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WHO Collaborating Centre for Mass Gatherings and Extreme Events, Health Protection Agency, London. AIM This review aims to develop disaster management practice using a health system strengthening approach through two objectives. METHOD A systematic review was conducted of the core literature published between January 2000 and November 2011 on the MEDLINE and Embase databases. CONCLUSION The findings of this review demonstrate that a holistic health system approach to disaster management has not been established in practice or evaluated in the core literature. Disasters cause devastation for populations and can limit a health system’s progress for years ahead. A resolution advocating a health system approach to disaster management was adopted at the World Health Assembly in May 2011, aiming to promote resilience and efficient recovery in the face of all-hazards disasters 1 . WHO asks member states to prepare for ‘all-hazards’ disasters, whether natural or man-made. The objective of this review is to use a health system approach to collate the worldwide experience of disasters, an initial step toward assessing the implementation of the World Health Assembly resolution of May 2011 4. This systematic review has been developed and written in light of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement 4 . Thus, inclusion criteria were broad, including reports of ‘round-table events’, evaluations of simulation exercises, opinion pieces and letters. The search strategy and application of the exclusion criteria yielded 143 relevant disaster management documents published between 1 January 2000 and 18 November 2011 (Figure 1). Table 1 summarises how many papers address the WHO disaster management components 5 within each health system lever.
This review analyses and collates the worldwide experience of disasters found in the core literature within the context of health system levers. This work provides an initial exploration of the evidence to support the aim that disaster management may be developed across countries using a health system approach. The review has demonstrated that a holistic health system approach to disaster management has not been described in the core literature – not as primary research, wider articles, or as a topic for review (Panel 2). As a review of current experience, this work provides a platform for further qualitative analysis to identify the emerging themes and deliver practical, translatable evidence for multi-professional teams to build resilience across the health system in the face of all-hazards.
Overall, this review shows that much of disaster management research and commentary is taking place in the United States (USA), which is progressive in disaster management funding, theory, and institutions. A bias to the literature selection is that this review did not include documents from the grey literature. Panel 3 – Key Messages• The World Health Assembly adopted a resolution on this issue in 2011 1 with the aim to promote a health systems approach to disaster management to build resilience in the face of all-hazards disasters. This site does not host any of the howtos or images, and rather link to pages accross the web.
Learning to draw is a great activity that encourages the creativity of children as well as adults. Kolla garna upp forlagets (State University of New York Press) hemsida, dar det kan finnas mer information. Firstly, to review the disaster management literature to test the hypothesis that a holistic health system approach has not been established in practice or evaluated in the core literature. The review found that none of these publications described a holistic health system approach to disaster management, and none evaluated such an approach. Important lessons identified through the collation and analyses of isolated disaster-related experience require further research to incorporate them within a holistic health system approach. In spite of funds being invested in disaster management in many countries, a comprehensive health system approach to build resilience in the face of disasters is still lacking. The health system can be defined as the structured and interrelated work of all agencies contributing to health within a country and “includes efforts to influence determinants of health as well as more direct health-improving activities” 2 .
Historically, different aspects of disaster management have been considered and described in isolation. The Statement consists of a checklist intended to standardise the reporting of systematic reviews of randomised trials, and although it is not applicable in full to this review, it provides a useful tool to guide the structure and content of this report in accordance with the principles of transparent, comprehensive review reporting (Appendix 2). Information sources.Database searches were conducted using Embase and MEDLINE accessed via Ovid using ‘text words’ and ‘MeSH’ terms (Panel 1).
Papers included were those published in peer-reviewed core clinical journals between 1 January 2000 and 18 November 2011. Retrieved records were excluded if the paper used the terms outside the context of disaster management or were of such a specific nature to warrant themselves inappropriate for the aims of the review (such as a new laboratory technique to identify a viral sub-strain). Justification for the breadth of inclusion is that each document had value in reaching the objectives of the review – firstly to establish whether a health systems approach exists in the literature, and secondly to collate the worldwide experience of disaster management using a health system perspective in order to develop this approach.

