International Journal of Disaster Risk Reduction 40 (2019) 101154

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International Journal of Disaster Risk Reduction

journal homepage: www.elsevier.com/locate/ijdrr

Examining disaster preparedness at Matara District General Hospital in Sri T

Lanka
Nimali Lakmini Munasinghe∗, Kenichi Matsui
University of Tsukuba, Japan

A R T I C LE I N FO A B S T R A C T

Keywords: Globally, the frequency of natural disasters has increased significantly in recent decades. Hospitals are expected
Disaster to remain functioning during and in the immediate aftermath of disasters as they are essential infrastructures in
Health facilities responding to them. Sri Lanka has experienced a number of natural disasters such as the tsunami of 2004,
Matara district landslides and floods of 2017. Although the government has made some improvement mainly for infrastructure
Preparedness
resiliency, inadequate disaster preparedness remains at many regional hospitals. Despite the critical role of
Safe hospital
Sri Lanka
hospitals in saving lives of disaster victims, very limited research has assessed disaster preparedness at hospitals
in Sri Lanka. This study attempts to fill this gap by examining disaster preparedness at one district-level hospital
in a disaster prone area. Field visits, phone interviews and an original questionnaire survey among doctors and
nurses were conducted to better understand how they perceived the preparedness of this hospital. The results of
the questionnaire survey revealed that most salient aspects of preparedness, such as human resources, com-
munication, safety, security, transportation, critical supplies, and morgue capacity were inadequate. It also il-
lustrated challenging areas in responding to a large number of disaster victims. Most of the respondents were
unaware of the disaster response plan. Also, they had not participated in disaster drills. However, almost all the
doctors and nurses demonstrated their willingness to improve their knowledge on disaster management and to
serve in future disaster situations. This paper concludes with a number of recommendations to improve the
disaster response capacity of Sri Lankan hospitals in the future.

1. Introduction disasters. Countries with special needs, particularly, in small island

Disasters, both natural and manmade, are increasing globally [1].
Health facilities, especially hospitals, are essential in responding to
disaster situations, including emergency treatment and trauma care.
Health facilities are expected to remain accessible and functioning at
their maximum capacity during and after disasters, emergencies, or
other crises [2].
Studies have shown that disasters cause proportionately more da-
mage to developing countries and poor communities [1]. Natural dis-
asters are more likely to affect people in Asia and the Pacific regions
[3]. One climate change vulnerability index indicates that all seven
cities globally classified as “extreme risk” are in Asia [4]. Since the
early 1990s, natural disasters have cost Asia nearly US$1 trillion, al-
most half of the estimated global cost for natural disaster damages [5].
A study that projects future impacts of disasters for the period between
2020 and 2030 suggests that people in most Asia-Pacific countries will
be at high risk for injuries and fatalities. The Asia-Pacific region will
endure 40% of the total worldwide future economic losses from
developing countries like Sri Lanka, may lose almost 4% of GDP due to
natural disasters [3].
The international community has placed disaster risk reduction at
the center of sustainable development [3]. The Hyogo framework for
action (HFA) 2005–2015 and its successor, the Sendai framework for
action (SFA) 2015–2030, highlight the importance of ensuring the re-
silience of critical infrastructure such as hospitals by undertaking dis-
aster risk reduction actions. The SFA has a direct link to health. It
promotes the safety of health facilities [6].
As disaster preparedness issues has gained increasing attention in
recent years, the World Health Organization (WHO) published a
number of safe hospital reports and toolkits to help hospitals be more
prepared for disasters. The WHO defines safe hospitals as “health fa-
cilities whose services remain accessible and functioning at maximum
capacity and within the same infrastructure during and immediately
following disasters, emergencies or crises” [7]. The WHO “Safe Hospital
Initiative” (SHI) concept meant to be adopted by hospitals globally to
ensure the structural integrity and functionality of health facilities

∗
Corresponding author.
E-mail addresses: nimalimlk@yahoo.com (N.L. Munasinghe), kenichim@envr.tsukuba.ac.jp (K. Matsui).

https://doi.org/10.1016/j.ijdrr.2019.101154
Received 8 December 2018; Received in revised form 11 April 2019; Accepted 14 April 2019
Available online 16 April 2019
2212-4209/ © 2019 Elsevier Ltd. All rights reserved.
N.L. Munasinghe and K. Matsui
under disaster situations [8]. In addition, it argues that making
healthcare facilities safe and resilient is a very cost effective investment
compared to spending on reconstruction after a disaster event [7].
According to the WHO, the structural elements include the load-
bearing components that make a building stand such as columns, beams
and the walls. The non-structural elements include non-load-bearing
walls, windows, doors, ceilings, fixtures, appliances, lifelines and
equipment. The functional elements include the physical design (e.g.,
the site, external and internal distribution of space, access routes),
maintenance and administration (PAHO and WHO, 2010; [7]).
1.1. Vulnerability of Sri Lanka
In Sri Lanka floods, landslides, cyclones, droughts and tidal waves
are more frequent. Since 2000, flood and drought events have cumu-
latively affected more than 13 million people across the island. In 2004,
almost two-thirds of the coastal area was severely affected by the Indian
Ocean tsunami [9]. This was the most devastating natural disaster re-
corded so far in the country. Sri Lanka was extremely hard-hit in terms
of loss of life and damages to infrastructure and economic assets. As a
result, more than 35,000 people died, about 5000 people went missing,
and about 100,000 houses were completely destroyed. In total, 260,967
families and 1.3 million people were affected in one way or another
[10].
Damage to the health sector was estimated to be US$60 million.
Where the tsunami struck, 44 health institutions, including a large
maternity hospital (teaching hospital) and many local clinics, were
completely damaged. Another 48 health institutions were partly de-
stroyed with loss of medical equipment and essential instruments [11].
Thirty-five healthcare workers lost their lives, including medical offi-
cers, technical staff, non-technical staff, and others. Furthermore, a
large number of health staff was injured and mentally traumatized.
Many of them lost their homes or family members. These damaged
hospitals suffered from the shortage of health workers. It was difficult
to find replacement staff. For example, five days after the tsunami at
Mahamodara Teaching Hospital in Galle district, only 25% of hospital's
staff reported to duty. In addition, this hospital lost many vehicles,
including ambulances [11]. The estimated total cost of rehabilitating
the health sector was approximately US$84 million. The main concern
was to supply basic health needs for displaced people, including the
clean water supply, sanitary facilities, the prevention of communicable
diseases, the psycho-social needs of the affected people, the establish-
ment of temporary health facilities, and the restoration of damaged
health centers [11].
