the impact of the response and monitor ongoing recovery efforts. The TRIAMS initiative will assist governments, aid agencies and affected TRIAMS, 2006–2010 Tsunami Recovery Impact Assessment and Monitoring System F r o m r e l i e f t o r e c o v e r y L o o k i n g t o t h e f u t u r e case of Sri Lanka, ensuring all national surveys included a stratification of the tsunami- affected population within the overall national household survey sampling process. The TRIAMS framework comprises four key areas which were disrupted by the tsunami and where recovery programmes are concentrated: = Vital needs, such as water and sanitation, food and shelter; = Access to basic services, such as health care and education; = Infrastructure, such as roads, transport and electricity; = Livelihoods and economic security. The development of a conceptual framework to analyse the impact of the tsunami and the progress of recovery efforts in each area is a key element of the TRIAMS process. The purpose of the framework is to facilitate the analysis of data at the district and subdistrict levels, using both absolute numbers and rates, to capture variations and allow for comparison across populations and geographical areas. Initial TRIAMS implementation plans summarized the following: = the indicators the country is planning to use and report on (core as well as country- specific); = data source and frequency of data collection for these indicators; = specific actions and resources needed for the development and implementation of the monitoring system; = additional qualitative ways to collect data to support more in-depth analysis; = a designated focal point and reporting schedule for TRIAMS implementation in the country concerned. These action plans will continue to undergo further elaboration and clarification. Simultaneously, a regional plan of action will be developed based on the individual country plans. Additional steps are needed to identify information gaps and determine ways to address them. A collective push by all governmental and nongovernmental partners is needed to meet the challenge of “building back better” in the areas devastated by the tsunami. The TRIAMS process will be implemented during the period 2006–2010. An extension of this period in some countries can be envisaged, according to the speed and coverage of the tsunami recovery process. Development of a conceptual framework for monitoring the tsunami recovery Country action plans for TRIAMS implementation EMERGENCY PREPAREDNESS AND RESPONSE Establishing benchmarks Background Benchmarks Background From the countries’ responses to the tsunami, there appeared to be a strong correlation between the levels of preparedness and the efficacy of the country’s responses to the disaster. Several crucial gaps were identified in the affected countries in terms of addressing various public health issues during emergencies, from policy and legislation to human resources management, to operational and coordination mechanisms. Countries in the Region needed to be better prepared to cope with the next such disaster. In November 2005, nearly a year after the tsunami, WHO SEARO convened a conference in Bangkok, Thailand on the health aspects of disaster preparedness and response. This conference was a follow up to the WHO Conference of May 2005 in Phuket, Thailand to assess the progress made by countries during the past year. The goal of the Conference was to produce a plan of action that would meet the specific needs of the countries of the Region and ensure that they would be better equipped to cope with any future disaster. The conference aimed to (1) identify gaps in the health needs of the affected and vulnerable populations for preparedness, responses, recovery and rehabilitation; (2) determine the next steps in addressing these gaps; and (3) develop benchmarks and a corresponding framework for action that must be achieved to strengthen the capacities and capabilities of the health sector to meet emergencies. The outcomes were (i) the development of 12 benchmarks, (ii) analysis of the current state of preparedness in each of the countries represented, and (iii) identification of strategies to meet these benchmarks. This report presents the 12 benchmarks developed by the participants of that meeting. For enhanced disaster preparedness, the following benchmarks were identified. 1. Legal framework A legal framework must be in place on which disaster preparedness and response can be based, to successfully bring the necessary resources together to prevent a disaster from occurring or enhance the preparedness to cope with disasters. It lays down the ground F r o m r e l i e f t o r e c o v e r y L o o k i n g t o t h e f u t u r e case of Sri Lanka, ensuring all national surveys included a stratification of the tsunami- affected population within the overall national household survey sampling process. The TRIAMS framework comprises four key areas which were disrupted by the tsunami and where recovery programmes are concentrated: = Vital needs, such as water and sanitation, food and shelter; = Access to basic services, such as health care and education; = Infrastructure, such as roads, transport and electricity; = Livelihoods and economic security. The development of a conceptual framework to analyse the impact of the tsunami and the progress of recovery efforts in each area is a key element of the TRIAMS process. The purpose of the framework is to facilitate the analysis of data at the district and subdistrict levels, using both absolute numbers and rates, to capture variations and allow for comparison across populations and geographical areas. Initial TRIAMS implementation plans summarized the following: = the indicators the country is planning to use and report on (core as well as country- specific); = data source and frequency of data collection for these indicators; = specific actions and resources needed for the development and implementation of the monitoring system; = additional qualitative ways to collect data to support more in-depth analysis; = a designated focal point and reporting schedule for TRIAMS implementation in the country concerned. These action plans will continue to undergo further elaboration and clarification. Simultaneously, a regional plan of action will be developed based on the individual country plans. Additional steps are needed to identify information gaps and determine ways to address them. A collective push by all governmental and nongovernmental partners is needed to meet the challenge of “building back better” in the areas devastated by the tsunami. The