Health Assessment Phemap 2009

module 9
HEALTH ASSESSMENTS
NINTH INTER-REGIONAL TRAINING COURSE ON
PUBLIC HEALTH AND EMERGENCY MANAGEMENT IN ASIA AND THE PACIFIC
PHEMAP 9
Learning Objectives
By the end of this module, the participant should be able to:

• Discuss the role of the Health Emergency Manager in
Health Assessment
• Discuss the purpose of Health Assessments including
the need for phased assessments corresponding to the
different phases of health emergencies
• Describe the components of a Rapid Health 2
Assessment tool and the process of conducting health

such assessments
• Discuss the benefits and problems associated with
health assessment processes, methods and
technologies
PHEMAP 9 MODULE 9 HEALTH ASSESSMENTS

Group Activity
• Work in groups to discuss the data sheet

handout. It is data from a recent earthquake in
an Asian country.

Earthquake August 2009 Red Province
COUNTY/ BASELINE PEOPLE PEOPLE PEOPLE HOSPITAL

AREA (km2) HOUSEHOLDS
DISTRICT POPULATION KILLED INJURED HOMELESS BEDS
Dragon 2869 46500 160500 15000 50000 100000 1600
Tiger 4083 35880 105400 15000 5000 15000 1000
Lion 3216 81270 248000 5000 10000 80000 2400

Total 163650 513900 35000 65000 195000 5000
Questions:
as a manager, what are your observations on this data ? 4
as a manager, what does this data tell you about what you need to do ?
Additional questions:
how many children under 5 ?
how many pregnant women ?
how many elderly ?
how much food do these people need ?

how much water do these people need ?
how many doses of measles vaccine are needed ?

how many deaths can you expect every week ?

Group Activity
• Work in groups to design the outline of a

Rapid Health Assessment form for local staff
to use in the scenario you have been assigned.
• The form is one that must be designed to 5
collect information that can be submitted

within 48 hours.
• At the end of the session, groups will work to

revise and present their forms.

The Purpose of Assessments
Q&A:
What is the purpose of conducting assessments in
emergencies?

The Purpose of Assessments
To give decision makers information that will allow

them to make timely and appropriate interventions
to:
• save lives
• minimise injury and illness

7
• prevent escalation of the emergency (increased

severity)
• prevent spread of the emergency to other areas
• support response and recovery planning

Phased Assessments
• One assessment cannot collect all the information

needed to manage all the phases of response,
recovery and reconstruction
• Additional assessments are needed to determine

the priorities and targets for immediate response,
8
early relief and recovery, and longer-term recovery
and reconstruction
• BUT to enable effective decision-making and to

avoid duplication and ‘assessment fatigue’
coordination is crucial.

Health Assessments are part of the HIS
Assessment is the first step in a continuous

information gathering process that includes:
• Assessments of damage and analysis of needs (of
the population and the responding agencies)
• Emergency Reporting system
 Morbidity and Mortality reporting (by age, sex,
location and cause of death) 9
 Surveillance of communicable disease, injury,

nutritional status, water quality and disability
 Ongoing monitoring of the effectiveness of
relief services (health and non-health activity
reports)
• Evaluation of the operation

Health Needs Assessments (DANA, RHA)
Reporting + Surveillance
Hospitals cough + fever
Clinics and Health Centers diarrhea + fever
Laboratories headache + fever
PHC Programmes: rash + fever
nutrition myalgia + fever
IMCI - epi, ari, cdd etc other fever
water and sanitation malnutrition <5s
vector control trauma, disability
MCH, safe motherhood DEP, VBD, VPD, DPHS, PUCD
daily daily 10
? workload ? investigation
expected needs unexpected needs

? enough supplies ? new supplies
? enough staff ? new staff
? referral system working ? new referral system
institution focus disease focus
are we meeting the needs?