More recently in May 2017, heavy rainfall due to the South-West
monsoon resulted in severe floods and landslides affecting 15 out of 25
districts in Sri Lanka. In total, 200 382 people were affected, 100 per-
sons lost their lives and 99 were missing. The healthcare institution
network was also affected. The Ministry of Health reported that 5
hospitals including the Base and Divisional hospitals were evacuated
partially or fully. Several hospitals had reported breakdowns in elec-
tricity and water supplies. The public health service provision in the
field was also affected. Matara was identified as one of the worst af-
fected districts [12]. The total impact on the health sector was esti-
mated to be LKR 349.46 million, including damages to infrastructure,
equipment and furniture as well as losses related to additional ex-
penditure for emergency response and medical supply. A total of 65
government healthcare institutions were partially or fully-affected in
four districts including the Matara district. Furthermore, significant
infrastructural damage was identified in some of these institutes which
were located in high risk areas [13].
Moreover, Sri Lanka is also vulnerable to infectious diseases such as
avian influenza and chikungunya. Waterborne diseases like cholera and
vector-borne diseases like dengue fever sometimes emerge as epidemics
especially after floods [14]. Sri Lanka had experienced an increased
number of dengue cases. From January 2017 to July 2017, for example,
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International Journal of Disaster Risk Reduction 40 (2019) 101154
the Ministry of Health, Nutrition and Indigenous Medicine recorded
82,543 dengue cases, including 250 deaths. The number of cases in
2017 was three-and-a-half times more than the average number of cases
reported between 2010 and 2016 [15]. Unplanned development pro-
jects and human settlements that encroached into flood plains and
unstable slopes might have been the cause of these worsening condi-
tions. These developments reclaimed paddy fields for commercial and
residential purposes and depleted the forest cover [14].
Also, the long-standing civil war between the Sri Lankan govern-
ment and the Liberation Tigers of Tamil Eelam (LTTE) delayed the
improvement of the public health sector in affected areas. The war
continued for 26 years and ended in 2009. During this prolonged
conflict period, more than 64,000 people died, hundreds of thousands
were injured, and more than 800,000 persons were displaced [16]. As a
country with multiple ethnic groups, there is a probability of ethnic
conflicts arising again.
Recent geological studies, most notably by James Cochran of the
Lamont-Doherty Earth Observatory predicted the possibility of earth-
quakes affecting Sri Lanka in the future. This is due to the splitting of
the Indo-Australian plate and its proximity to the country [17]. This
possibility has to be borne in mind in the future construction on the
coastal areas.
1.2. Health care system of Sri Lanka
Despite these challenges, Sri Lanka has developed one of the most
effective health care systems among developing nations (CFE-DMHA,
2014). Its health system has been enriched by a mix of Western,
Ayurvedic, unani and other medicinal traditions. The Western medicine
is dominant and caters to the majority of the population's health needs
through public and private providers [18].
The Ministry of Health (MoH) is the leading national agency that
oversees health service development and delivery. It formulates public
health policies and regulates services for both public and private health
services, including the National Hospital of Sri Lanka, teaching hospi-
tals, specialized hospitals, provincial general hospitals and selected
district general hospitals. The rest of the government services in the
Western medical system is managed by the decentralized system under
nine provincial health authorities [18].
Sri Lanka spends less on health (3.5% of GDP) than many other
countries, but its life expectancy at birth in 2017 was 75.4 years for
women and 70.7 for men [18]. Maternal mortality ratio was 30 deaths
per 100,000 live births (in 2015). Infant mortality rate was 7.4 deaths
per 1000 live births (in 2015). Neonatal mortality rate and child mor-
tality rate were 5.3 and 9.4 respectively per 1000 live births in 2016
(Sri Lanka: Health, 2018).
At the end of 2015, there were 631 government medical institutions
with indoor health facilities. It consisted of 16 teaching hospitals in-
cluding the National Hospital of Sri Lanka. There were three provincial
general hospitals, 20 district general hospitals, 71 base hospitals (ca-
tegorized as types A and B), 482 divisional hospitals (categorized as
types A, B and C), and 14 primary medical care units with maternity
homes. In 2015 there were 341 offices for the Medical Officer of Health
(MOH), providing preventive care services. The total bed strength of all
the institutions was 80,581, of which 19,696 belonged to teaching
hospitals that are typically located in urban areas. There were 473
primary medical care units that operated in outdoor clinical facilities.
Also, 14 primary medical care units had limited indoor facilities for
maternal services. The national ratio of beds for inpatient care was 3.5
per 1000 persons. The total number of medical officers serving na-
tionally was 18,243 in 2015. There were 85 medical officers per
100,000 persons in 2014 and 87 in 2015. The total number of nurses
employed was 42,420 in 2015. There were 185 nurses per 100,000
population in 2014, and it was 202 in 2015 ([18]: 22).
N.L. Munasinghe and K. Matsui
1.3. Sri Lanka's progress towards disaster safety
In the aftermath of 2004 tsunami, Sri Lanka did much work to im-
prove its disaster management system. In May 2005, Sri Lanka Disaster
Management Act No.13 was enacted, establishing the disaster risk
management (DRM) system with three key administrative bodies. One
is the National Council for Disaster Management (NCDM) chaired by
the President and the Prime Minister. It consists of ministers, provincial
council chief ministers and five opposition party leaders. The NCDM
has mandates to formulate the national policy that gives strategic di-
rections to disaster risk management [19]. The Disaster Management
Act also created the Disaster Management Centre (DMC) to implement
and coordinate national and sub-national level programs that aim to
reduce disaster risks with the participation of all relevant stakeholders
[20]. In November 2005, the Ministry of Disaster Management (MoDM)
was established under the Act. No. 13. It mainly directs the strategic
planning process for disaster responses, such as risk mitigation, pre-
paredness planning and risk reduction [20].
The roadmap document for disaster risk management for
2006–2010 devoted one chapter to the health sector preparedness and
response mechanism. The target organizations were the MoH, pro-
vincial health ministries, universities, and NGOs. The roadmap identi-
fied 13 urgent tasks focusing mainly on improving the resilience and
response capacity of health institutions [21].
Responding to the roadmap tasks in 2008, the Ministry of Health
(MoH) established the Disaster Preparedness and Response Division
(DPRD) to coordinate health disaster preparedness and response ac-
tivities. It appointed trained staff, including consultants for public
health and medical administration, medical officers, and support staff.
