Disaster Management Planning for Health

Organizations in a Developing Country

Hesam Seyedin, Ph.D.1; James Ryan2; and Mohammed Keshtgar3

Abstract: Disasters are rare occurrences, fortunately. However, careful planning and training are vital to prepare individual health organ-
izations for such events. This manuscript investigates disaster management planning and rehearsal within health organizations in Iran.
A cross-sectional quantitative study was conducted, and 230 questionnaires were distributed among health managers in these organizations.
Analysis of the data was performed by SPSS software using different tests. The study found that, although comprehensive plans exist within
the organizations, contingency plans, business continuity plans, and action cards have not been considered. The current system of operating
disaster management committees in health organizations in Iran is not conducive to improvement in their ability to respond to disaster.
Recommendations are presented in this paper for improving the national disaster management system, including system reengineering
and designing an appropriate disaster management system, improvement of disaster response and recovery using appropriate plans and
preparedness activities, creation of protocols and standards, training of staff, and regular rehearsals. DOI: 10.1061/(ASCE)UP.1943-
5444.0000045. © 2011 American Society of Civil Engineers.
CE Database subject headings: Disasters; Developing countries; Emergency services; Training.
Author keywords: Disaster management; Planning; Disaster; Preparedness; Mitigation; Response; Business continuity; Action cards.

Introduction resources, possibly including stockpiling supplies and earmarking

Disasters are serious disruptions that overwhelm the capacity of
local, regional, or national systems (Bulut et al. 2005; Louis and
Thomas 1987; Redmond 2005) and require special mobilization
and organization of resources above those normally available
(Abrahams 2001). Fortunately, disasters are rare occurrences. How-
ever, careful planning and training are vital to adequately prepare
individual health organizations for such events (Alexander et al.
2009; Madge et al. 2004; Kovel 2000). Brewton (1987) defined
the purpose of disaster management planning in the follow-
ing terms:
The purpose of crisis management planning is to enable man-
agement to make qualitative decisions under pressure of time
while avoiding or minimizing injury.
Planning is a complex issue involving key actions and crucial
decisions (McCormick and Wardrope 2003). It improves response
to the effects of a disaster by organizing the delivery of timely and
effective rescue, relief, and assistance and ensures that the
right people are in the right place at the right time. (Kenar and
Karayilanoglu 2004; Psomas 1990; Taylor et al. 2003; Wong et al.
2006; Seyedin et al. 2009). Effective plans also consider securing
1
Assistant Professor, School of Health Services and Information
Management, Tehran Univ. of Medical Sciences, Tehran, Iran. E-mail:
seyedin@tums.ac.ir
2
Emeritus Professor of Conflict Recovery, Leonard Cheshire Centre,
Univ. College London, London, U.K. E-mail: jryan@sgul.ac.uk
3
Consultant Surgeon and Senior Lecturer, Royal Free Hospital and
Univ. College London, London, U.K. E-mail: m.keshtgar@ucl.ac.uk
Note. This manuscript was submitted on June 30, 2009; approved on
June 29, 2010; published online on July 10, 2010. Discussion period open
until August 1, 2011; separate discussions must be submitted for individual
papers. This paper is part of the Journal of Urban Planning and Devel-
opment, Vol. 137, No. 1, March 1, 2011. ©ASCE, ISSN 0733-9488/2011/
1-77–81/$25.00.
funds provided through enabling legislation (Madzimbamuto
2003). Having written and well-documented plans will increase
the probability of successful outcomes (George et al. 2002).
In general, there are three types of planning: comprehensive
disaster management planning, business continuity planning, and
contingency planning. A comprehensive disaster management plan
deals with how an organization helps its clients cope with the
extraordinary demands that a disaster creates. It outlines the oper-
ating procedures, guidelines, and standards of service for all
responsible departments (Vatsa and Joseph 2003). In contrast, a
business continuity plan deals with how an organization itself copes
with the impact of the disaster on its own system and resources
(Seyedin 2008). A business continuity plan aims to prepare an
organization to adapt quickly and appropriately to sudden changes
in its human resources or its physical environment. It addresses
issues such as succession and delegation processes; alternative
work locations; and practices or technologies (Manitoba Health
2002). Contingency plans are another vital element of the planning
process. Different disaster scenarios, in all their variations, must be
considered in contingency planning, considering that some scenar-
ios are more likely to happen than others (Carley et al. 1998). For
example, Redmond (2005) declared that the greatest effects of
earthquakes are nonmedical, including the loss of communication,
transportation, and power and disruption of water supplies. These
issues are considered in contingency plans.
Disaster plans require regular review and should take place at
least annually to ensure their correct functioning when needed
(Klein and Weigelt 1991; Seyedin and Ryan 2008). All staff mem-
bers and employees should feel free to contribute any ideas to such
a process. Health organizations are constantly evolving, with spe-
cialties being moved from site to site, buildings redesigned, and
phone systems changed. New threats appear and old ones disap-
pear. All of these events will have an impact on planning (Savage
1979; McCormick and Wardrope 2003).