TRIAMS process will be implemented during the period 2006–2010. An extension of this period in some countries can be envisaged, according to the speed and coverage of the tsunami recovery process. Development of a conceptual framework for monitoring the tsunami recovery Country action plans for TRIAMS implementation EMERGENCY PREPAREDNESS AND RESPONSE Establishing benchmarks Background Benchmarks Background From the countries’ responses to the tsunami, there appeared to be a strong correlation between the levels of preparedness and the efficacy of the country’s responses to the disaster. Several crucial gaps were identified in the affected countries in terms of addressing various public health issues during emergencies, from policy and legislation to human resources management, to operational and coordination mechanisms. Countries in the Region needed to be better prepared to cope with the next such disaster. In November 2005, nearly a year after the tsunami, WHO SEARO convened a conference in Bangkok, Thailand on the health aspects of disaster preparedness and response. This conference was a follow up to the WHO Conference of May 2005 in Phuket, Thailand to assess the progress made by countries during the past year. The goal of the Conference was to produce a plan of action that would meet the specific needs of the countries of the Region and ensure that they would be better equipped to cope with any future disaster. The conference aimed to (1) identify gaps in the health needs of the affected and vulnerable populations for preparedness, responses, recovery and rehabilitation; (2) determine the next steps in addressing these gaps; and (3) develop benchmarks and a corresponding framework for action that must be achieved to strengthen the capacities and capabilities of the health sector to meet emergencies. The outcomes were (i) the development of 12 benchmarks, (ii) analysis of the current state of preparedness in each of the countries represented, and (iii) identification of strategies to meet these benchmarks. This report presents the 12 benchmarks developed by the participants of that meeting. For enhanced disaster preparedness, the following benchmarks were identified. 1. Legal framework A legal framework must be in place on which disaster preparedness and response can be based, to successfully bring the necessary resources together to prevent a disaster from occurring or enhance the preparedness to cope with disasters. It lays down the ground L o o k i n g t o t h e f u t u r eF r o m r e l i e f t o r e c o v e r y 3. Community disaster plans for preparedness and response Many communities did not have comprehensive community-level disaster management plans. Experiences from most countries indicated that preparedness at the community level was the most effective tool for mitigating the damage created by a disaster. Good plans need to include: (1) SOPs; (2) memoranda of understanding; (3) mechanisms for coordination and control; (4) responses; and (5) and all-hazards and hazard-specific approaches. Community-level plans for damage mitigation, preparedness and responses should be in place to reduce the damage and loss of function created by a disaster. These plans must include the ability to request and receive the needed resources. 4. Community capacity A sudden-onset disaster calls for immediate responses. However, there is often a time gap before external assistance arrives following a disaster. Given the magnitude of the tsunami, launching a full-scale response was a challenge for Thailand. Though Thailand was relatively well-prepared, the first medical teams from Bangkok arrived in the tsunami-affected areas only after about eight hours. For a community to be self- reliant following a disaster, it is not enough to have a plan and trained people; it must have access to the other resources required to manage the crisis. Community-based response and preparedness capacities should be supported. Local people must be trained so that they know what to do in the event of a disaster. This includes identifying or building suitable places that could serve as temporary shelters, taking measures to increase the absorbing and buffering capacities of communities, and performing regular simulation/mock drills. The community must have access to the resources required so that it can survive until external assistance arrives. Background Recommendation Benchmark 3 A community plan for mitigation, preparedness and response that is based on risk identification and participatory vulnerability assessments, and backed by a higher level of capacity has been developed. Background Recommendation Benchmark 4 Community-based response and preparedness capacities have been developed, and are supported with training and regular simulation/mock trials. rules and principles to be adopted in disaster management, and places the actions to be taken into a broader ethical and lawful social context. The legal framework must not only provide a mandate, but must also include funding, the required resources and designation of authority. A legal framework reflects awareness of, and political commitment to, the importance of disaster preparedness. Many countries did not have a legal framework upon which to base preparedness and responses. Some legal frameworks were response-oriented and did not encompass preparedness or mitigation strategies. All countries must have an established legal framework upon which to base preparedness activities and responses. This framework must include allocation of resources and transfer of necessary authority as well as organizational structure and mechanisms for the coordination of preparedness and response activities. 