It established one emergency operations room overseeing activities
during disaster situations. The DPRD assists policy development, ca-
pacity building, inter-agency networking, research support, and the
maintenance of the communication network and database. District
emergency operation centers were established in Ratnapura, Badulla
and Trincomalee districts. These regional centers would coordinate
with the DPRD in responding to disasters [22].
In 2014, Sri Lanka launched the safe hospital initiatives (SHI) after
WHO experts in this field conducted several training workshops for Sri
Lankan health personnel [23]. In the following year, the DPRD revised
the SPHSDEP for the next five years with renewed emphasis on SHI
[22]. Considering major disaster events in the past and identifying
vulnerable areas in the country, the efforts highlighted the importance
of southern province, especially Galle and Matara districts. Also, this
revised plan placed significant emphasis on identifying and strength-
ening means of improving intersectoral coordination, information and
knowledge management. It recently introduced result-based monitoring
and systematic evaluation for the health sector disaster management
system [22].
Most recently, the central government formulated the Sri Lanka
Comprehensive Disaster Management Program (SLCDMP) for
2014–2018 [24]. Under this strategy the MoH develops the pre-hospital
care system and promotes community participation in disaster response
activities. As the community is the first responder in disaster situations,
this program trains community people on lifesaving first aid, and safe
transportation of victims to hospitals.
Responding to these policy changes, education institutions have also
created disaster training programs. For example, the Health Sector
Disaster Management Diploma program started in 2012 in collabora-
tion with the Post Graduate Institute of Medicine. This is a twelve
month training program to enhance the capacity of doctors/medical
officers in disaster risk assessment, mass casualty management, primary
trauma care, medico-legal and ethical aspects, recovery and re-
habilitation, and all other healthcare and administrative activities [25].
So far about 80 doctors have been trained. Since 2014 training drills
have been conducted at 56 health institutions [22]. In addition, the
Health Emergency and Disaster Management Training Center Program
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International Journal of Disaster Risk Reduction 40 (2019) 101154
at the University of Peradeniya and Emergency and Disaster Manage-
ment Training by National Hospital of Sri Lanka provide short-term
training courses on disaster preparedness and response for health pro-
fessionals, including doctors and nurses [22].
Despite these efforts, the WHO's 2012 assessment on Sri Lanka's
emergency preparedness and response found the following gaps [14].
Sri Lanka's health sector had not adequately updated the basic knowl-
edge and skills of doctors and nurses for local emergency responses.
Emergency Standard Operation Procedures were still in the draft stage.
Those hospitals that were at risk did not have mass casualty and eva-
cuation plans. A national contingency plan had not yet been in-
corporated into subnational and institutional contingency plans. Co-
ordination for preparedness among health stakeholders was found to be
weak. Health sector vulnerability maps were not available. No regular
simulations had been done to test the emergency response capacity of
the health sector. Budget allocation for health emergency preparedness
and response is not based on gaps or needs analysis. National guidelines
did not clarify on how and when to get volunteer support. No follow-up
training had been conducted after the initial training. Trained per-
sonnel had not been properly placed to utilize the knowledge thus
gained. Awareness about safe hospital concept was not sufficiently
widespread [14].
1.4. Disaster preparedness studies
Many hospitals in other countries are not prepared to handle major
disasters. For example, an Indian study assessed 29 public health care
facilities at Orissa in India with the focus on the functional capacity of
the primary health care system in responding to the devastating flood of
September 2008. This assessment was based on the questionnaire
survey. It found that these healthcare facilities were generally ill pre-
pared to handle the flood, although these hospitals had been affected by
flood annually. These hospitals did not have backup power, essential
medical supplies, communication tools and there were shortages of
human resources. Moreover, lack of standard operating procedures,
incident command systems, effective leadership and financial structures
hindered an adequate response to disaster preparedness [26]. Similar
study conducted in Iran and central Vietnam found inadequate pre-
paredness in the system [27,28].
[29] evaluated hospitals' disaster plans in Makkah, the Kingdom of
Saudi Arabia. This survey evaluated 17 hospitals in this City regarding
three key domains of disaster plans (disaster planning, buildings’
structural feasibility, and health care worker training). Makkah ex-
perienced multiple disaster incidents over the past decades. This study
found problems especially with most aspects of hospital emergency
operations plans. Its preparedness was not sufficient for chemical,
biological or nuclear-explosion (CBRNE) and infectious diseases out-
breaks.
Six medical doctors examined eleven hospitals in Sana'a, Yemen, in
“The impact of the 2011 revolution on hospital disaster preparedness in
Yemen.” The evaluation tool they used was the hospital emergency
response checklist published by the WHO in 2011. In the first evalua-
tion, the level of preparedness at seven hospitals were rated as “un-
acceptable” and four were “insufficient.” At the second evaluation, only
one hospital could improve to an “effective” level. None of them were
able to reach the standard level. This study revealed that there was no
significant improvement in hospital disaster preparedness in Sana'a
between 2011 and 2013. The evaluation team recommended that the
health authorities should take responsibility for issuing strategic plans,
standards, guidelines and procedures to improve hospital disaster pre-
paredness in the country [30].
In Hong Kong, researchers conducted the questionnaire survey
about disaster preparedness among 164 registered nurses who were
studying in master's degree programs at a university [31]. This study
found that almost all the respondents (94%) were inadequately pre-
pared for disaster handling. Also, all believed that training courses
N.L. Munasinghe and K. Matsui
would enhance their preparedness, and more than 80% of them were
willing to take such courses.
In fact, a lack of training at hospitals for disaster preparedness ap-
pears to be common in developed countries. In 2006, a web-based
survey among 1500 Canadian nurses who worked in emergency de-
partments revealed that the nurses and their institutions were under-
prepared for a large-scale disaster [32]. The respondents showed a
significant lack of awareness about institutional emergency plans,
partly due to lack of education on emergency planning and infection
control. This finding emphasized the need to further examine training
programs and stockpiling of supplies for disasters [33]. found a lack of
disaster education in the undergraduate nursing curriculum among
Australian public health nurses. Despite good availability of emergency
equipment and supplies among hospitals in Los Angeles County in the
USA, disaster preparedness and surge capacity appeared to be limited
due to failure of fully integrated interagency training and planning
[34].