Common Approach to Assessment Methodologies
• Methodologies should be based on standard

health indicators
• Health assessments should take account of

health status of population before the disaster
Health indicators can be used in Health Emergency 11
Management for:
• Assessing disaster impacts and needs
• Monitoring and evaluating programme

implementation and outcomes

A Policy on Assessments
• Defines the general purpose of assessments

 Defines the data to be collected
• Defines the classification of victims
• Defines the classification of damage
• Defines the format for the collection

13
• Defines the reporting schedule
• Defines the assessment roles and responsibilities of agencies

and departments in preparedness and response
• Defines the knowledge and skills needed for assessments

The All Hazards Approach and Assessment
• 80% of what we do in emergencies is generic –

we do it for every emergency – the all hazards
approach
 No need to wait for field information to do this
• 15% is specific to the hazard

 Much can be done before field data is available 14
but an assessment is needed to provide the

quantitative data
• 5% is unique to the event – the people, the place

and the time
 The assessment will provide all of this data

Disaster Management is:
80% generic 15% specific 5% unique
to all disasters to the hazard to the event
1. Operational Organisation
EOC/command and control systems earthquake time
coordination mechanisms large numbers of trapped and injured place
communications systems large numbers of homeless and displaced weather
transport and traffic management systems large numbers of dead and missing
logistics and supplies systems geography
assessment and reporting systems dead, injured and missing staff climate
information systems and media management damaged critical infrastruture/resources (hospitals, vehicles)
resource mobilisation/tracking systems loss of water, gas, electricity, phone, transport, fuel networks
donated supplies/foreign teams management systems loss of road, sea, air, rail infrastructure / access security
2. Response Operations politics

search and rescue long period of Search/Rescue, victim extraction economy
evacuation high demand for FA, stretchers, triage, medical transport governance
mass casualty management high demand for beds, surgery, blood products, referral
management of dead and missing many wound infections, amputations, tetanus, dust inhalation emergency management capacity 15
security and traffic control high demand for orthotics, prosthetics, disability, dental logistics capacity
temporary shelter, clothing and utensils demand for specialised spinal and head injury care disposal of inappropriate donations
emergency water, sanitation and energy high demand for temporary shelter, food, utensils, stoves,
emergency food / cooking supplies water, energy, clothing, tents, blankets leadership
emergency public and environmental health high demand for psychosocial support of victims and staff solidarity
emergency engineering and public works severe disrupiton of public health services morale
3. Recovery Operations low risk outbreaks of communicable diseases corruption

lifelines variable demand for medicines and equipment crime / looting
curative and public health care (acute/chronic injury care - high, infectious disease - low, looting
education potentially unstable chronic disease - medium)
agriculture medium risk contamination of water and soil compensation claims
trade and commerce medium risk fertiliser, chemical, sewerage and gas leaks/spills insurance claims
4. Rehabilitation and Reconstruction urban fires, explosions ownership disputes

people contaminated, infested and unsafe foods property disputes
property increased vector breeding
services high demand for debris clearance and disposal foreign assistance
livelihoods foreign teams
environment
PHEMAP 9 MODULE 9 loss of livelihoods,
HEALTH markets, distribution networks
ASSESSMENTS
THIS IS WHAT WE PLAN FOR ….
Multi-sectoral assessments
16

Damage Assessment and Needs Analysis (DANA)
A multi-sectoral, team activity that uses standard

protocols to collect data that is analysed to define:
• the causative factors of problems

 what needs to be done?
17
• the extent of the problem

 how much of which resources are needed?

Damage Assessment and Needs Analysis (DANA)
• the likely trends

 for how long?
• constraints (climatic, geographic, political,

social, logistical, organisational etc.)
18
• priorities and targets over the relief and

recovery period

Group Activity
Work in your groups to answer the following

questions:
• What are the benefits of the health sector

being involved in a multi-sector DANA?
19
• What can be some constraints to a multi-

sectoral approach?

Which Information?
The population: The basic needs:

demography, culture, food
geography, climate water
baseline causes of shelter
morbidity and mortality energy / fuel
The support systems: 20
information flows security

logistics acute medical care
coordination hygiene and sanitation
communication etc.
resource flows

Pre-assessment Information
• any existing demographic information

• any existing national, provincial or district emergency
profiles
• local risk assessments
• local capacity assessments
• inventory of resources and deficits 21
• maps
• directory of local staff and experts (government and
NGO)
• lists of emergency materials and supplies
• logistics arrangements for emergencies
• standing orders and administrative guidelines

Why Assess Damage?
• Guides the setting of relief priorities:

 Needs caused by damage:
• Direct needs e.g. treat the injured – will the
damages affect this?
• Indirect needs – caused by damage e.g.
loss of access to water supply
 Function and safety issues –– can a service be 22
delivered, is a building safe (building “triage”)