2. National disaster plans for preparedness and response Many countries in the Region did not have adequate disaster plans. As disasters often require immediate responses, the chain of coordination and control for disaster management needs to be clearly defined, along with clarity in the decision-making process. Without these, the effectiveness of the response may be diminished and lead to critical delays. Good plans must include: (1) standard operating procedures (SOPs); (2) memoranda of understanding; (3) mechanisms for coordination and control; (4) responses; and (5) all-hazards and hazard-specific approaches. Disaster preparedness plans must be clearly laid out to protect the population at risk. These plans should be practised and critiqued at all levels and at frequent intervals. Issues Recommendation Benchmark 1 A legal framework with functioning coordination mechanisms and an organized structure is in place for preparedness and response. Background Recommendation Benchmark 2 Regularly updated disaster preparedness and emergency management plans for the health sector are in place. They must include: (1) SOPs (emergency directory, national coordination focal point); (2) memoranda of understanding; (3) mechanisms for coordination and control; (4) responses; and (5) all-hazards and hazard-specific approaches. L o o k i n g t o t h e f u t u r eF r o m r e l i e f t o r e c o v e r y 3. Community disaster plans for preparedness and response Many communities did not have comprehensive community-level disaster management plans. Experiences from most countries indicated that preparedness at the community level was the most effective tool for mitigating the damage created by a disaster. Good plans need to include: (1) SOPs; (2) memoranda of understanding; (3) mechanisms for coordination and control; (4) responses; and (5) and all-hazards and hazard-specific approaches. Community-level plans for damage mitigation, preparedness and responses should be in place to reduce the damage and loss of function created by a disaster. These plans must include the ability to request and receive the needed resources. 4. Community capacity A sudden-onset disaster calls for immediate responses. However, there is often a time gap before external assistance arrives following a disaster. Given the magnitude of the tsunami, launching a full-scale response was a challenge for Thailand. Though Thailand was relatively well-prepared, the first medical teams from Bangkok arrived in the tsunami-affected areas only after about eight hours. For a community to be self- reliant following a disaster, it is not enough to have a plan and trained people; it must have access to the other resources required to manage the crisis. Community-based response and preparedness capacities should be supported. Local people must be trained so that they know what to do in the event of a disaster. This includes identifying or building suitable places that could serve as temporary shelters, taking measures to increase the absorbing and buffering capacities of communities, and performing regular simulation/mock drills. The community must have access to the resources required so that it can survive until external assistance arrives. Background Recommendation Benchmark 3 A community plan for mitigation, preparedness and response that is based on risk identification and participatory vulnerability assessments, and backed by a higher level of capacity has been developed. Background Recommendation Benchmark 4 Community-based response and preparedness capacities have been developed, and are supported with training and regular simulation/mock trials. rules and principles to be adopted in disaster management, and places the actions to be taken into a broader ethical and lawful social context. The legal framework must not only provide a mandate, but must also include funding, the required resources and designation of authority. A legal framework reflects awareness of, and political commitment to, the importance of disaster preparedness. Many countries did not have a legal framework upon which to base preparedness and responses. Some legal frameworks were response-oriented and did not encompass preparedness or mitigation strategies. All countries must have an established legal framework upon which to base preparedness activities and responses. This framework must include allocation of resources and transfer of necessary authority as well as organizational structure and mechanisms for the coordination of preparedness and response activities. 2. National disaster plans for preparedness and response Many countries in the Region did not have adequate disaster plans. As disasters often require immediate responses, the chain of coordination and control for disaster management needs to be clearly defined, along with clarity in the decision-making process. Without these, the effectiveness of the response may be diminished and lead to critical delays. Good plans must include: (1) standard operating procedures (SOPs); (2) memoranda of understanding; (3) mechanisms for coordination and control; (4) responses; and (5) all-hazards and hazard-specific approaches. Disaster preparedness plans must be clearly laid out to protect the population at risk. These plans should be practised and critiqued at all levels and at frequent intervals. Issues Recommendation Benchmark 1 A legal framework with functioning coordination mechanisms and an organized structure is in place for preparedness and response. Background Recommendation Benchmark 2 Regularly updated disaster preparedness and emergency management plans for the health sector are in place. They must include: (1) SOPs (emergency directory, national coordination focal point); (2) memoranda of understanding; (3) mechanisms for coordination and control; (4) responses; and (5) all-hazards and hazard-specific approaches. F r o m r e l i e f t o r e c o v e r y L o o k i n g t o t h e f u t u r e 5 6. Emergency budget, resources and accountability Following an emergency, resources should be immediately available. Attempting to identify the resources required after an event often leads to loss of valuable time, unnecessary loss of life, and increased pain and suffering. Careful accounting must be done of how and why the resources were consumed, as well as the amount. Although resources are required immediately to cope with emergencies, these are often not readily available. Attempting to obtain these resources at the time of an actual crisis is difficult, if not impossible. Local and national budgets should take into account financial resources for disaster preparedness and responses. Additional funds must also be accessible in the time of emergency. Accountability procedures for documenting their use should be in place. 