Disaster preparedness and response capacity of regional hospitals in Tanzania: a descriptive cross-sectional study

Disasters are serious disruptions of the functioning of a community or society, causing widespread human, material, economic and environmental losses that exceed the ability of the affected community or society to cope using its own resources [1, 2]. Disaster preparedness and response include a range of activities to protect communities, property and the environment. Health care facilities are critical to disaster response; they should have a dedicated hospital disaster plan and surge capacity to allow them to quickly expand to accommodate the additional patients affected by a given emergency [3]. Surge capacity is regarded as a marker of the ability to deliver effective emergency care in a disaster situation [4, 5]. Poor disaster preparedness at the hospital level is known to result in poor patient outcomes, provider frustration and fatigue, and overall system disruption [6].

In most high-income countries, disaster preparedness and response are well developed pre-disaster, with clear plans of action established by a team representing multiple sectors [7]. Despite suffering some of the deadliest disasters, disaster planning is often lacking in most low-income countries even in hospitals with some elements of a disaster plan in place, the details may not be known by key stakeholders, including the providers staffing the facility [8‐11].

In Tanzania, the number of disasters has increased substantially in the past decade. These disasters have claimed the life of many citizens, leaving some with permanent disabilities, and causing disruption of infrastructure and settlement. Disaster Management activities in Tanzania are under the disaster management department in the Prime Minister’s office, and they are guided by the Disaster Relief Coordination Act, and the National Guideline and Policy for disasters [12]. The health system plays an essential role in the management of disaster. The Tanzanian public health system is a referral-based system starting at the dispensary, advancing through the health centre, the district hospital and regional hospitals, and ending at tertiary referral hospitals [13]. At the time of this study, Tanzania had 25 geo-political regions [14, 15]. The capacity and capability of the Tanzanian health care infrastructure to manage disasters is unknown. In this study, we describe the current state of disaster preparedness and response in Tanzanian regional hospitals. This will provide a baseline against which future progress regarding the impact of disaster preparedness interventions and projects can be measured and guide the development of disaster preparedness and response strategies.

This study represents one of the most comprehensive surveys of regional hospitals in sub-Saharan Africa (SSA), a region with one of the highest rates of conflicts, natural emergencies and disruption of services [18]. Our results show that nearly all-regional hospitals experienced a disaster in the past 5 years, further demonstrating the importance of preparedness to ensure resilience to emergencies and disasters. Disasters reported were most often caused by large MTCs (87%). This finding is consistent with prior studies, which have shown an increase in MTCs in Tanzania due to rapid urbanization, deficient road conditions and poor adherence to general road safety [19‐21].

We have noted several gaps in disaster preparedness in Tanzanian regional hospitals. Human resources available for health care delivery at each regional hospital are below the recommended ratio for all the cadres [22]. Similar to prior studies done in SSA [23], we found the few highly skilled workers tended to be in administrative positions at the hospital, which limited their clinical roles. Thus, when disasters occur, responding personnel might be junior clinical or nursing staff. In our study, the Assistant Medical Officers and Clinical Officers formed the largest group of clinicians in regions that were remotely located and under-resourced; whereas specialists and medical officers were more prevalent in big cities. This uneven distribution suggests the need to re-distribute the workforce as the numbers of medical officers and specialists increase, so as to improve the capacity of regional hospitals to respond to disasters.

Another gap identified was the lack of disaster planning in more than half of the regional hospitals. Forty percent of the hospitals had no disaster committee at all. Disaster plans and a disaster committee are paramount to effective management of any disaster [23, 24] as they lay out a clear plan for how to effectively address disaster-related challenges and delineate the roles and required resource allocation during a disaster.

The review of elements to support catastrophic surge revealed that no hospital had all components of surge capacity. Further analysis showed that 84% of hospitals had fewer than 50% of the surge capacity components. Furthermore, close to one-half of the hospitals reported the ability to pull in staff from other facilities in a disaster. We believe this is a result of similar phenomenon observed in previous studies in Tanzania [24, 25], which noted the over-saturation of hospital beds with very sick patients, a situation which significantly stretches providers capacity at baseline, resulting in lack of additional staff to mobilize during a disaster. Prior studies recommended that for a hospital to be capable of taking care of patients in disasters, it should be able to expand its operations for both paediatrics and adults to about 500 patients per million population [26, 27]. In Tanzania, this would require increasing capacity to treat approximately an additional 22,000 patients. To address a catastrophic surge with limited staff and resources, a number of actions have been proposed as being effective in supporting the disaster response and mitigating morbidity and mortality [28, 29]. Such actions include discharging stable patients from emergency departments and hospitals, cancelling elective surgeries, opening alternate care areas, and calling in stand-by or off-duty staff. However, all these approaches require careful pre-event planning.

Regional hospitals in Tanzania have one x-ray machine on average, and therefore their capacity to handle casualties requiring diagnostic radiography is limited to about six patients an hour [27]. This can cause a large delay or inadequate care of patients in event of a mass casualty incident. ICU beds are available in less than half of the hospitals, and while our study was not designed to assess ICU capacity, previous studies from similar settings have shown variable and poor levels of resources available in most Tanzanian ICUs, limiting the capacity to care for critically ill patients [30]. All regional hospitals have electricity, back-up generators and wheel chairs; however, none had CT scan machines, reflecting high variability in elements available to support hospitals during disasters.

Triage is a crucial component of routine emergency care and of disaster management [31]. In our survey, more than half of the hospitals reported having a “triage system” in place, though most of these referred to having a clinical provider sort patients based on individual judgement not to use of a validated instrument or systematic protocol. Further more, less than one third of providers involved in triage had received training. During a disaster event, the mass influx of people in a hospital is likely to add stress to an already overextended hospital staff. Providers may be pulled from clinical care to attend to their own family members, political leaders, media personnel, and the non-critical patients [32]. validated triage protocols and training are necessary to ensure effective care and appropriate resource utilization. While we did not directly assess the knowledge and practices of hospital staff our findings suggests a potential gap in emergency preparedness and response capability of hospital staff and future studies should focus on studying and addressing this gap. Safety and security for staff are also necessary to enable care for patients. Most regional hospitals are fenced with a designated entry, which makes it possible to control entry into the hospital compounds. However, the majority of hospitals did not have a fire alarm system and none has a decontamination area. Communication was found to rely mainly on cellular network phones and landline telephones which have been shown to fail due to overwhelming volume in disasters [33, 34]. Disasters are likely to overwhelm communication networks within the facility and outside. It is therefore important to have a back-up communication system or facility-specific plan such as radios and runners.

This nationwide survey found that hospital disaster preparedness is at an early stage of development in Tanzania, and important opportunities exist to better prepare regional hospitals to respond to disasters. We have identified specific areas for potential action based on our findings. We hope that our findings and discussion will support coordinated planning at the regional and national level in Tanzania.