A study conducted in Texas, the USA, found that rural hospitals
faced many challenges in disaster preparedness due to insufficient staff,
training facilities, and constrained resources [35]. It emphasized the
necessity to enhance regional collaboration to overcome these barriers.
Further the authors recommended that hospitals adopt table top ex-
ercises that can offer a simple, cheap and effective tool to improve
medical preparedness [35].
Regarding disaster preparedness in Sri Lanka's health institutions,
only one study has so far been published [36]. This study evaluated
flood preparedness at government healthcare facilities in Eastern Pro-
vince by analyzing questionnaire survey results among medical officers
in-charge in 31 government healthcare facilities. The researchers also
interviewed seven randomly selected personnel among the respondents.
This questionnaire used the World Health Organization (WHO) Hospital
Safety Index. The study found some barriers such as staff absenteeism,
inadequate medical equipment and supplies, the shortage of qualified
personnel, and lack of disaster plans.
No studies have assessed or examined disaster safety at hospitals in
southern Sri Lanka. Our research attempts to fill this gap, especially,
focusing on Matara District. This study examines some salient aspects of
functional preparedness and structural preparedness. The shortcomings
in the preparedness are identified based on WHO recommendations in
order to improve its preparedness for all hazards. Also, our re-
commendations are discussed regarding health care facilities’ barriers
and possible room for improvement for disaster safety at hospitals. Our
study focuses on Matara District General Hospital and a few other
peripheral hospitals in southern Sri Lanka, but findings can contribute
to global-scale case studies in the future.
Our research has revealed that virtually no study has examined the
perceptions among doctors and nurses regarding the disaster pre-
paredness of hospitals in Sri Lanka. Hospital administrations generally
give less priority to disaster safety due to budget constraints. Lack of
strong policies, legislation, expertise and technical know-hows are some
other drawbacks to improve disaster safety of hospitals in Sri Lanka.
Thus, this paper examines how doctors and nurses in vulnerable coastal
areas of Sri Lanka perceived disaster preparedness. In the following
discussion, we first introduce our study area and its significance in
examining disaster preparedness. Then our methodology and results are
discussed. Finally, we analyze the implications of our survey results for
Sri Lanka and other small island nations.
1.5. Matara District
Matara District is a major commercial hub in southern Sri Lanka,
which was substantially affected by the 2004 tsunami. It is located
160 km away from Colombo, the capital city on the southern shore of
the Island. The land area is 1282 km2 with a population of 831,000
people in 2014. The population density was 630/km2 [37]. The ma-
jority population was Sinhalese (94.3%), and minorities were Moors
4
International Journal of Disaster Risk Reduction 40 (2019) 101154
(3.1%) and Tamils (2.6%) [38].
The geography of Matara makes it vulnerable to floods and tsu-
namis. Its altitude is 9 m above the sea level [39] between 5.8 and 6.4
north latitude and between 80.4 and 80.7 east longitude. It has a wet
climate with a mean rainfall of 2553.2 ml and the mean temperature of
26.7 °C [40]. Nilwala, the largest river in the south runs through the
district. It originates in the Sinharaja highland, which is covered with
natural forests at the altitude of 1050 m above sea level within Matara
District. It traverses about 72 km and flows into the Indian Ocean at
Matara. This rivershed is prone to flooding during the southwest
monsoon and cyclone season. Nearly 90% of its catchment belongs to
Matara District.
When the devastating tsunami struck Sri Lanka, Matara was one of
the worst affected districts. In total, 108,688 people were affected,
killing 1342 and injuring 1865 people. Many more people were dis-
placed from their houses [41]. Seven health facilities were affected,
including the Office of Deputy Provincial Director of Health Services.
Regional drug stores, which had been located close to the sea, were
completely destroyed. Matara District General Hospital, the main focus
of this paper, was partly damaged. One part of its ground floor was
affected and some ground floor wards were evacuated to upper floors.
Also, some damage to the hospital's drug store was reported although
serious damage was not reported. The Medical Officer of Health Office
and three Gramodaya Health centers in the district, which provided
maternal and child health services, were also partly damaged [42].
1.6. Matara District General Hospital
Within this disaster-prone area, we found that the Matara District
General Hospital is the only hospital that is located within the most
vulnerable area. It is also one of hospitals that have a capacity of
treating a large number of patients at times of disaster. In case of a
major disaster, this hospital plays a critical role in saving lives. In case
the hospital is damaged or stranded by disaster, it causes a tremendous
impact on many lives in the hospital. These reasons behooved us to
closely examine its disaster preparedness as a pilot study so that we can
provide a model for future investigations at other major hospitals in Sri
Lanka.
Fig. 1 shows the map of the study area. Matara District General
Hospital (highlighted orange in the map) is the largest public hospital in
the district and also one of the main referral centers in the southern
province of Sri Lanka. This hospital has 1050 beds and employs 33
medical specialists, 290 medical officers, 902 nursing staff and 543
supporting staff. It serves the public 24/7. The hospital is located within
50 m from the Nilwala River. The rivershed is prone to flooding during
the southwest monsoon and cyclones. The Indian Ocean is just 500 m
away from the hospital premises. Therefore, the vulnerability of the
hospital to flooding and tsunamis cannot be ignored. As such, it needs
to be well prepared to withstand and continue functioning during fu-
ture disasters. Three private hospitals are shown in green color and are
located within 1 km. The fire brigade, police station, army camp and
several public schools are also situated very close to the Hospital. This is
advantageous for the Hospital during an emergency or disaster situa-
tion to obtain assistance from those agencies to carry out effective
disaster response.
2. Methodology
This paper adopted the mixed methods approach. As the Ministry of
Health showed strong interests in strengthening hospital's disaster
preparedness, we first examined WHO safe hospital standards.
Reflecting on these standards and more recent international disaster
preparedness developments (e.g., Sendai Protocol), we wanted to un-
derstand how Sri Lanka's regional hospitals are prepared for disasters.
As discussed above, we chose Matara District General Hospital for the
critical role it plays during major disasters. We then approached the
N.L. Munasinghe and K. Matsui
Fig. 1. Map of the study area.
Hospital to obtain permission for our research. Thereafter, we con-
ducted a field survey to identify the general preparedness of its major
hospital. This research was approved by the Ministry of Health, Sri
Lanka and partially funded by the Japan International Cooperation
Agency. Permission was obtained from the hospital administration to
conduct the field visit and questionnaire survey.
The following examination of disaster preparedness at Matara
District General Hospital was based on our questionnaire survey, field
visits, phone interviews, and personal work experience in this hospital.
