The learning model using tabletop aims at examining the healthcare system response and governance towards the disaster. The varied healthcare system responses cover: flow of disaster management, relation among the doers in disaster, communication system between institution and individual, and the existence of structural preparedness in encountering disaster. It is expected that this training is participated by health office, Red Cross, various NGOs in Disaster Sector, also the institutions of healthcare provider. The more institutional representatives join the training, the better.

In brief, the objectives of the training are as follows:

• Clarifying the roles and responsibilities of varied health sector components in managing disaster in different phases
• Maximizing social network and public participation
• Practicing cooperation in disaster response
• Training different skills in disaster management, including leadership and communication technique
• Anticipating the occurrence of disaster by preparing better health sector in the levels of district/ municipality and province
• Preparing financial resource for disaster management

Learning process carried out through:

• Participants read the description of disaster occurrence
• Participants discuss varied key questions
• Supported by facilitators, participants seek out recommendation and develop disaster preparedness system

Tectonic earthquake with magnitude 5.9 SR struck Bantul district on Saturday, May 27, 2006 at 05.53 West Indonesian Time, the epicenter was in Bantul area with 33 km depth. The earthquake claimed thousand of death tolls, thousand of damaged houses, hundreds of collapsed schools, and many damaged sub- health centers/ health center/ hospital/ healthcare facilities. Bantul suffered from the most victims and damages. Chaotic condition emerged, telecommunication system was disturbed, electricity died out, tsunami rumor spread, and it was a long holiday. Hospital, treating health centers and clinics were visited by thousand of victims. The district government, including Bantul Health Office established disaster unit (posko) at the regent's house.

At 06.30 the head of DIY Provincial Health Office coordinated with the Orderliness and Security Office (Dinas Tramtib) and Red Cross officials. At 07.30 he consolidated DIY Provincial Health Office. Government in health sector started to mobilize but it faced varied constraints. Community groups started to move with their own strength. Provincial Health Office announced news to the public via Sonora Radio station, including the drugs distribution. Several hospitals had asked aids especially from those outside Yogyakarta . At 8.00 drugs were distributed to hospitals and Red Cross health posts. Earthquake victims occupied hospitals, and they were not treated well. At 7.00 (?) Red Cross built “ a field hospital” on Dwi Windu field and coordinated immediately with the district health office.

The head of Bantul Health Office found difficulty in contacting his staffs. Even though he could, most of them were the earthquake victims; consequently, there were only 7 staffs of the health office served in the disaster post. Such limited staffs should be divided into 3, in the main disaster unit (the regent's official house), in the Drug Warehouse, and on Dwi Windu field. The head of Bantul health office should move from one place to another due to the complex problems encountered by the hospitals and on the field. And what become a burden was the number of SMS and calls received by his HP from all over Indonesia, and those were offering help (fortunately, the head of the health office once was the leader of DIY Arsada before he became the member of Adinkes).

Many helps offered were the results of friendship. As an example: at 10 in the morning, there was a SMS received by a lecturer of Medical Faculty- GMU from Dr. Sri at Tabanan District Hospital, Bali who sent a team to Bantul. This SMS was followed by many other SMS with the same content. Meanwhile, there was a SMS from Nur Hidayah Clinic in Jetis. The clinic leader asked for staff assistance. At that time, the health office was difficult to be reached due to communication problem and there was hardly any medical staff. The clinic should seek for external assistance. At 13, emergency team from Tabanan District Hospital moved to Yogya, 7 hours aftermath. The team consisted of 12 personnel using two ambulances. By the lecturer of MF- GMU, the team from Tabanan, Bali , was directed to Nur Hidayah Clinic after reporting to the disaster post. Persahabatan Hospital , Jakarta , sent a team to assist Muhammadiyah Hospital , Bantul, because the hospital director was a good friend of the dean of MF- Muhammadiyah University . In many areas, community groups actively helped others. On the first day, there were lots of parties who sent their teams to Yogya. Actually, many of them had prepared themselves for Merapi eruption.