The initial piloting involved analysing 20 varied papers and confirmed the method of content analysis using a matrix combining the WHO’s six levers of health systems with components drawn from the WHO’s Global Assessment of National Health Sector Emergency Preparedness and Response65 , the WHO’s baseline survey of member states (Matrix Template, Appendix 2).
Harden’s quality appraisal tool 6 was identified as the most suitable for public health literature (see Appendix 1).
While it should be expected that some areas are less well addressed by the literature, Table 1 shows that there is little coverage of complex and crucial issues such as international cooperation and partnership. The aim and analysis structure of this review are innovative and the outcomes have international topical relevance and applicability, as evidenced by the recent World Health Assembly’s adopted resolution on this topic 1 and WHO Regional Office for Europe’s recent development of the WHO Toolkit for Evaluating Crisis Management 12.
This paper calls for further research, or the publication of previously unpublished data, to establish objective measures to support policy and practice in integrating disaster management across the health system.
The WHO has placed an emphasis on health systems since the World Health Report in 2000, culminating in the 64th World Health Assembly in May 2011 adopting a resolution on ‘strengthening national health emergency and disaster management capacities and resilience of health systems’ 1 .
For example, further qualitative analyses of these publications, not reported here, have been used to complement the WHO Toolkit on Evaluating Crisis Management for the WHO Regional Office of Europe 1112.
The variety of papers analysed meant that some quality appraisal categories were not applicable for all documents; it was thus not appropriate to assign a numerical value to the quality appraisal.
Bias is inherent to some of the individual documents reviewed due to the variety of formats included, such as opinion pieces and letters to journals. Thus, a significant portion of the literature reviewed is USA-centric and reflects the availability of resources found only in the developed world. Instead, the objective was to establish whether the academic literature supported the objectives of the World Health Assembly resolution. The Summary Table of Reviewed Papers (Appendix 2) collates a diverse range of worldwide disaster experiences and identifies the specific literature which can provide valuable lessons. A holistic health system approach to all-hazards disaster management should reduce resource duplication at every phase of disaster management, maximise human and capital investment, optimise immediate and long term health outcomes, and prevent set-backs to a health system in the wake of a disaster 14 . Anyone can improve their drawing skills by following simple free step by step drawing online tutorials.
Secondly, to collate the worldwide experience of disaster management found in the core literature according to the components of a health system.
This approach, supported by the resolution passed at the World Health Assembly in 2011, aims to build health system resilience to protect immediate and long-term population health in the face of all-hazards disasters.
As a result, populations can suffer unnecessarily during and in the aftermath of disasters. The WHO describes it as being composed of six building blocks – 1) service delivery, 2) health workers, 3) health information, 4) medical products, technology and vaccines, 5) health finance, and 6) governance and leadership 2 , which were originally derived from the World Health Report 2000 3 .
However, the ‘all-hazards’ approach to disaster management suggests that a health system needs resilience built into its structure across all levers.
In addition to the papers identified from these sources, a further 37 papers were selected for inclusion after being identified from the reference lists of retrieved articles and from citations.
Disaster management has been a rapidly evolving area over the last decade; thus this review concentrates on up-to-date information, while allowing the inclusion of materials describing a range of disasters across different continents. Appraisal details were recorded along with additional relevant comments outlining the relevance of each document (Summary Table of Reviewed Paper, Appendix 2). A large proportion of the documents considered the importance of taking an all-hazards approach to disaster management, but described this through the context of isolated ‘vertical’ programmes, such as health professional training programmes or surge capacity development within hospitals.
Conversely, many publications highlight ‘vulnerabilities’ in disaster management and identify lessons for the ‘health sector plan’.
This will contribute to sustainable health system resilience for populations in the face of all-hazards disaster. This review establishes the current lack of data to support the implementation of the resolution. This recently developed tool aims to progress a health systems approach to disaster management112.