7. Rules of engagement A disaster often requires a multisectoral approach involving a wide range of actors. Following the tsunami, in Aceh alone, there were more than 350 organizations working in the health sector. The situation in Sri Lanka was similar. While some organizations were well-trained and brought the resources required for their operations, others had goodwill and good intentions, but their skills and resources were limited. In addition, responders and responding agencies did not always understand the cultural context in which they were working, and therefore hampered . Benchmark 5 Local capacity for emergency provision of essential services and supplies (shelters, safe drinking water, food, communication) is developed. Background Issue Recommendation Benchmark 6 Countries have a line item in their budget and system to ensure that financial resources are accessible to meet the immediate needs in case of a catastrophic event. Essential personnel, equipment and supplies also are available in quantities necessary to cope with the damage created by an event for which it is at risk. Accounting procedures for the use of such resources are in place. Emergency financial (including national budget), physical and regular human resource allocation and accountability procedures have been established. Background rather than helped the relief and rehabilitation efforts. Confusion and duplication of efforts often results unless the responses are well- coordinated between the responding sectors. Often, responses by external actors are not coordinated by an authorized national and local agency. External actors who wish to provide assistance to the stricken must be self-sufficient or they create an additional burden on the affected society. The assistance offered by external humanitarian actors may not be appropriate to local conditions and culture, and may even offend those affected. Rules of engagement (including conduct) for external humanitarian actors based on needs must be developed and implemented in each country. Specific attention must be directed to qualification of the responders to meet the needs of the affected population including psychosocial support. Each responding agency must be self-supporting. 8. Advocacy and awareness Following the tsunami, there were various rumours, e.g. dead bodies spread diseases, and that fish were contaminated because they had fed on the dead human bodies. WHO and the Ministries of Health of the affected countries countered these rumours with accurate information. Advocacy and awareness development through education of the population, information management and communication (before, during and after the event) are essential. A competent spokesperson should be appointed to provide updated, correct information to the mass media. In Myanmar, essential information about methods of protection during a disaster is included in the school curricula. Lack of awareness about the hazards and risks, as well as not knowing what to do in case of an emergency, results in preventable deaths and injuries. Awareness of the dangers of and education on how to cope with disasters and other emergencies should have high priority at the country and community levels. Appropriate information should be provided by the inclusion of these messages in school curricula. Educational materials must be prepared and distributed to the general Issue Recommendation Benchmark 7 Rules of engagement exist for the management of external actors. Background Issue Recommendation F r o m r e l i e f t o r e c o v e r y L o o k i n g t o t h e f u t u r e 5 6. Emergency budget, resources and accountability Following an emergency, resources should be immediately available. Attempting to identify the resources required after an event often leads to loss of valuable time, unnecessary loss of life, and increased pain and suffering. Careful accounting must be done of how and why the resources were consumed, as well as the amount. Although resources are required immediately to cope with emergencies, these are often not readily available. Attempting to obtain these resources at the time of an actual crisis is difficult, if not impossible. Local and national budgets should take into account financial resources for disaster preparedness and responses. Additional funds must also be accessible in the time of emergency. Accountability procedures for documenting their use should be in place. 7. Rules of engagement A disaster often requires a multisectoral approach involving a wide range of actors. Following the tsunami, in Aceh alone, there were more than 350 organizations working in the health sector. The situation in Sri Lanka was similar. While some organizations were well-trained and brought the resources required for their operations, others had goodwill and good intentions, but their skills and resources were limited. In addition, responders and responding agencies did not always understand the cultural context in which they were working, and therefore hampered . Benchmark 5 Local capacity for emergency provision of essential services and supplies (shelters, safe drinking water, food, communication) is developed. Background Issue Recommendation Benchmark 6 Countries have a line item in their budget and system to ensure that financial resources are accessible to meet the immediate needs in case of a catastrophic event. Essential personnel, equipment and supplies also are available in quantities necessary to cope with the damage created by an event for which it is at risk. Accounting procedures for the use of such resources are in place. Emergency financial (including national budget), physical and regular human resource allocation and accountability procedures have been established. Background rather than helped the relief and rehabilitation efforts. Confusion and duplication of efforts often results unless the responses are well- coordinated between the responding sectors. Often, responses by external actors are not coordinated by an authorized national and local agency. External actors who wish to provide assistance to the stricken must be self-sufficient or they create an additional burden on the affected society. The assistance offered by external humanitarian actors may not be appropriate to local conditions and culture, and may even offend those affected. Rules of engagement (including conduct) for external humanitarian actors based on needs must be developed and implemented in each country. Specific attention must be directed to qualification of the responders to meet the needs of the affected population including psychosocial support. Each responding agency must be self-supporting. 