• Evacuate or not ?
• Can people access the service?
• Repair or provide a temporary service?
• Guides planning for repair, rebuilding and
reconstruction

Factors Determining Damage and Needs
• the vulnerabilities of the affected communities

and of different individuals and groups within
those communities
• the readiness of response agencies

23
• the gaps in essential resources, including

logistics capacities
• the impact, extent and duration of the hazard

General and Health Needs
Stage Time-frame General Needs Health Sector Responsibilities
Immediate first search and rescue safe extraction, resuscitation and first aid
24 evacuation / shelter triage and transport system
hours food primary medical care
water detoxification / decontamination
public information system acute medical and surgical care (first line and referral)
emergency coordination, communication, logistics and reporting systems (including injury and disability registers)
Short term end of security emergency epidemiological surveillance for VBD, VPD, DEP, DPHS
first week energy (fuel, heating, light etc.) treatment and control of cases of VBD, VPD, DEP, DPHS, PUCD
environmental health services: strengthen blood banks and laboratories (diagnosis, confirmation, referral)
* vector control strengthen burns, spinal / head injury, orthotics / prosthetics, dental services
* personal hygiene strengthen referral system - curative, mental health and obstetric services
* sanitation, waste disposal etc. nutrition surveillance and support (including micronutrient supplementation)
24
dead and missing (emergency measles vaccination and Vitamin A)
Medium end of protection (legal and physical) (re) establishment of the health information system
term first month employment restoration of preventative health care services such as EPI, MCH, etc.
public transport restoration of priority disease control programmes such as TB, malaria etc.
public communications restoration for services of non-communicable diseases / obstetrics
psychosocial services care of the disabled (mental and physical)
Long term end of education reconstruction and rehabilitation
3 months agriculture specific training programmes
environmental protection health information campaigns / health education programmes
disability and psychosocial care
Conclusion compensation / reconstruction evaluation of lessons learned
restitution / rehabilitation revision of policies, guidelines, procedures and plans
prevention and preparedness upgrade knowledge and skills, change attitudes and practices
Vector Born Disease, Vaccine Preventable Disease, Diseases of Epidemic Potential, Diseases of Public Health Significance, Potentially Unstable Chronic Disease)

Categories of Information
The assessment involves the collection of two key

categories of information:
• Analysis of the needs of the victims

 Immediate needs arising from the situation
 Future needs arising from damage / disruption 25
to services / infrastructure
• Analysis of the damage to:

 Critical resources
 Critical infrastructure and fixtures
 Critical services

Information on Victims
A report describing the impact of a hazard will

provide:
• Number of casualties
• killed; injured; sick; disabled;
• by age, sex, location and probable cause of 26
death
• Number of affected
• total affected; severely affected; critically
affected;

Classification Based on Severity
The following criteria are used to describe the severity of the

impact on people:
• affected
 all those living within the geographical area involved
• severely affected
 those who have lost one or more of their lifelines 27
• critically affected
 those who have lost all of their lifelines
 OR who have been displaced i.e. those totally
dependent on others to support them

Critical Services - Basic Needs and Lifelines
Basic needs are the minimum requirements needed

for the survival of the affected population (also called
“pre-requisites for health”).
Q&A:What are the basic needs for survival of a

population?
28

Critical Services – Basic Needs and Lifelines
Basic needs for survival:
• water
• food
29
• shelter (and clothing in cold climates)
• energy (fuel)
• (acute medical care)

Lifelines are services that are needed to deliver the

basic needs.
Q&A: What lifelines can you identify that would

enable the meeting of these basic needs?
30

Critical lifelines:
• Utilities (water, electricity, gas) – sources and

networks
• Communications systems
• Transport networks (air, sea, road) 31
• Distribution systems

First priority of the government:

To restore lifelines and meet basic needs
32

Assessing Facilities and Services
For each facility or service in the affected area, the

assessment grades function according to a pre-
defined scale:
For example:
• destroyed / no function possible 33
• more than 50% reduction in capacity
• less than 50% reduction in capacity
• undamaged / full function

Health Assessments
34

What is a Rapid Health Assessment?
“collection of subjective and objective information

in order to measure damage and identify those
basic needs of the affected population that require
immediate response”
Rapid Health Assessment protocols for emergencies, WHO, 1999