JOURNAL OF URBAN PLANNING AND DEVELOPMENT © ASCE / MARCH 2011 / 77

 It is believed that benefits can accrue by rehearsing the plans,
just as the military prepares for combat with war games (Fink
1986). Experience has shown that practice makes the organization
perfect and that it probably is not reasonable to expect everything to
be orderly, sane, and appropriate during disaster management
(Klein and Weigelt 1991). Preparing for disasters provides an
opportunity for cognitive rehearsal of coping with high levels of
uncertainty. Frequent, regular, full-scale testing of the major inci-
dent plan or individual components of the plan must be carried out.
Staff doing “calling cascades” (i.e., each person calls a predeter-
mined group of people), testing of communications, and tabletop
exercises are some valuable examples of preparedness exercises.
However, there is a real need to practice major incident plans in
the real world (McCormick and Wardrope 2003).
The current article investigates the disaster management plan-
ning of health organizations in Iran. It explores the extent to which
the current system meets the planning and rehearsal necessities of
health organizations regarding disaster management. The aim is to
analyze the findings and propose recommendations for improve-
ments that can be useful for the developing countries.
Method
A quantitative approach was adopted for this study. The writers
used a cross-sectional survey, and data was collected at one point
in time from the sample organizations. A questionnaire was used as
an instrument to collect the data. The questionnaire included ques-
tions about comprehensive planning, action cards or standard
operation plans, business continuity planning and contingency
planning (see the Appendix). It used a five-level Likert scale,
the choices of which were, “strongly agree,” “agree,” “I do not
know,” “disagree,” and “strongly disagree.” In order to ensure that
the right questions were asked within the questionnaire and to avoid
ambiguity, a pilot study was performed to test the validity and reli-
ability of the questionnaire, and amendments were made to the
questionnaire as a result of the pilot study (Bryman 2001). To test
the validity, the questionnaire was sent to 15 specialists of disaster
management, and their views were considered. In addition, to
examine the reliability of the questionnaire, it was sent to 30 health
managers, from which 19 questionnaires were returned. The
Cronbach’s alpha was α ¼ 0:885 which shows a significant
reliability for the questionnaire.
In each province in Iran, there is usually one medical university.
All health networks, health centers, and the majority of hospitals
are located in urban areas and are under the catchment area of the
medical universities that govern them. Based on a statistician’s
advice, a random sample of 230 health managers including hospital
managers, health center managers, and health network managers
was selected, with the expectation of a 50% rate of return of ques-
tionnaires. To increase the response rate and make participation as
convenient as possible, all of the respondents were given the choice
to use a print version of the questionnaire that was delivered to each
Table 1. Comprehensive and Contingency Plans
There is a comprehensive plan for disaster management
Disaster management plans are reviewed and modified
Individual and team action cards have been created
Comprehensive contingency plans, including generic and specific plans,
prepared ahead for potentially threatening situations (e.g., big bang, rising tide) exist
Note: Test value was considered to be 3.50.
78 / JOURNAL OF URBAN PLANNING AND DEVELOPMENT © ASCE / MARCH 2011
office with a stamped, addressed envelope for its return, or to use an
online version of the questionnaire. A total of 114 questionnaires
were returned. All data were entered into SPSS software and, after
data clearance, the whole data set was analyzed.
After consulting a statistician and relevant literature, in analyz-
ing the data it was decided to assign a scale from one to five, for
“completely disagree” to “completely agree.” The null hypothesis
was set as M > 3:50 and a one-sample, one-tailed t-test was
performed to test the hypothesis for each question.
Results
Comprehensive Plan and Action Cards
There are variations among organizations regarding comprehensive
plans. Some health organizations have comprehensive plans,
whereas some others do not have any plan. However the survey
result revealed that the respondents (mean ¼ 3:63) believed that
their organizations have comprehensive plans (Table 1). In contrast,
the respondents in the survey were shown the statement, “Disaster
management plans are reviewed and modified” and were asked to
express their level of agreement or disagreement. Table 1 clarifies
that the respondents rejected this statement. Action cards are some
simple sentences that show the duty that each individual is to per-
form during a disaster (Carley and Mackway-Jones 1996). Action
cards are kept in an emergency operations control room (EOC) and
distributed in the event of disasters. It appears from the survey that
respondents disagree with the practice of having action cards pre-