Field visits were conducted from August 13 to 15, 2016 at the hospital.
Relevant information was gathered by observation and communication
with key figures at the hospital namely the heads of the quality control
department, logistics division, and the emergency department.
This was a descriptive cross-sectional study. As doctors and nurses
working in the emergency units are the first responders in any emer-
gency situation, and therefore also have a reasonable understanding
about their working environment, they were chosen to answer the
questionnaire. After explaining about our research objectives and
asking their cooperation for our survey, we collected a random sample
of 30 doctors and 30 nurses for convenience from different emergency
units of the hospital namely the Emergency Treatment Unit, the
Medical Intensive Care Unit, the Surgical Intensive Care Unit and the
Coronary Care Unit. The total number of doctors and nurses working in
these units was 60 and 100 respectively.
The questionnaire survey was conducted from 10 to 30 September
2017. The questions aimed to assess the perceptions among doctors and
nurses about the current level of disaster preparedness at the Matara
District General Hospital. The questionnaire consisted of 34 questions.
The first set of questions aimed to identify the demographic char-
acteristics of the respondents. Other questions attempted to understand
various aspects of preparedness, including vulnerability, disaster re-
sponse capacity, communication facilities, critical supplies, transport
availability, morgue capacity, willingness of the respondents, and fu-
ture needs. In creating these criteria, we used some ideas from the WHO
toolkit for safe hospitals, especially its functional aspects [43].
Sixty hard copies of the questionnaire were distributed and 10 were
emailed to the respondents. Fifty-five hard copies and five emails re-
turned with effective answers. The response rate for hard copies was
92% and for emails 50%. The average response rate was 86%. The
number of respondents and the percentages of respondents were ana-
lyzed for each question using an excel sheet and the results displayed on
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International Journal of Disaster Risk Reduction 40 (2019) 101154
tables or graphs.
Informal phone interviews were also conducted in October 2017
with several nurses in charge and administrators in order to clarify
some details that were not clear after analyzing the questionnaire
survey. This supplemented information we could not get during our
survey period as some nurses and administrators worked under emer-
gency conditions and were not available for us. Our phone interviews
tried mainly to clarify factual information concerning physical aspects,
such as the available stocks of water, food, fuel reserves and medica-
tion. Their contact numbers were obtained from the telephone ex-
change at the hospital.
We chose nurses in charge because they had worked for this hospital
for many years and were knowledgeable about facilities and daily
routines of this hospital. In addition, the lead author of this paper has
four years of working experience as a doctor in the Medical Intensive
Care Unit of this hospital. This experience helped better understand and
analyze the results of this survey.
3. Results
3.1. Findings from the field visits and informal phone interviews at Matara
District General Hospital
The WHO safe hospital standards emphasize the importance of both
physical and functional aspects of disaster preparedness. As we focus on
functional aspects in our questionnaire survey, we conducted field visits
and phone interviews to better understand the physical conditions for
disaster preparedness at Matara District Hospital in accordance with
WHO standards.
We found that the hospital premises extended over eight acres of flat
land. It had about 25 buildings, many of them were single storied while
eight buildings were two storied and only three of them were three
storied. Most of them were built more than 50 years ago though some
were newly built. Some buildings were more than 100 years old.
The Hospital had 29 wards that were designated as medical ward,
surgical ward, obstetrics and gynecology, pediatrics, cardiology, or-
thopedics, ophthalmology, hematology, and many other specialties.
The emergency department consisted of the Medical Intensive Care Unit
(MICU), Surgical Intensive Care Unit (SICU), the Coronary Care Unit
(CCU), and the Emergency Treatment Unit (ETU). Altogether there
were 20 ICU beds with 12 ventilators. Among five operating theaters,
N.L. Munasinghe and K. Matsui
two were designated for the surgical department, two for gynecology
and obstetrics, and one for ophthalmology operations. The bed occu-
pancy rate was more than 70%. At any given time more than 2000
people occupy the Hospital.
There were four wide paved access routes to the Hospital, which
were usually crowded with pedestrians and vehicles. During the visiting
hours (5–6 am, 12-1 pm, 5–6 pm), hospital premises were heavily
crowded with visitors. From six gates to enter and exit, two were open
for visitors, four for staff and hospital vehicles. The Hospital closes
some gates during an emergency situation for crowd control and se-
curity reasons. The Hospital morgue had a capacity for 15–20 bodies at
a time. Mobile cold storage facilities were not available, also, there was
no plan to expand temporary morgue spaces.
The Hospital had only three fire extinguishers. They were not reg-
ularly maintained for their functionality or expiry dates. We did not
find fire detecting alarms, smoke detectors or sprinklers installed. This
is one of the weakest areas noted in disaster preparedness at this
Hospital. Its security team consisted of 28 security officers from a pri-
vate security company. In addition, there is a hospital police unit,
which is not involved in hospital security matters other than medico
legal duties.
According to the information gathered from the head of quality
control unit, this Hospital had one doctor who was trained for disaster
management. When he was a postgraduate diploma trainee, he con-
ducted a disaster drill at this Hospital in 2014. He created a disaster
drill scenario, in which a public bus was on fire in the southern highway
with allegedly 50 casualties being carried into the Hospital. This drill
found that the Hospital could manage about 20–30 major casualties
effectively at once with available facilities. Lack of emergency man-
agement equipment and facilities in the emergency treatment unit was
evident. The staff at the time realized that the main entrance gate to the
ETU was not wide enough to move two ambulances at once.
Thereafter, no drills or exercises were conducted in the Hospital, but
the same doctor drafted a mass casualty incident preparedness plan for
the Hospital in the same year as part of his diploma completion. This
plan was designed to manage casualties coming from external disaster
while the Hospital is intact. As a result of this drill, the Hospital wi-
dened the main entrance gate to the ETU in 2017. Nevertheless, the
Hospital is yet to have comprehensive disaster plans that anticipates
power failure, telecommunication failure, loss of ground transportation
and also for evacuation of hospital patients and staff under disaster
conditions.
The raw food supply to the Hospital kitchen was arranged by a
contractor who was approved by the Ministry of Health. It was on the
daily basis from the supplier according to the dietary requirements of
the patients and for meal preparation for the supporting staff. This
kitchen provides meal for the supporting staff as well. No food storage
system was available inside the Hospital. The Hospital had a water
storage tank of 100,000 L and this amount was adequate for one day.