35

Public Health Consequences of Disasters
• temporary population displacements
• increased numbers of deaths and injuries
• new cases of disease and disability

36
• exacerbation of and increased numbers of cases

of psychological and social behaviour disorders
• food shortages and nutritional deficiencies

Public Health Consequences of Disasters - cont.
• environmental disruption causing hazards –

vectors, waste management, sanitation
• destruction of infrastructure
• disruption to routine health services

37
• disruption to routine disease surveillance and

control services
• diversion of capital investment funds to

emergency relief and the rehabilitation or
reconstruction of essential infrastructure

Emergencies and Health
HEALTH RESPONSE
Community
search and rescue
first aid
triage
DIRECT medical evacuation
IMPACTS primary care
Damage
disease surveillance and control
and
curative care
VULNERABILITIES Needs blood banks
CAPACITIES laboratories
referral system
INDIRECT special units (burns, spinal)
EMERGENCY IMPACTS 38
evacuation centres
shelter
water
food and nutrition
energy
ASSOCIATED FACTORS
security
Climate / weather / time of day environmental health

Location primary health care
Security situation
Political environment care of the dead
Economic environment psychosocial care
Socio-cultural environment disability care
Morale, solidarity, spirit
Competence, corruption recovery
reconstruction

Objectives of Rapid Health Assessments
Collection objectives
• identify existing and potential public health needs
• identify gaps and problems in meeting urgent

medical needs
• assess existing and potential environmental risk 39
factors
• assess resource and logistics needs
• identify managerial, coordination and

organisational gaps, overlaps and problems

Objectives of Rapid Health Assessments
Analysis objectives
• set priorities for response / relief
• set priorities for information dissemination and

communication
40
• identify resources needed to meet priorities –

external and internal
• identify additional information needs for the

response and for planning recovery and
reconstruction

Questions Answered by a Rapid Health Assessment
• Is there an emergency or not?
• What is the existing response capacity?
• What decisions need to be made?

41
• What information is needed to make these

decisions?
• What are the sources of that information?

Categories of Information
The assessment involves the collection of three key

categories of information:
• Analysis of the damage to:
 critical resources
 critical infrastructure and fixtures
 critical services
• Analysis of the needs of the response agencies 44
 immediate needs arising from the situation

 future needs arising from damage / disruption to services
/ infrastructure
• Analysis of the needs of the victims
 immediate needs arising from the situation
 future needs arising from damage / disruption to services
/ infrastructure

Rapid Health Assessment task
The first task is to assess functioning of all the health

facilities in the area (hospitals, clinics, laboratories,
warehouses, blood banks, administration):
a. Staff – dead, injured, missing, absent
b. Access – can staff / people reach the facility 45
c. Buildings – damages, safety, loss of electricity /

gas / water, loss of fuel (diesel)
d. Supplies and equipment damaged or lost,

including vehicles

Rapid Health Assessment tasks - cont.
The next task is to assess needs arising from loss

function :
a. Temporary services needed?
b. Repairs needed? 46
c. Replacements needed (staff and materials)?

Rapid Health Assessment tasks - cont.
The next task is to assess urgent health needs of the

population:
a. Overview of actual and potential causes of
morbidity and mortality, and numbers of cases
The final report will make recommendations on: 47
a. Resource needs
b. Personnel needs
c. Management and organisational needs
d. Logistics and communication needs

Use the Coordination Mechanism
It is not necessary to go to the field to collect

detailed information from other sectors
At the daily coordination meetings, reports and

assessments from other sectors are shared – these
can be sent as ANNEXES to health sector reports
48
The Emergency Reporting System should take over

from assessments as soon as possible

Planning a Rapid Health Assessment
• Set the assessment objectives, team skill needs

and time frame
• Collect the data:
 reviewing existing information
 inspecting the affected area
 interviewing key people 49
 carrying out a rapid survey

• Analyse and interpret the findings
• Issue orders and instructions
• Disseminate the report and communicate the
findings

Preparing for an Rapid Health Assessment
• What information should I collect before going

to the field?
• What collection methods are appropriate

given:
 the specific context of the emergency, and 50
 weather, security, time, logistics, technical,

cultural constraints?
• What will be the main sources of information?

Is an interpreter needed?