The condition of hospitals in Yogya was not yet secure due to minor earthquake threat. Patients were treated on the hospital yard which resulted in agonizing view. Sardjito Hospital , Panembahan Senopati Hospital , PKU Hospital and others looked like camps treating war victims, and the hospitals were lack of ATS.

In the evening, around Magrib hour, after the visit of President SBY at the disaster post, the head of Bantul Health Office decided to stay in the post to coordinate the arriving helps. With the assistance of one staff and without proper writing tools, he started to note down (on a piece of paper) the team names of medical assistances, and also names of locations which required helps. To the arriving medical team, he asked the human resource, if they brought ambulance (equipped with medical assistance and drugs) they were then given some address of the needy village/ location. They went to the location with the address and some compass direction, without any map or local assistant; meanwhile most of the teams were not from Yogya.

Interesting, it happened that the health desk was at the centre of the disaster post (building) and so community members who came for help or gave general logistic help (food, tents, others) directly went to the health desk. Meanwhile, at the disaster post, there was not any clear coordination and job distribution. Many of the community members who asked for first aid packages came individually. Almost all day, the health office head, his staff and staffs from Bantul government did not eat or drink, because there was not any food stall opened, and at the disaster post, there was not any logistics or public kitchen for the staffs.

Key Questions

1. Describe the map of disaster management executor/ group! Who were the leaders of the groups active on the first day?
2. Who should become the disaster coordinator in health sector? From the government or NGO?
3. Who should manage helps/ aids from external parties?
4. What can be done to maximize the role of social network in disaster?
5. How to activate first aid package (family) and emergency skill in the community?
6. How should the data system, communication and information be done?

DIY Provincial Health Office conducted assessment to healthcare facilities, and distributed under- five food and medicines. DIY Provincial Health Office coordinated with Civil Work Office (Dinas PU) to establish public waste system and medical waste system. The management of medical team was still conducted by Bantul District Health Office assisted by 10 staffs. Medicinal and medical device needs were compiled. Various community components moved. Team form the Center for Health Service management MF- GMU facilitated the supply of external medical assistants and logistics for clinics.

At the mean time, there was an instruction (by unclear resource) to evacuate patients to outside Yogya. However, the condition made it impossible for the evacuation. There were too many patients, transportation facility shortage, and culturally, it was impossible to send patient out of the province without being accompanied by some family member. Most of the emergency volunteers having the field experience stated that the policy to evacuate patients out of Yogyakarta was impossible to do. Discussions in Panembahan Senopati, Bantul, were conducted, including with the director of Bantul District Hospital who was close to the President in Gedung Agung. Soon, it was decided by the volunteers that the urgent thing to do was opening emergency field operating sites as many as possible and there was not any evacuation. As an illustration (one example from various emergency hospitals). Nur Hidayat Clinic in Jetis whose building was relatively not damaged was soon turned its status into a field hospital.

Assistances from outside Yogya and overseas grew larger, and field coordination started to operate in Bantul. At 10 in the morning, Medical Team from Tabanan District Hospital arrived in Yogya after 17 hours traveling from Bali , and the team was approved by Bantul Health Office to assist in Nur Hidayah Clinic. To be noted, this team from Bali was the first team assisted in Nur Hidayah Clinic. There had been so many assistances in Bantul District Hospital .

Surprisingly, there grow more people in the disaster post; besides those who asked or gave assistances, there were other parties who looked for data and news, including from the MoH, NGOs, mass media, etc, and those should be served. Unexpectedly, there came an official from the MoH who got irritated and said that the function of health office was not supposed like that. The donators/ NGOs asked for regular meetings to be held every day at certain schedule.

On that day, it was considered necessary to have a figure of disaster manager in health sector. Informally, staff from MF- GMU asked Provincial Health Office to form an emergency team under the authority of Provincial Health Office.

Key Questions

1. Who became the disaster manager in Bantul District, and in DIY Province? What was the legal foundation for such disaster manager? Should the manager be a government official or NGO? When was the manager be better appointed? Before or after the disaster?
2. How is the proper leadership style applied by a government institution and public institution in such uncoordinated phase?
3. Who is the authority to make decision in health sector during the emergency phase?
4. Who should talk to the press? How is the technique to provide data and information?
5. How is the coordination system among the government, private and public?