Water was supplied from the municipal water supply system.
The drug supply to the Hospital was the responsibility of the
Medical Supplies Division (MSD) of the Ministry of Health in Colombo.
At any given time there was a drug stock sufficient for one week, stock
of medical gases and wall oxygen for two weeks and also a three day
stock of portable oxygen cylinders.
The emergency power supply at the hospital was secured by three
backup diesel generators, two of which have 500 kW capacity each, and
the other with 250 kW. Altogether the adequate power supply could be
obtained for all the critical areas of the hospital only for 24 h with
available fuel reserves. All these generators were located on the ground
floor, about 2 feet above the ground level. This could be disadvantage,
especially during a heavy flood situation. In the past the hospital ex-
perienced main line power failures, but the generators supplied all the
critical areas, including air conditioning. The five lifts located in the
two and three storied buildings were connected to the backup gen-
erators.
6
International Journal of Disaster Risk Reduction 40 (2019) 101154
The hospital had eight ambulances manned by trained personnel.
There was no arrangement with boats or helicopter suppliers for
emergency evacuation of the hospital in case ground transportation
become impossible. Many critical areas of the Hospital such as the
emergency treatment unit, surgical ICU, pharmacy and laboratory were
located in the ground floor. As for communication availability the
hospital had an intercom and land line systems in addition to mobile
phones. Walkie-talkies and radio communication systems were not
available. Only the administrative office and few other units had email
and fax facilities.
3.2. Analysis of the questionnaire survey
3.2.1. Demographic characteristics
Our questionnaire survey focused on functional aspects of disaster
preparedness. It first attempted to clarify the demographic character-
istics of the respondents. About 47% of them were aged between 30 and
39 years and about 68% of them were females. Significantly, male to
female ratio among nurses was high (1:5). However, this ratio among
the doctors was approximately one-to-one (1:1). There were two ad-
ministrative grade officers among the respondents, one consultant
doctor and one chief nurse.
The nurses had more work experience than the doctors in this
sample. About 80% of the nurses had more than 10 years of work ex-
perience at the hospital. Also, the majority of the respondents, mostly
nurses, had worked in an emergency department. From the total study
sample, 57% had worked during a disaster situation. An equal number
of doctors and nurses (17 persons each) had experienced some natural
disasters in the area and almost all had experienced floods or the tsu-
nami of 2004.
Almost all the respondents perceived that the hospital was vulner-
able to natural disasters. We provided them with six possible hazard
categories and asked them to rate the risk level in each in a scale of five.
Fig. 2 below shows the result.
We found that more than 80% of the respondents rated tsunami as
the highest disaster risk for this hospital with a strong sense of urgency.
Flood risk was second highest. The risk of epidemics moderately con-
cerned them. Both cyclone and fire risks were rated as small risk, and
landslides posed the least risk for them.
3.2.2. Disaster response capacity
Table 1 shows the respondents’ perceptions of the disaster response
capacity at Matara Hospital. About 77% of them believed the hospital
would be accessible to the community if a disaster affected the area.
Most doctors (70%) were aware of the disaster response plan but 57%
of nurses were unaware. Also, the majority of the respondents (70%)
had not participated in disaster drills before. About 92% of the re-
spondents were not familiar with their responsibilities in a disaster drill.
Significantly, both the doctors and nurses in our survey had no clear
idea about the number of patients they could effectively manage during
a mass casualty incident.
Regarding the Personal Protective Equipment (PPE), 80% of the
doctors and 57% of the nurses did not think PPE was adequate. Most
respondents (78%) also believed that available fire extinguishers were
inadequate.
3.2.3. Disaster communication, critical supplies, transport and morgue
capacities
All the doctors and nurses believed that they would rely solely on
mobile phones in case landlines failed. Other than mobile phones, 28%
said they would rely on emails. Only 8% of them believed they would
be able to use fax during a disaster situation at their hospital. No one
mentioned about walkie-talkies, ham radio or any other communication
facilities.
We inquired from the respondents about the availability of critical
supplies such as food, water, fuel and medications, and for how many
N.L. Munasinghe and K. Matsui International Journal of Disaster Risk Reduction 40 (2019) 101154

Fig. 2. Level of risk for each disaster.

Table 1 Table 2
Disaster response capacity. Availability of critical supplies during a disaster.
Questions Number of Doctors Number of Nurses Total Critical resources Number of Doctors Number of Nurses Total (%)
availability (%) (%)
The hospital is accessible for community
Agree 23 (77%) 23 (77%) 46 (77%) Running water
Not agree 7 (23%) 7 (23%) 14 (23%) 1 day 8 (27%) 6 (20%) 14 (23%)
Aware of disaster response plan? 2 days 13 (43%) 3 (10%) 16 (27%)
Yes 21 (70%) 13 (43%) 34 (57%) 3 days 4 (13%) 5 (17%) 9 (15%)
No 9 (30%) 17 (57%) 26 (43%) 1 week 5 (17%) 16 (53%) 21 (35%)
Have participated in drills? Food
Yes 5 (17%) 13 (47%) 18 (30%) 1 day 14 (47%) 8 (27%) 22 (37%)
No 25 (83%) 17 (57%) 42 (70%) 2 days 5 (17%) 3 (10%) 8 (13%)
Familiar with your responsibilities? 3 days 6 (20%) 10 (33%) 16 (27%)
Familiar 1 (3%) 4 (13%) 5 (8%) 1 week 5 (17%) 9 (30%) 14 (23%)
Not familiar 29 (97%) 26 (87%) 55 (92%) Fuel reserves for generators
Aware of evacuation area? 1 day 5 (17%) 6 (20%) 11 (18%)
Yes 5 (17%) 13 (43%) 18 (30%) 2 days 14 (47%) 9 (30%) 23 (38%)
No 25 (83%) 17 (57%) 42 (70%) 3 days 6 (20%) 9 (30%) 15 (25%)
Number of casualties hospital could manage 1 week 5 (17%) 6 (20%) 11 (18%)
< =50 4 (13%) 5 (17%) 9 (15%) Medicine, medical gases and blood products
50–100 11 (37%) 10 (33%) 21 (35%) 1 day 3 (10%) 0 3 (5%)
100–150 4 (13%) 12 (40%) 16 (27%) 2 days 2 (7%) 1 (3%) 3 (5%)
> =150 11 (37%) 3 (10%) 14 (23%) 3 days 10 (33%) 11 (37%) 21 (35%)
PPE adequacy? 1 week 15 (50%) 18 (60%) 33 (55%)
Yes 6 (20%) 13 (43%) 19 (32%)
No 24 (80%) 17 (57%) 41 (68%)
Fire extinguisher adequate?