Preparing for an Rapid Health Assessment - cont.
• What is the composition of the team and the

role of each team member?
• What are the security, logistics and

communication needs of the team?
51
• What equipment to take – maps, contact

information, forms, specimen bottles, paper /
pens, personal items

Q&A
• Does your country have a policy and

guidelines, protocols, standard forms for
Rapid Health Assessment?
• Are people trained in health assessment?

52
• What are the common weaknesses of rapid

health assessments?

Rapid Health Assessment: Common Mistakes
• No policy or guidelines on assessment

• No standard collection formats
• No training in assessment skills
• Different sectors use different terms and methods
• Data cannot be consolidated 53
• Too much irrelevant/duplicate data collected

• Too much time taken – accurate is better than
precise
• Those collecting the data don’t know how it will be
used and don’t have the opportunity to improve
the assessment system

Rapid Health Assessment - Common Mistakes
The biggest mistake in forms used by the health

sector is that they focus too much on collecting
(unavailable or unreliable) morbidity and mortality
data rather than health sector function information
54

Resources for planning assessments
57

WHO
58

What is Available in the EHA Webpage?
• Short introduction with objectives
• Sitrep Template
• Instructions
59
• Reference Values

Reference Values
60

Activity
Based on what you have just learned, work in your

groups to review and revise the form you developed
in the first exercise
61

Q&A
Is it possible to develop one single form that covers

the assessment needs for all possible
emergencies?
62

Health Sector Assessments by Hazard Class
1. Natural Hazards
• focus first on recording damage to health sector,
then on the needs of the health facilities to
restore some function, then on the meeting needs
arising from actual and potential causes of
morbidity and mortality
63
2. Technological Hazards
• focus on capacity to meet the needs arising from
the actual and potential causes of morbidity and
mortality

Health Sector Assessments by Hazard Class
3. Biological hazards
• focus on capacity to meet the needs arising from
the actual and potential causes of morbidity and
mortality
4. Societal Hazards
• In conflict - focus first on recording damage to 64
health sector, then on the needs of the health

facilities to restore some function, then on the
meeting needs arising from actual and potential
causes of morbidity and mortality
• In other situations - focus on capacity to meet
the needs arising from the actual and potential
causes of morbidity and mortality

Different Needs, Equal Opportunities
Differences between individuals and groups can lead them to

having different types and degrees of need(s), which might
have to be met in different ways.
Examples of differences between individuals and groups:

• Age
• Sex/gender
• Wealth 67
• Social status, caste

• Geographic location
• Legal status
• Ethnicity, race
• Religion

Recap: the Purpose of Assessments
To give decision makers information that will allow

them to make timely and appropriate interventions
to:
• save lives
• minimise injury and illness 71
• prevent escalation
• prevent spread
• support recovery planning

Advantages of a Standard Template
• prepared for the people who need to use the

information (managers, decision makers)
• controls what kind of information is collected

 standardised protocols for data collection
 standardised terminology, technologies, 72
methods and procedures

 enforces “Zero” reporting
• facilitates preparation of consolidated reports
• facilitates rapid analysis and dissemination

Disadvantages of a Standard Template
• prepared by the people who need the information

 those collecting the information have no input
into design
• controls what kind of information is collected

 non standard information cannot be included
73
• standardises the terms used

 qualitative information might not be captured

Needs Assessment and Programme Monitoring
Assess resources and Assess health status

infrastructure (morbidity, mortality, nutrition) Programme Indicators
Is there damage to health water, sanitation, waste, shelter, food supply and
1
sector infrastructure? nutrition services in place / meeting needs
Is there damage to health NO curative, preventative, promotional and
Is there a major health problem? 2
sector resources? rehabilitative services in place / meeting needs
situation specific preventative actions being taken –
Is there damage to lifelines? 3 vector control, measles vaccination, vitamin A,
public awareness, antenatal care etc
YES YES 4 guidelines issued and being followed
Monitor and Evaluate

reporting and surveillance systems for injury,
Can the health system cope? YES 5 disease, nutrition, water quality, vectors, food
safety, mental health, disability in place 74
referral systems in place, including laboratories,
Can the community cope? 6
psychosocial, chronic diseases and disability care
essential drugs and equipment available,
NO 7
appropriate and sufficient
strengthen existing services/ management, logistics, security and

8
organise temporary services communications systems in place / meeting needs
Mobilise additional resources 9 staff safety, information, training needs being met
community health information / health education