8. Advocacy and awareness Following the tsunami, there were various rumours, e.g. dead bodies spread diseases, and that fish were contaminated because they had fed on the dead human bodies. WHO and the Ministries of Health of the affected countries countered these rumours with accurate information. Advocacy and awareness development through education of the population, information management and communication (before, during and after the event) are essential. A competent spokesperson should be appointed to provide updated, correct information to the mass media. In Myanmar, essential information about methods of protection during a disaster is included in the school curricula. Lack of awareness about the hazards and risks, as well as not knowing what to do in case of an emergency, results in preventable deaths and injuries. Awareness of the dangers of and education on how to cope with disasters and other emergencies should have high priority at the country and community levels. Appropriate information should be provided by the inclusion of these messages in school curricula. Educational materials must be prepared and distributed to the general Issue Recommendation Benchmark 7 Rules of engagement exist for the management of external actors. Background Issue Recommendation F r o m r e l i e f t o r e c o v e r y L o o k i n g t o t h e f u t u r e population. Advocacy programmes to promote awareness must be in place before a potentially catastrophic event occurs. 9. Risk identification and hazard–vulnerability assessments During disasters, people should be physically and psychologically prepared. For example, although the response to the tsunami in Thailand was very good, it could have been even better. Prior to the tsunami, Thailand was not considered to be a disaster-prone nation, so all of the appropriate measures were not in place and the society was physically (buildings and infrastructure) and psychologically not well prepared. The hazards and the risks to which a society is susceptible should be estimated. Some preparedness measures are appropriate for all hazards, while others are event specific. Knowledge of the hazards allows assessment of the vulnerability of the population at risk for the hazard. Such vulnerability assessments are essential for setting priorities for implementation of appropriate preparedness measures. Many societies are not aware of all of the hazards to which they are exposed and/or of their respective vulnerability to the hazards. The hazards, risks and vulnerabilities for which the population is at risk should be identified at all levels (local to national). Appropriate measures should be taken to reduce the vulnerability of the population to specific and all hazards. 10. Human resources During any sudden-onset disaster, there usually is an immediate demand for a large number of skilled persons such as doctors, nurses and paramedics, to tend to injured persons; water and sanitation engineers to ensure the provision of safe, clean water; and public health workers to monitor outbreaks of diseases. To ensure that adequate Benchmark 8 Advocacy and awareness have been developed through education, information management and communication (before, during and after the event). Background Issue Recommendations Benchmark 9 Capacity to identify risks and assess vulnerability levels has been established. Appropriate measures have been implemented to reduce the vulnerabilities. Background numbers of people with the required skills are available during a disaster, it is important that there is commitment to train human resources, and that these skills and abilities are refreshed and maintained. In the affected countries, there was a paucity of trained individuals who could cope with the damages created by a disaster. Adequate numbers of people must be educated and trained to participate in preparedness activities and to provide appropriate responses once an event has occurred. 11. “Disaster-resistant”health facilities (“safe hospitals”) Earthquakes and similar events, by themselves, do not lead to deaths. Deaths and injuries are a consequence of buildings and structures that collapse because they could not withstand the forces exerted by the earthquake. In Aceh, the earthquake and tsunami destroyed a large number of health facilities. This worsened the impact of the event, as people needing medical attention had nowhere to be treated. Many health-care facilities were not structured to withstand or continue to operate during disasters. Health facilities should be built/modified to withstand the forces of expected events. This may require retrofitting existing structures and strengthening the building codes for the construction of new facilities. 12. Surveillance and early warning systems Issue Recommendation Benchmark 10 Human resources capabilities are updated and maintained continuously. Appropriate programmes to educate and train people to cope with events and disasters have been implemented. Adequate numbers of people are being trained, and trained experts are on call in case of a disaster. Background Issue Recommendation Benchmark 11 Health facilities are built/modified to withstand expected risks and to be able to continue to provide the required medical care during events and disasters. Background F r o m r e l i e f t o r e c o v e r y L o o k i n g t o t h e f u t u r e population. Advocacy programmes to promote awareness must be in place before a potentially catastrophic event occurs. 9. Risk identification and hazard–vulnerability assessments During disasters, people should be physically and psychologically prepared. For example, although the response to the tsunami in Thailand was very good, it could have been even better. Prior to the tsunami, Thailand was not considered to be a disaster-prone nation, so all of the appropriate measures were not in place and the society was physically (buildings and infrastructure) and psychologically not well prepared. The hazards and the risks to which a society is susceptible should be estimated. Some preparedness measures are appropriate for all hazards, while others are event specific. Knowledge of the hazards allows assessment of the vulnerability of the population at risk for the hazard. Such vulnerability assessments are essential for setting priorities for implementation of appropriate preparedness measures. Many societies are not aware of all of the hazards to which they are exposed and/or of their respective vulnerability to the hazards. The hazards, risks and vulnerabilities for which the population is at risk should be identified at all levels (local to national). Appropriate measures should be taken to reduce the vulnerability of the population to specific and all hazards. 