pared and distributed during disasters, which means that they do
not have individual or team action cards (Table 1).
Contingency Plan
To understand whether contingency plans are prepared in these
organizations, the following statement was asked in the survey:
“My organization has comprehensive contingency plans, including
generic and specific plans for potentially threatening situations (big
bang, rising tide…).” As Table 1 illustrates, the respondents do not
believe that the contingency plans are prepared (mean ¼ 2:85).
Business Continuity Plan
The business continuity plan enables organizations to keep their
normal services alive during disasters (UK Resilience 2006). This
type of planning is a new subject that has been included in disaster
management in some developed countries. The survey result for the
business continuity factor established that there was no effective
business continuity planning. As Table 2 elucidates, the mean
for the three statements under the business continuity factor is
under 3:50.
Rehearsal
Rehearsals and maneuvers increase burden- and stress-tolerance
levels of people and organizations, especially for more frequent
Total respondents Mean Sig. (1-tailed) P-value Std. deviation
111 3.53 0.009 1.19
111 2.69 0.000 1.05
111 2.36 0.000 1.06
111 2.85 0.000 1.06
Table 2. Business Continuity Factor
Total respondents
There is a business continuity strategy and plan
Procedures are in place to activate business continuity plans
We have exercised our business continuity plan during the last year
Note: Test value was considered to be 3.50.
Table 3. Respondents’ Answers to Rehearsal Statements
The plan has been rehearsed during last 12 months via internal
organizational exercises
The plan has been rehearsed during last 12 months with external and other
supporting organizations
The disaster management unit members have practiced their roles and
functions in an appropriate setting (exercise or actual incident)
Note: Test value was considered to be 3.50.
disasters such as earthquakes. The writers realized that there
were some rehearsals in hospitals and public health departments.
However, such rehearsals are not universal to all organizations.
The study did not find any information supporting the existence
of a multiorganization rehearsal among all health and nonhealth
organizations. It can be observed in Table 3 that the means for
the three statements that ask about internal and external
exercises are less than 3:50.
Discussion
As has been presented, three types of plans were considered in dis-
aster management. Results of the current study show that there are
comprehensive plans in organizations. This observation is sup-
ported by another study in Italy which shows that more than
two-thirds of responding organizations (68.2%) had an emergency
plan in place (Alexander et al. 2009). However, these plans are not
modified and updated regularly. This problem would keep organ-
izations behind schedule and would certainly result in an improper
response. The modern world environment changes constantly, and
organizations and their needs change constantly as well. Health
organizations are continuously evolving, with specialties being
moved, buildings redesigned, while new threats emerge and old
ones fade away (Savage 1979; McCormick and Wardrope
2003). All these events will have an impact on planning. When
a disaster plan is not updated, the result will be a false sense of
security for the organizations. This finding is supported by other
research that emphasizes continuous updating and revision of plans
(Klein and Weigelt 1991). One study showed that auditing of plans
was performed in only 41% of the organizations studied (Carley
and Mackway-Jones 1996). Contingency planning is inadequately
considered in Iran at the present time. Furthermore, business con-
tinuity planning, that is, planning for maintaining services of an
organization in the event of a disaster, is a new subject and most
organizations are not aware of it. Many studies, in different parts of
the world, have come to the same conclusion in this regard (Carley
and Mackway-Jones 1996; Leiba et al. 2006; Flynn 2007; Seyedin
and Ryan 2008; Seyedin and Jamali 2009). Results of a project in
1996 identified fundamental problems with major incident plans in
the 142 hospitals that they surveyed. Their conclusion was that only
4% of hospitals had plans fully compliant with health service
guidelines (Carley and Mackway-Jones 1996). Another study in
the United Kingdom in 2002 showed that only 45% of trainees
JOURNAL OF URBAN PLANNING AND DEVELOPMENT © ASCE / MARCH 2011 / 79
Mean Sig. (1-tailed) P-value Std. deviation
109 2.49 0.000 1.02
109 2.51 0.000 1.06
109 2.17 0.000 1.06
Total respondents Mean Sig. (1-tailed) P-value Std. deviation
112 2.38 0.000 1.19
111 2.32 0.000 1.18
110 2.69 0.000 1.27
at the specialist registrar’s level felt confident of their role should
they be asked to react to a major incident.
Turning to the matter of action cards—there should be individ-
ual action cards for all posts that are involved in delivering the
emergency response. These require constant updating (Carley
and Mackway-Jones 1996; McCormick and Wardrope 2003).
These action cards, which include brief and unambiguous instruc-