Seek expert advice 10
needs being meet
plans for rehabilitation and reconstruction address
Organise epidemiological studies 11 issues of equity, access, coverage and risk
and surveys
reduction

Health Needs Assessments (DANA, RHA)
Reporting + Surveillance
Hospitals cough + fever
Clinics and Health Centers diarrhea + fever
Laboratories headache + fever
PHC Programmes: rash + fever
nutrition myalgia + fever
IMCI - epi, ari, cdd etc other fever
water and sanitation malnutrition <5s
vector control trauma, disability
MCH, safe motherhood DEP, VBD, VPD, DPHS, PUCD
daily daily 75
? workload ? investigation
expected needs unexpected needs

? enough supplies ? new supplies
? enough staff ? new staff
? referral system working ? new referral system
institution focus disease focus
are we meeting the needs?

Learning Objectives
By the end of this module, the participant should be able to:
• Discuss the purpose of Health Assessments including

the need for phased assessments responding to the
different phases of health emergencies
• Describe the components of a rapid health assessment
tool and the process of conducting health assessments
• Discuss the benefits and problems associated with 76
health assessment processes, methods and

technologies
• Discuss the role of the Health Emergency Manager in
Health Assessment

77
THANK YOU

Health Assessment Phemap 2009

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module 9

NINTH INTER-REGIONAL TRAINING COURSE ON

PUBLIC HEALTH AND EMERGENCY MANAGEMENT IN ASIA AND THE PACIFIC

By the end of this module, the participant should be able to:

Assessment tool and the process of conducting health

PHEMAP 9 MODULE 9 HEALTH ASSESSMENTS

• Work in groups to discuss the data sheet

PHEMAP 9 MODULE 9 HEALTH ASSESSMENTS

COUNTY/ BASELINE PEOPLE PEOPLE PEOPLE HOSPITAL

Dragon 2869 46500 160500 15000 50000 100000 1600

Tiger 4083 35880 105400 15000 5000 15000 1000

Lion 3216 81270 248000 5000 10000 80000 2400

how much food do these people need ?

how many doses of measles vaccine are needed ?

PHEMAP 9 MODULE 9 HEALTH ASSESSMENTS

• Work in groups to design the outline of a

• The form is one that must be designed to 5

collect information that can be submitted

• At the end of the session, groups will work to

PHEMAP 9 MODULE 9 HEALTH ASSESSMENTS

PHEMAP 9 MODULE 9 HEALTH ASSESSMENTS

To give decision makers information that will allow

• minimise injury and illness

• prevent escalation of the emergency (increased

• prevent spread of the emergency to other areas

• support response and recovery planning

PHEMAP 9 MODULE 9 HEALTH ASSESSMENTS

• One assessment cannot collect all the information

• Additional assessments are needed to determine

• BUT to enable effective decision-making and to

PHEMAP 9 MODULE 9 HEALTH ASSESSMENTS

Assessment is the first step in a continuous

 Surveillance of communicable disease, injury,

PHEMAP 9 MODULE 9 HEALTH ASSESSMENTS

expected needs unexpected needs

are we meeting the needs?

PHEMAP 9 MODULE 9 HEALTH ASSESSMENTS

• Methodologies should be based on standard

• Health assessments should take account of

Health indicators can be used in Health Emergency 11

• Assessing disaster impacts and needs

• Monitoring and evaluating programme

PHEMAP 9 MODULE 9 HEALTH ASSESSMENTS

• Defines the general purpose of assessments

• Defines the format for the collection

• Defines the reporting schedule

• Defines the assessment roles and responsibilities of agencies

• Defines the knowledge and skills needed for assessments

PHEMAP 9 MODULE 9 HEALTH ASSESSMENTS

• 80% of what we do in emergencies is generic –

• 15% is specific to the hazard

but an assessment is needed to provide the

• 5% is unique to the event – the people, the place

PHEMAP 9 MODULE 9 HEALTH ASSESSMENTS

2. Response Operations politics

3. Recovery Operations low risk outbreaks of communicable diseases corruption

4. Rehabilitation and Reconstruction urban fires, explosions ownership disputes

PHEMAP 9 MODULE 9 HEALTH ASSESSMENTS

A multi-sectoral, team activity that uses standard

• the causative factors of problems

• the extent of the problem

PHEMAP 9 MODULE 9 HEALTH ASSESSMENTS

• the likely trends