Long holiday was over, offices opened although they should build tents. The morning ceremony in Bantul Health Office was only attended by half of the staffs. However, staffing function still could be accomplished. The staffs were divided into several teams, namely: surveillance team, logistics team, damaged healthcare and environment facility assessment team, medical ambulatory team, etc. Fortunately, three weeks prior to the earthquake, Bantul Health Office had established Disaster Alert Team (Tim Siaga Bencana), but they had not have any chance to join training or perform disaster simulation, except send medical team to Merapi refugees. CHSM/ Public Health Science GMU assisted in the recording and information by assigning a staff and a computer unit.

The disaster management had been put to order, and it required some operational budget (non patient care). Bantul Health Office tried to propose some fund (emergency fund) to the district government, but the office was then asked to prepare the detailed plan first. So did happen when the office asked some fund to the provincial government, the health office was required to make some responsibility document (SPJ) first.

Coordination meeting was officially conducted in the health sector including in Provincial Health Office. Public Health Science/ IKM- GMU as one of public components performed activities covering four aspects: mapping, surveillance preparation, telecommunication infrastructure preparation, daily bulletin, and meeting facilitation. On that day Provincial Health Office conducted coordination meeting with hospitals and district/ municipal health offices and came up with some agreement as follows: all patients were free from any charges, reporting all activities to the data information centre of health office everyday before 5 noon .

Bapel JAMKESOS provided some down payment for the hospitals in needs. MoH team started to conduct need assessment and data gathering. Environmental health staff distributed plastic bags for medical wastes to health posts, and monitored basic sanitation facilities. Public activities grew larger. Foreign teams arrived.

At night in the coordination meeting, it was reported that there were five corpses in some hospitals unidentified by the family, and the corpses started to decay. The district secretary asked the head of Bantul Health Office to take care of them, but the head was confused, not knowing what to do.

Key Questions

1. How is the authority and responsibility division in the disaster management among the central MoH, Provincial Health Office, and District Health Office in the decentralized era?
2. How is the coordination system between the local government and MoH?
3. How is the financing system during emergency be established nationally and locally?
4. Where is the financial resource during the disaster originated?
5. How is the procedure in withdrawing and using disaster fund in the local district/municipality?
6. How to make the disaster teams well coordinated?
7. What is the role of the central government in the disaster management?
8. How is the volunteer management?

More helps arrived. Mobilizing assisting teams grew larger. Staffs of Bantul Health Office could not handle them any longer. Medicinal logistics and health device aids grew larger, many of them were not completed with invoices and mixed with other logistics such as breads, instant noodles, etc. More MoH staffs arrived in Yogya. WHO came to set- up the disaster management system. Sardjito Hospital became the center of activities during the emergency phase. Red Cross conducted health coordination meeting attended by various NGOs and foreign teams. At 5 noon , informal meeting was conducted among GMU, MoH, Health office and WHO in Sardjito Hospital discussing how to better manage the disaster. It was considered necessary to establish coordination during the emergency phase in the decentralization. MoH served as the facilitator, Provincial Health Office was expected to be the leader. MoH Work Unit was assisting here. Activities should be under the authority of health office.

Bantul health Office conducted coordination meeting with the heads of health centers discussing the recent condition and plan forward. Many medical cases had been handled by volunteer teams in the field, but Bantul Health Office had not had good reporting format and system. There was a format by MoH but it was very complicated and so the field staffs were not interested to complete it. What matter was how to help patients without being bothered by administrative stuff.