10. Human resources During any sudden-onset disaster, there usually is an immediate demand for a large number of skilled persons such as doctors, nurses and paramedics, to tend to injured persons; water and sanitation engineers to ensure the provision of safe, clean water; and public health workers to monitor outbreaks of diseases. To ensure that adequate Benchmark 8 Advocacy and awareness have been developed through education, information management and communication (before, during and after the event). Background Issue Recommendations Benchmark 9 Capacity to identify risks and assess vulnerability levels has been established. Appropriate measures have been implemented to reduce the vulnerabilities. Background numbers of people with the required skills are available during a disaster, it is important that there is commitment to train human resources, and that these skills and abilities are refreshed and maintained. In the affected countries, there was a paucity of trained individuals who could cope with the damages created by a disaster. Adequate numbers of people must be educated and trained to participate in preparedness activities and to provide appropriate responses once an event has occurred. 11. “Disaster-resistant”health facilities (“safe hospitals”) Earthquakes and similar events, by themselves, do not lead to deaths. Deaths and injuries are a consequence of buildings and structures that collapse because they could not withstand the forces exerted by the earthquake. In Aceh, the earthquake and tsunami destroyed a large number of health facilities. This worsened the impact of the event, as people needing medical attention had nowhere to be treated. Many health-care facilities were not structured to withstand or continue to operate during disasters. Health facilities should be built/modified to withstand the forces of expected events. This may require retrofitting existing structures and strengthening the building codes for the construction of new facilities. 12. Surveillance and early warning systems Issue Recommendation Benchmark 10 Human resources capabilities are updated and maintained continuously. Appropriate programmes to educate and train people to cope with events and disasters have been implemented. Adequate numbers of people are being trained, and trained experts are on call in case of a disaster. Background Issue Recommendation Benchmark 11 Health facilities are built/modified to withstand expected risks and to be able to continue to provide the required medical care during events and disasters. Background F r o m r e l i e f t o r e c o v e r y L o o k i n g t o t h e f u t u r e Surveillance and early warning systems are necessary for identifying health concerns. In Thailand, previous experiences with SARS and avian influenza had helped establish an effective mechanism for surveillance of an outbreak of communicable diseases. In Thailand, community involvement was good, and health workers were trained in surveillance and reporting. Adequate public health surveillance and early warning systems were not in place in all countries. Surveillance systems should be strengthened and be functional before a precipitating event strikes. An early warning system for hazards to which the population is at risk should be strengthened to provide the community with information prior to the event when possible. Strategies and mechanisms by which these benchmarks could be achieved were identified and developed to assist the countries in improving their levels of preparedness for the next event. These were categorized into seven different themes. 1. Monitoring, evaluation, surveillance and assessments 2. Education and training 3. Information and communication 4. Legislation, policy and authority 5. Funding 6. Planning and preparedness 7. Coordination and control With the country status identified in all of the critical areas of disaster management (including preparedness), the priorities for each country were listed by the participants. Based on these outcomes, a framework of action was taken by the countries to achieve these benchmarks. To enable countries of the Region to share experiences and track progress, a password-controlled, online forum for emergency preparedness and response was suggested. The progress achieved would be reviewed. Issue Recommendation Benchmark 12 Early warning and surveillance systems for identifying health concerns are established. Strategies and mechanisms Future steps BALI DECLARATION The relief and rehabilitation phase of the tsunami of 2004 came to a close on 30 June 2006. The end of this phase was considered an appropriate time to reflect on the work done and strategies undertaken in the past one-and-a-half years, and evaluate how the lessons from this experience could be applied to future disasters all over the world. A Regional Consultation on “Emergency Preparedness and Response: From Lessons to Action” was held in Bali, Indonesia on 27–29 June 2006 to identify strategic actions to ensure that the lessons learnt from the tsunami were integrated into disaster management plans and implemented in countries of the Region. Representatives of the governments of all tsunami-affected countries attended the meeting along with several NGOs and donors. The meeting culminated in the Bali Declaration, wherein participants resolved to urge Member States to improve multihazard disaster preparedness, empower communities in this regard, and convert the Bangkok Meeting benchmarks into a strategic action framework by developing measurable indicators with timelines. The response to the tsunami was also reviewed in terms of how the experience helped in the response to the Yogyakarta earthquake. In Yogyakarta, health personnel from within the country were mobilized within a day of the disaster. Surveillance systems drawn up for the tsunami were adapted to local needs for the Yogyakarta earthquake. Guidelines developed after the tsunami on mental health and psychosocial support also proved useful. The meeting also analysed the progress made by countries on the 12 benchmarks for disaster preparedness that had been developed in November 2005 at the Bangkok meeting. Analysis was carried out with respect to multisectoral cooperation, capacity building, community empowerment, and standards and guidelines. Successful examples within countries which could be replicated across the Region as well as barriers to achieving the benchmarks were identified. The analysis included validation of the benchmarks in non- natural hazard emergencies such as pandemics. Eight of the 12 benchmarks were found valid and necessary for pandemic preparedness. Concrete recommendations from the Bali Meeting included the continued support of WHO in achieving the benchmarks and the establishment of a Regional Emergency Fund. The WHO SEARO EHA Programme is pursuing these recommendations. Both will contribute directly to risk reduction, and reduction of avoidable mortality and morbidity during emergencies through improved capacities in preparedness and response. F r o m r e l i e f t o r e c o v e r y L o o k i n g t o t h e f u t u r e Surveillance and early warning systems are necessary for identifying health concerns. In Thailand, previous experiences with SARS and avian influenza had helped establish an effective mechanism for surveillance of an outbreak of communicable diseases. In Thailand, community involvement was good, and health workers were trained in surveillance and reporting. Adequate public health surveillance and early warning systems were not in place in all countries. Surveillance systems should be strengthened and be functional before a precipitating event strikes. An early warning system for hazards to which the population is at risk should be strengthened to provide the community with information prior to the event when possible. Strategies and mechanisms by which these benchmarks could be achieved were identified and developed to assist the countries in improving their levels of preparedness for the next event. These were categorized into seven different themes. 