tions on how to perform during a disaster, do not exist in organ-
izations. The same problem occurs in other countries. For example,
a survey of hospital major incident plans in 1996 showed that,
although 119 plans used action cards, in only 65 were these com-
prehensive enough to include all staff likely to be involved in
response to a major incident (Carley and Mackway-Jones 1996).
In contrast to the this lack, there is a critical need for health ser-
vice organizations to have a feasible and tested plan that is actually
followed at the time of disasters. (Pou 2008; Marchive and
Wolshon 2007; Mattox 2001). There is no doubt that rehearsal
increases cooperation and coordination among health organizations
and clarifies faults and malfunctions of all systems (Bahrainy
2003). In some geographic locations where natural disasters are
frequent—such as earthquakes in Japan—disaster practice drills
are common (Mattox 2001). This important issue has not been con-
sidered in many organizations, as the studies show (Mattox 2001;
Pou 2008; Seyedin and Ryan 2008). The writers found that there
were some rehearsals and maneuvers in hospitals and public health
departments, and some others were planning to have rehearsals.
However, the drills were not performed in a coordinated manner
nationally and by all organizations. In addition, most drills that
were performed in Iran evaluated an individual hospital’s response
and rarely a region’s ability to adapt to varying resources and
governance requirements. There is, also, no multiagency rehearsal
among all organizations and outside stakeholders [such as
police, fire brigades, Red Crescent organizations, municipalities,
power supply institutions, water and wastewater institutions, and
international organizations, e.g., World Health Organization
(WHO)] or even within universities. In addition, a control system
to supervise and evaluate drills was not found in Iran.
Conclusion
The current study is the first study in its kind to have been
conducted in Iran. The study showed that there are some disaster
management preparedness activities, such as contingency plans,
business continuity plans, and action cards, together with rehearsals
and maneuvers in the organizations, that could improve the disaster
response and recovery within the health organizations and the com-
munities. However, the current system, which includes a disaster
management task force in each city and a disaster management
committee in each health organization, does not produce adequate
preparedness activities. To improve the existing situation, the
following recommendations can be made:
1. Reengineering disaster management system at the local,
regional, and national level;
2. As a matter of urgency, setting up a system for future audits
of the health organizations’ performance after a disaster
or drill;
3. Considering the importance of disaster management planning
and activities in policy-making;
4. Creating protocols and standards for planning and
rehearsals;
5. Training staff on disaster management and planning is-
sues; and
6. Creating a national networked database for disaster-related
information.
Although this study was conducted with respect to Iran, there
are lessons for health organizations in developing and developed
countries, especially the Middle East countries where the same sys-
tem of disaster management exists. This system includes disaster
task forces at national, regional and local levels and a disaster man-
agement committee in each organization. Although some other
factors need to be considered, this paper gives evidences for the
productiveness and effectiveness of the current system. Therefore,
implementing the aforementioned recommendations could improve
the disaster management system in developing countries, especially
in the Middle East.
Acknowledgments
The writers gratefully acknowledge the guidance and intellectual
contribution of Professor Tony Redmond at the University of
Manchester.
Appendix: Questionnaire
Please indicate the extent of your agreement or disagreement with
the items below.
[Five-level Likert scale (from 1 to 5) is: Strongly Agree/Agree/
Neutral (or I don’t know)/Disagree/Strongly Disagree].
• There is a comprehensive plan for disaster management in our
organization.
• Disaster management plans are continuously reviewed and
modified.
• Individual and team action cards have been created.
• The system has been tested by exercises or a real incident in the
last 12 months.
• The plan has been rehearsed during the last 12 months via inter-
nal organizational exercises.
• The plan has been rehearsed during the last 12 months with
external and other supporting organizations.
• My organization has comprehensive contingency plans includ-
ing generic and specific plans ahead for potentially threatening
situations (big bang, rising tide…).
• There are maintenance schedules and inspection plans for facil-
ities and equipment, and these have clear auditable checklists.
• There is a business continuity strategy and plan.
80 / JOURNAL OF URBAN PLANNING AND DEVELOPMENT © ASCE / MARCH 2011
• Procedures are in place to activate business continuity
plans.
• We have exercised our business continuity plan during the
last year.
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