A separate content matrix was originally completed on every paper reviewed, providing detail that can be used to guide disaster management from planning to acute response, recovery and rebuilding health systems post-disaster. The qualitative nature of the documents means that this bias does not reduce the validity of each document for inclusion in the review, as they expose important areas of controversy and present pertinent, all be it often specific, experiences from the field.
The disconnected nature of health disaster management in the USA means that much of the planning and resources have been implemented within isolation 13 , thus the literature generated is illuminating for all countries. I expect that inclusion of the grey literature would result in a less USA-centric view of disasters and management structures.
Professionals concerned with disaster management from around the world can use this review to identify developments to be made across all health system levers to enhance their preparedness and resilience to all-hazards disasters. Future health system research must address the issue of disaster management in response to the call made by this World Health Assembly resolution in May 2011.

Start by learning the basic concepts of drawing and improve your drawing technic as you go along. These health system components will be described as ‘levers’ to better represent the dynamic, inter-dependent nature of the components. In this way, the health system can be strengthened to respond better to the challenges presented by any disaster.
Following a pilot exploration of the literature, search terms were chosen to reflect the aim to identify a broad range of document type whilst avoiding the retrieval of an excessive number of irrelevant papers. The Summary Table of Reviewed Papers (Appendix 2) identifies which components are addressed in each publication. These collated results identify the valuable disaster management experience found in the core literature within the context of the health system levers. Their findings highlight the lack of any previous reviews in this area and the paucity of rigorous research in spite of the emergency preparedness literature having grown by about 33% per year since 2001 7. The analysis and collation of this evidence within the context of health system levers would allow a holistic approach to disaster management to be progressed. The Summary Table of Reviewed Papers (Appendix 2) presents comments that are pertinent to the aim of this review, including the type of evidence presented by the publications, such as ‘case report’. The nature of disasters means that most will not happen again in precisely the same way, so each experience and related lessons warrant consideration in their contribution to a health system strengthening approach to disaster management. This highlights the limitations and additional obstacles of not employing a health system wide approach.
An analysis of the wider relevant literature would be a worthwhile progression of this work. This collation is important as much of the health system literature ignores the need to incorporate disaster planning and management.
This is an initial step to progress research and practice in this area, describing the importance of a health systems approach to disaster management, and providing evidence to be used in developing policy and practice. Content analysis identified the disaster management components discussed within the context of the health system. This enables valuable experience in building health system resilience to be located in the literature.
These findings can be used by researchers and practitioners to develop a holistic health system approach to disaster management, supporting the aims of the adopted World Health Assembly resolution. The use of peer-reviewed core journals from 2000 to 2011 establishes a quality standard on the otherwise diverse formats of the reviewed publications, while allowing the identified disaster management material to be up-to-date. Issues of practical implementation must be clarified so that priorities can be established, such as how to incorporate disaster management across local, national and regional levels to produce an integrated health system. A second reviewer independently assessed the selection of documents according to the eligibility criteria.
They found this component of disaster management under-developed in the literature and the appropriate evaluation of the effectiveness of the systems absent 8.
This resulted in two discrepancies which were considered further against objectives of the review, resulting in establishing a consensus for inclusion and exclusion. They identify the need for evaluations of training, and that this should be based on performance improvement assessed through field exercises 9.
The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration.
WHO member states and researchers are yet to adequately respond to the World Health Assembly’s 2011 resolution to build health system resilience to disasters 1. This review progresses that agenda; it identifies the lack of comprehensive disaster management implementation across health systems and the need for objective measures to be developed. Applying systematic review methods to studies of people’s views: an example from public health research. Public health emergency preparedness and response communications with health care providers: a literature review.
Developing a health system approach to disaster management: A qualitative analysis of the core literature to complement the WHO Toolkit for assessing health-system capacity for crisis management.
Strengthening health-system emergency preparedness: Toolkit for Assessing Health System Capacity for Crisis Management . Responding in a Crisis: The Role of National and International Health Workers – Lessons from Haiti.

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