Table 3
Yes 3 (10%) 10 (33%) 13 (22%)
Future needs.
No 27 (90%) 20 (67%) 47 (78%)
Willingness of the Number of Doctors Number of Nurses Total (%)
respondents (%) (%)
days these stocks would last if replacements did not arrive. The ma-
Willing to serve during future disasters
jority believed the water stock would suffice for one week, food supply
Yes 27 (90%) 27 (90%) 54 (90%)
for one day, fuel reserves for two days and medical supplies for one No 3 (10%) 3 (10%) 6 (10%)
week (Table 2). Interested in improving knowledge
In response to our questionnaire about the adequacy of emergency Yes 29 (97%) 24 (80%) 53 (88%)
transportation, 80% of the respondents found it inadequate during No 1 (3%) 6 (20%) 7 (12%)
Need more comprehensive disaster plan
natural disasters. Agree 21 (70%) 18 (60%) 39 (65%)
On the question regarding the adequacy of morgue capacity, 70% of Do not agree 9 (30%) 12 (40%) 21 (35%)
the doctors and 57% of the nurses agreed that it was inadequate. The Frequency of update such a plan
hospital morgue was able to only handle up to 20 bodies. In 6 months 14 (47%) 22 (73%) 36 (60%)
Once a year 14 (47%) 6 (20%) 20 (33%)
In 2 years 2 (7%) 2 (7%) 4 (7%)
3.2.4. Future prospects: willingness of the respondents
Table 3 illustrates the respondent's perception on future needs. Our
results showed that 90% of the respondents were willing to serve during annually.
disaster situations. As to the question about willingness to improve
knowledge, about 97% of the doctors and 80% of the nurses were
willing to improve their knowledge of disaster management. 4. Discussion
About 65% said that they needed a more comprehensive disaster
management plan for the hospital. Also, most of the respondents be- Firstly we tried to identify what the respondents perceived as the
lieved that a disaster plan needs to be updated every six months or current risk level at their hospital. The respondents identified the most

7
N.L. Munasinghe and K. Matsui
probable vulnerabilities of the hospital as tsunamis and floods. These
results were partially explained by the proximity of the hospital to the
river and the sea. As the hospital was located in a flat land they cor-
rectly identified landslide as the least risk for them. Although there had
not been any infectious disease outbreaks originating from the hospital,
some external disease outbreaks were reported in the past. For example,
in 2017 there was a deadly dengue epidemic in many parts of the
country and this hospital was also overloaded with patients [44].
According to the WHO standards for safe hospitals, a hospital should
be located near good roads with an adequate means of transportation
[43]. Access routes need to be clear without any obstructions; therefore,
potential roadblocks need to be identified. Roads need to be in good
condition with well paved, carpeted surfaces. In addition, there should
be alternative access routes to a hospital with separate entrances and
exits [43]. During the field visit we observed that this hospital had
adequate accessibility. The respondents of the questionnaire survey also
agreed with this opinion.
Drills and exercises do improve the knowledge and skills of health
professionals and empower them to be prepared for any emergency
[45]. For example, Ishinomaki Red Cross Hospital in Miyagi Prefecture,
Japan, played a central role during the Great East Japan Earthquake
and Tsunami in 2011. As this hospital regularly practiced drills, simu-
lation exercises, and tabletop exercises and also as the hospital ad-
ministration revised its disaster manual accordingly, all staff con-
fidently responded to the real situation [46].
During the field visits and from the information gathered during
phone interviews we found that only one disaster drill was conducted at
this hospital. Accordingly, the questionnaire revealed that the majority
of the respondents were unaware of the available disaster plan and also
the evacuation area of the hospital. They did not participate in drills
and were not familiar with their responsibilities.
We then asked if the doctors and nurses had reasonably accurate
ideas about the hospital's capacity to treat disaster victims. We wanted
to understand if they knew how many victims the hospital could
handle. The WHO suggests that prior preparation could prevent over-
loading the hospital and also build confidence among the respondents
[47]. However, both doctors and nurses seemed not to have an accurate
idea.
According to WHO standards in preparing for managing disaster
situations at hospitals, doctors and nurses are expected to know if they
have access to personnel protective equipment (PPE). PPE is defined by
the Occupational Safety and Health Administration as “specialized
clothing or equipment, worn by an employee for protection against
infectious materials.” [48]. PPE should be available in appropriate
quantities and in various sizes and employees should be trained to use it
(ADVISEN Insurance Intelligence, 2014). Therefore, we asked if the
respondents think that Matara Hospital had adequate PPE. The majority
believed that the available PPE were inadequate to handle mass ca-
sualties. Also, the field observation confirmed this.
Regarding physical preparedness the WHO safe hospital standards
emphasize on the necessity of adequate fire safety equipment. We in-
quired if Matara hospital had properly installed fire extinguishers.
However, the majority of respondents perceived the available fire ex-
tinguishers were inadequate. In addition, as observed during the field
visit, non-availability of fire alarms, smoke detectors and sprinkler
systems emphasized the poor preparedness of the hospital for fire
safety.
Handling disasters requires hospitals to establish communication
with administrators, staff, patients, neighboring hospitals, health au-
thorities, the public and the media. Hospitals need to summon addi-
tional staff for duties or get additional support from nearby hospitals,
police, defense forces, fire brigade, disaster management center per-
sonnel, and volunteers ([49]; Twigg, 2015). Timely and concise in-
formation sharing helps prevent unnecessary anxiety that may develop
among the public due to incorrect information and rumors. Further,
communication helps patients to be directed to the most appropriate
8
International Journal of Disaster Risk Reduction 40 (2019) 101154
facilities. Also, receiving hospitals can be alerted sufficiently before
patients’ arrival so that hospital resources are allocated effectively [50].
Therefore, reliable and secured communication means are vital in dis-
aster management [51]. It was evident that adequate reliable commu-
nication facilities were unavailable at the Matara hospital.