1. Monitoring, evaluation, surveillance and assessments 2. Education and training 3. Information and communication 4. Legislation, policy and authority 5. Funding 6. Planning and preparedness 7. Coordination and control With the country status identified in all of the critical areas of disaster management (including preparedness), the priorities for each country were listed by the participants. Based on these outcomes, a framework of action was taken by the countries to achieve these benchmarks. To enable countries of the Region to share experiences and track progress, a password-controlled, online forum for emergency preparedness and response was suggested. The progress achieved would be reviewed. Issue Recommendation Benchmark 12 Early warning and surveillance systems for identifying health concerns are established. Strategies and mechanisms Future steps BALI DECLARATION The relief and rehabilitation phase of the tsunami of 2004 came to a close on 30 June 2006. The end of this phase was considered an appropriate time to reflect on the work done and strategies undertaken in the past one-and-a-half years, and evaluate how the lessons from this experience could be applied to future disasters all over the world. A Regional Consultation on “Emergency Preparedness and Response: From Lessons to Action” was held in Bali, Indonesia on 27–29 June 2006 to identify strategic actions to ensure that the lessons learnt from the tsunami were integrated into disaster management plans and implemented in countries of the Region. Representatives of the governments of all tsunami-affected countries attended the meeting along with several NGOs and donors. The meeting culminated in the Bali Declaration, wherein participants resolved to urge Member States to improve multihazard disaster preparedness, empower communities in this regard, and convert the Bangkok Meeting benchmarks into a strategic action framework by developing measurable indicators with timelines. The response to the tsunami was also reviewed in terms of how the experience helped in the response to the Yogyakarta earthquake. In Yogyakarta, health personnel from within the country were mobilized within a day of the disaster. Surveillance systems drawn up for the tsunami were adapted to local needs for the Yogyakarta earthquake. Guidelines developed after the tsunami on mental health and psychosocial support also proved useful. The meeting also analysed the progress made by countries on the 12 benchmarks for disaster preparedness that had been developed in November 2005 at the Bangkok meeting. Analysis was carried out with respect to multisectoral cooperation, capacity building, community empowerment, and standards and guidelines. Successful examples within countries which could be replicated across the Region as well as barriers to achieving the benchmarks were identified. The analysis included validation of the benchmarks in non- natural hazard emergencies such as pandemics. Eight of the 12 benchmarks were found valid and necessary for pandemic preparedness. Concrete recommendations from the Bali Meeting included the continued support of WHO in achieving the benchmarks and the establishment of a Regional Emergency Fund. The WHO SEARO EHA Programme is pursuing these recommendations. Both will contribute directly to risk reduction, and reduction of avoidable mortality and morbidity during emergencies through improved capacities in preparedness and response. S O U R C E S O F I N F O R M A T I O N Carballo M, Vichit-Vadakan N, Van der Putten M. A comprehensive evaluation of the SEARO response to South-East Asian tsunami. Geneva, International Centre for Migration and Health, 2006. Ministry of Health and Family Welfare, Government of India. Tsunami crisis: national health perspective. Country Report —India. Presentation at Phuket, Thailand, WHO, 2005. http://pdm.medicine.wisc.edu/TOC206.htm Raks Thai Foundation and Care International. Mental health psychosocial assessment. Thailand, STAAR (Southern Thailand Tsunami Affected Area Relief & Rehabilitation Program), 2006. Republic of Maldives, ADB, IFRC, UN, World Bank, Government of Japan, American Red Cross, Australian Red Cross, British Red Cross, Canadian Red Cross, French Red Cross, German Red Cross, OCHA, UNDP, UNEP, UNFPA, UNICEF, WFP, and WHO. The Maldives: One year after the tsunami. Malé, The Maldives, Ministry of Planning and National Development, 2005. United Nations/World Health Organization/International Federation of Red Cross and Red Crescent Societies. Report of the Tsunami Recovery Impact Assessment and Monitoring System.New York, Geneva; OSE, WHO, IFRC, 2006. World Health Organization and Ministries of Health. Country Presentations at the Coordination Workshop for tsunami-affected countries, New Delhi, WHO/SEARO, 1–2 March 2005. World Health Organization. Annual report 2005. Geneva, WHO, Department of Health Action in Crises, 2005. World Health Organization. Communicable diseases profile for Indonesia. Geneva, WHO/CDS.2005.30, 2005. World Health Organization. Emergency Health Action Programme for South East Asia (first 100 days). New Delhi, WHO SEARO, 2004. World Health Organization. Environmental health relief efforts after the tsunami in South-East Asia. New Delhi, WHO SEARO, 2005. World Health Organization. Fact sheets on Indonesia. Jakarta, Indonesia, WHO, 2005. World Health Organization. Mental health and psychosocial relief efforts after the tsunami in South-East Asia. New Delhi, WHO SEARO, 2005. World Health Organization. Moving beyond the tsunami. New Delhi, WHO SEARO, 2005. World Health Organization. Presentations from the WHO Conference on the Health aspects of the tsunami disaster in Asia. Phuket, Thailand, WHO, May 2005. World Health Organization. Rebuilding health systems:WHO's efforts through partnerships. The tsunami experience. New Delhi, WHO SEARO, 2006. World Health Organization. Report of the meeting on Health aspects of emergency preparedness and response. New Delhi, WHO SEARO, 2006. World Health Organization. Responding to communicable diseases following the tsunami in South-East Asia. New Delhi, WHO SEARO, 2005. World Health Organization. Tsunami recovery programme: Indonesia Final Report. 