After there was ambulatory team from MoH, the reporting was through SMS, but this was also not effective considering that the head of health office HP was too overloaded. To obtain data, Bantul Health Office made a policy, for the medical team living Yogya should report the cases which had been handled. There were teams who reported as their versions, but many others did not. Surveillance system which was supported by WHO had been operated but still limited in 10 diseases having the outbreak potential; hence, those cases had been documented well. Data on the damaged health facilities had been gathered. Based on the temporary data, there were 15 health centers were severely damaged and collapsed, and so were the sub- health centers, and private health facilities. Realizing such condition, the head of Bantul Health Office reported to the regent, and the regent asked him to find the best solution and provided him inclusive authority to manage health problems.

Key Questions

1. How to coordinate external assisting teams, including the mobile medical emergency team?
2. Is there any guideline for providing assistance?
3. How is the proper reporting format and system in such disaster management?

As planned, in the morning a disaster management team (Crisis Center) was established in Sardjito hospital under the authority of Provincial Health office supoorted by WHO covering all components in the community (118 Brigade, universities, MoH, etc). During the meeting, there was an interesting discussion on whether the team was under MoH, Sardjito hospital or Health Office. And it was firmly decided that the Crisis Center should be under Provincial Health Office. The site of crisis management activities during the emergency phase which was naturally in Sardjito Hospital would be gradually moved to the health office. On the same day, the telecommunication network was established by the assistance of Data and Information Center (Pusdatin). In the afternoon, Red Cross still conducted health coordination meeting.

The head of Bantul Health Office went to CHSM/ IKM to discuss the encountered condition in Bantul. Fortunately, he met the dean and the dean assistants of MF – GMU who were thinking about what can be given to Bantul. In the mean time, there was a contact from the dean of MF- Hasannudin University , Makasar, and it was agreed that PT INKO, being facilitated by both MFs would re- build Piyungan Health center. With this first success, Bantul Health Office was optimistic. Hence, data on the health center damages were gathered, and the requirement was spread via internet.

Key Questions

1. Is Crisis Center really necessary to be established? What role does WHO play?
2. How is the best team structure which may involve all competent parties?
3. How to build collaboration network with private sector and NGO?

The infrastructure of the disaster management team under Provincial Health Office was strengthened. Telephone and internet lines were also strengthened in some spots. Daily meeting which previously managed by Red Cross was moved to the disaster coordination team in Sardjito Hospital . Although the meeting leadership had not been effective yet, but the management process by the government was undertaking. The coordination process in health sector including foreign NGO by the Bantul Health Office grew better. Bantul Health Office decided that by D+7 health center as the area leader should re- function in managing the volunteer teams in field. Not all of the heads of the health centers agreed with this, considering the health center resource which was still in poor condition; however, the head of Bantul Health Office persisted with his decision. This was to show to the external parties that governance (in health affairs) was not collapsed although it was managed in health center tent, and to motivate health center staff to rise up soon. In Provincial Health Office there were meetings by groups/ clusters such as surveillance, maternal and child health, hospitals, and many others.

Disaster management team led by DIY Provincial Health Office started to function effectively, including in managing various sub- groups. Daily coordination meeting at 5 at noon was conducted well. The meeting was directly led by the head of DIY Provincial Health Office and attended by 90% participants from various foreign and domestic institutions providing assistances. Preparation for moving the location from Sardjito Hospital to Provincial Health Office was done gradually.

In this period, transition process from emergency phase to recovery phase occurred. Various telecommunication devices were moved from Sardjito Hospital to Provincial Health Office. Starting on today, the activity coordination more took place in Provincial Health Office. Coordination and command system were better managed.

Government (Health Office) played more role as the coordinator of community groups and business world in managing disaster. There were different sub- groups, such as: technical meeting on Immunization as Disaster Impact, Disease Surveillance, Hospital and Health center Referral, Logistics, Mental Health as Disaster Impact, Disaster data & Information Center .

Key Questions

1. Would the government function re- function normally? How is its relation with NGO and other assisting parties?
2. Is it right that large hospital which functions as the center of disaster management moves its function to provincial health office when it comes to recovery phase?
3. How is the proper leadership style of health office during the transition period from emergency to recovery phases?
4. What are the required coordination meeting types? Who are invited? How much is the frequency of effective coordination meeting? Who should be the meeting leader?
5. What are the required skills during those coordination meetings?