Many disasters occur unexpectedly. The stockpiling of essential
items are very important to allow people to survive the first few days
after a disaster [52]. Water, food and fuel reserves for backup gen-
erators, medicines, medical gases and blood products are the essential
supplies to continue the functionality of a hospital. During disaster si-
tuations, resources become further limited, requiring hospitals to ef-
fectively and carefully use hospital resources. The WHO recommends a
hospital to keep sufficient water, food, fuel reserves for backup gen-
erators and medications at least for three days when preparing for
disasters [43]. According to WHO, daily water consumption in health
facilities is estimated to be 5 L per outpatient and 60–100 L per in-
patient. Additional water is required for laundry, flushing toilets and
other purposes. However, it was revealed that in this hospital all the
critical resources were not sufficient for three days except medicines.
The questionnaire survey found that both groups had poor under-
standing about the actual capacity of these supplies (Table 2). It was
also revealed that the perception of the doctors was close to reality,
whereas the nurses tended to exaggerate the availability of supplies
(Table 2). However, about the availability of medicine, medical gases
and blood products, both doctors and nurses had a reasonable under-
standing as they were more relatively well-aware of these supplies.
In the event of a power failure, hospitals may face the breakdown of
medical devices, lighting, heating, and cooling systems, elevators, and
IT-based patient information systems [53]. Therefore, several mobile
emergency power generators are available at some hospitals. The Joint
Commission on Accreditation of Hospitals Organization (JCAHO) re-
quires hospitals to have emergency generators and test them monthly
[54]. The WHO toolkit recommends that a hospital has generators
capable of supplying at least 50–60% of the normal electric load of the
facility in order to allow the functionality of the critical areas [43]. At
least a few elevators that are necessary for emergency need to be
powered by the backup system. In addition, to secure these basic sup-
plies, the building or facility that houses generators should be protected
from disasters. One option is to build it with reinforced concrete walls
on elevated ground (ADVISEN Insurance Intelligence, 2014). All the
generators in Matara hospital were placed on the vulnerable ground
floor.
According to WHO, a hospital is expected to have adequate trans-
port facilities to evacuate the hospital or promptly send fully equipped
ambulances with qualified staff to the disaster site. Also, vehicles need
to be filled with fuel and park them in a protected area. If road access
becomes impossible due to inundation for example, there should be
adequate alternative means of transport, such as boats or helicopters.
Many modern hospitals have their own helipads. Those without it may
need prior agreements with government or private transport companies
for boats or helicopters. Also, prior mutual help agreements with
neighboring hospitals are important to transfer patents if the hospital is
overcrowded [50].
Regarding transportation, we observed that Matara hospital had
only eight ambulances. Also, the lack of a helipad was a major dis-
advantage at this hospital if the ground transportation becomes im-
possible during floods. Moreover, Matara Hospital did not have prior
agreements with transportation companies or private ambulance or
boat suppliers. In response to our questionnaire about the adequacy of
emergency transportation, the majority of the respondents found it
inadequate.
A proper management of dead bodies also becomes a challenge
during and after a disaster situation. In case of major disaster, hospitals
are expected to handle a large number of bodies. According to WHO
standards, procedures need to be in place for appropriate management
of dead bodies, including temporary storage. The procedures include
N.L. Munasinghe and K. Matsui
on-site or off-site arrangements to increase morgue capacity and cold
storage facilities. Trained staff should be available for dead body
identification. Efforts should be made to ensure appropriate handling of
the dead with particular regard for religious and cultural expectations
[43]. In 2004, this hospital and its premises were overloaded with
thousands of bodies. Since then no arrangement had been made to
expand temporary morgue spaces or mobile cold-storage facilities. Our
field survey and questionnaire found the current capacity of the morgue
was inadequate. Also, there was a lack of staff who can identify dead
bodies in case of handling mass fatalities.
Our questionnaire found that the majority of the respondents was
willing to learn more about disaster management. This finding agrees
with [31]; in which more than 80% of the respondents were willing to
take training courses. Also, the majority were willing to serve during
disaster situations. This result contradicts with previous studies, which
revealed that many health professionals were not willing to work
during crisis situations for various reasons [55]. This is mostly due to
fear for the safety of themselves and their loved ones (family, friends, or
pets) [56–58]. In contrast, our respondents were willing to offer their
service regardless of potential risks and uncertainties. This result sug-
gests that if the Sri Lankan government, Matara Hospital or other or-
ganizations can provide training, the respondents will improve their
knowledge effectively and possibly become reliable disaster risk man-
agers in the future.
Our survey also revealed the need of a more comprehensive and
updated disaster plan for this hospital. Many critical areas of the
Hospital such as the emergency treatment unit, surgical ICU, pharmacy
and laboratory were found to be located in the ground floor which
made them vulnerable in times of disaster.
It was found that the only doctor who was trained in disaster
management was employed in an irrelevant unit. Therefore his
knowledge was not available in the division where it was most re-
quired. Health administrators had not yet shown much interest in im-
proving the management of hospital preparedness for disasters. Lack of
available master's and PhD programs in health sector disaster man-
agement was one of the disadvantages in improving the knowledge and
skills for those who have interest in this field in Sri Lanka.
5. Conclusion
Although Sri Lanka has significantly improved disaster management
and hospital preparedness plans, our survey revealed that Matara
District Hospital did not have basic requirements for disaster safety. It is
more vulnerable to floods and tsunamis that may lead to mass casualty
incidents. The current disaster preparedness among the respondents
were overall inadequate. The reasons were not attributed to gender,
work experience and job types. This hospital's lack of preparedness was
largely due to insufficient disaster drills and training. Nevertheless,
both the doctors and nurses were willing to improve their knowledge
about disaster management and willingness to serve in future cala-
mities. Also, this study found that the available backup communication
facilities, PPE, fire protection, means of transport and morgue capacity
of the hospital were inadequate.
6. Recommendations
A more comprehensive disaster plan should be prepared for this
hospital incorporating all possible hazards. This plan needs to be up-
dated regularly. Also, our study revealed the existing high demands for
capacity building and awareness-raising for staff to deal with disaster
situations in the future. Therefore, at least once a year disaster drill or
simulation exercise is recommended for the staff. In service training
programs would be also advantageous to improve their knowledge of
disaster management.
Health authorities and the hospital administration should give
priority to improve the identified gaps in the disaster preparedness to
9
International Journal of Disaster Risk Reduction 40 (2019) 101154
make this hospital more resilient in the future. Some critical facilities
such as backup generators, emergency units, laboratory and pharmacy
which were located in vulnerable areas on the ground should be es-
tablished on an upper floor. This type of survey could be expanded to
other parts of the country so that we can better understand nation-wide
disaster preparedness.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://
doi.org/10.1016/j.ijdrr.2019.101154.
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