2006 (unpublished document). World Health Organization. Tsunami response—external progress. New Delhi, WHO SEARO, 2005. www.reliefweb.int/rw/RWB.NSF/db900SID/KHII-6SK33V?OpenDocument www.reliefweb.int/rw/rwb.nsf/db900SID/YAOI-6S429Z?OpenDocument www.reliefweb.int/rw/rwb.nsf/AUDocsByUNID/40b19a67d90fb4b585256f800073eda1 www.searo.who.int/ www.searo.who.int/EN/Section1243/Section1310/Section1343/Section1344/Section1974_9705.htm www.searo.who.int/LinkFiles/Advocacy_Efforts_window_on_sear_tsunami05.pdf www.searo.who.int/LinkFiles/Countries_SIT__REP_THA__5JAN.pdf www.searo.who.int/LinkFiles/Reports_Tsunami_and_after-indonesia.pdf www.tsunamispecialenvoy.org/ www.who.int/countryfocus/resources/ccsbrief_srilanka_lka_06_en.pdf www.who.int/hac/crises/international/asia_tsunami/3months/en/index.html www.who.int/hac/crises/international/asia_tsunami/3months/idn/en/index.html· www.who.int/hac/crises/international/asia_tsunami/appeal/tsunami_contributions/en/index.html www.who.int/hac/events/tsunamiconf/purpose/en/index4.html Www.who.int/hac/techguidance/training/Day%204%20functions.pdf S O U R C E S O F I N F O R M A T I O N Carballo M, Vichit-Vadakan N, Van der Putten M. A comprehensive evaluation of the SEARO response to South-East Asian tsunami. Geneva, International Centre for Migration and Health, 2006. Ministry of Health and Family Welfare, Government of India. Tsunami crisis: national health perspective. Country Report —India. Presentation at Phuket, Thailand, WHO, 2005. http://pdm.medicine.wisc.edu/TOC206.htm Raks Thai Foundation and Care International. Mental health psychosocial assessment. Thailand, STAAR (Southern Thailand Tsunami Affected Area Relief & Rehabilitation Program), 2006. Republic of Maldives, ADB, IFRC, UN, World Bank, Government of Japan, American Red Cross, Australian Red Cross, British Red Cross, Canadian Red Cross, French Red Cross, German Red Cross, OCHA, UNDP, UNEP, UNFPA, UNICEF, WFP, and WHO. The Maldives: One year after the tsunami. Malé, The Maldives, Ministry of Planning and National Development, 2005. United Nations/World Health Organization/International Federation of Red Cross and Red Crescent Societies. Report of the Tsunami Recovery Impact Assessment and Monitoring System.New York, Geneva; OSE, WHO, IFRC, 2006. World Health Organization and Ministries of Health. Country Presentations at the Coordination Workshop for tsunami-affected countries, New Delhi, WHO/SEARO, 1–2 March 2005. World Health Organization. Annual report 2005. Geneva, WHO, Department of Health Action in Crises, 2005. World Health Organization. Communicable diseases profile for Indonesia. Geneva, WHO/CDS.2005.30, 2005. World Health Organization. Emergency Health Action Programme for South East Asia (first 100 days). New Delhi, WHO SEARO, 2004. World Health Organization. Environmental health relief efforts after the tsunami in South-East Asia. New Delhi, WHO SEARO, 2005. World Health Organization. Fact sheets on Indonesia. Jakarta, Indonesia, WHO, 2005. World Health Organization. Mental health and psychosocial relief efforts after the tsunami in South-East Asia. New Delhi, WHO SEARO, 2005. World Health Organization. Moving beyond the tsunami. New Delhi, WHO SEARO, 2005. World Health Organization. Presentations from the WHO Conference on the Health aspects of the tsunami disaster in Asia. Phuket, Thailand, WHO, May 2005. World Health Organization. Rebuilding health systems:WHO's efforts through partnerships. The tsunami experience. New Delhi, WHO SEARO, 2006. World Health Organization. Report of the meeting on Health aspects of emergency preparedness and response. New Delhi, WHO SEARO, 2006. World Health Organization. Responding to communicable diseases following the tsunami in South-East Asia. New Delhi, WHO SEARO, 2005. World Health Organization. Tsunami recovery programme: Indonesia Final Report. 2006 (unpublished document). World Health Organization. Tsunami response—external progress. New Delhi, WHO SEARO, 2005. www.reliefweb.int/rw/RWB.NSF/db900SID/KHII-6SK33V?OpenDocument www.reliefweb.int/rw/rwb.nsf/db900SID/YAOI-6S429Z?OpenDocument www.reliefweb.int/rw/rwb.nsf/AUDocsByUNID/40b19a67d90fb4b585256f800073eda1 www.searo.who.int/ www.searo.who.int/EN/Section1243/Section1310/Section1343/Section1344/Section1974_9705.htm www.searo.who.int/LinkFiles/Advocacy_Efforts_window_on_sear_tsunami05.pdf www.searo.who.int/LinkFiles/Countries_SIT__REP_THA__5JAN.pdf www.searo.who.int/LinkFiles/Reports_Tsunami_and_after-indonesia.pdf www.tsunamispecialenvoy.org/ www.who.int/countryfocus/resources/ccsbrief_srilanka_lka_06_en.pdf www.who.int/hac/crises/international/asia_tsunami/3months/en/index.html www.who.int/hac/crises/international/asia_tsunami/3months/idn/en/index.html· www.who.int/hac/crises/international/asia_tsunami/appeal/tsunami_contributions/en/index.html www.who.int/hac/events/tsunamiconf/purpose/en/index4.html Www.who.int/hac/techguidance/training/Day%204%20functions.pdf WHO Library Cataloguing-in-Publication data World Health Organization, Regional Office for South-East Asia From relief to recovery: the WHO tsunami operations 1. Natural Disasters. 2. Emergency Medical Services—organization and administration. 3. Relief Work. 4. International Agencies. 5. International Cooperation. 6. India. 7. Indonesia. 8. Maldives. 9. Myanmar. 10. Sri Lanka. 11. Thailand. ISBN 978–92–9022–243–9 (NLM classification: HC 79.D45) © World Health Organization 2007 All rights reserved. Requests for publications, or for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – can be obtained from Publishing and Sales, World Health Organization, Regional Office for South-East Asia, Indraprastha Estate, Mahatma Gandhi Marg, New Delhi 110 002, India (fax: +91 11 23370197; e-mail: publications@searo.who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed by , New Delhi, India Design and layout: Ms Netra Shyam Printed in India Acknowledgements Foreword Abbreviations A cataclysmic event Gearing up to respond Country reports Indonesia Sri Lanka The Maldives India Thailand Myanmar Looking to the future Sources of information iv v v i i 1 5 27 83 113 143 169 187 193 206 C O N T E N T S ii iii