Introduction

Whether it is a wildfire sweeping across California, Hurricane Beryl battering the Caribbean, or an earthquake fracturing communities in Turkey and Nepal, when a disaster strikes, the immediate public reflex is to look toward the health system. Communities depend on hospitals to be the penultimate safety nets, the facilities where lives are saved, where chaos is managed. Yet, time and again, global disasters have revealed a harrowing vulnerability: the safety net itself is fragile.

We instinctively measure a hospital’s resilience by the dedication of its medical staff and the robustness of its emergency response plans. However, a health system cannot be resilient if the physical and structural infrastructure that supports clinical care collapses during a crisis. If the lights go out, ventilators stop. If water supply is contaminated, sanitation and infection control fail. If telecommunications drop, coordinated emergency response becomes impossible. Resilience, therefore, is much more than ensuring a hospital building remains standing after a shock. It requires ensuring that critical services continue without interruption, inter-departmental dependencies hold firm, and post-disaster recovery happens rapidly.

At the GLC4HSR Annual Conclave 2026, Ms. Ranjini M. presented a vision on behalf of the Coalition for Disaster Resilient Infrastructure (CDRI). Set up in 2019 under the leadership of the Prime Minister of India, CDRI has grown into a powerful international coalition comprising 53 countries, 12 organizations, UN agencies, multilateral development banks, and the private sector. With India serving as the permanent co-chair, alongside rotating co-chairs like France and soon Brazil, CDRI is steering a critical global agenda: accelerating the resilience of critical infrastructure.

The central argument of CDRI's presentation is that building the resilience of health infrastructure is no longer a peripheral concern. It is a fundamental prerequisite. A country simply cannot sustain economic resilience or overall disaster resilience if it fails to invest in the resilience of its health system.

The Overlooked Problem in Health Security

Historically, when global health actors discuss health sector resilience, the conversation tends to gravitate toward clinical preparedness. Investments are funneled into expanding surge capacity, stockpiling medical countermeasures, training emergency medical teams, and enhancing epidemiological surveillance. While these public health emergency functions are absolutely critical, they represent only one side of the coin.

What frequently gets overlooked is the web of infrastructure upon which modern medicine relies. Hospitals do not operate in a vacuum. They are highly dependent nodes within broader municipal and national infrastructure networks. They depend on continuous electricity to power life-saving equipment, vast amounts of clean water for hygiene and operations, sophisticated wastewater management systems to prevent secondary public health crises, robust telecom networks for emergency dispatch, and passable roads for ambulances and supply chains.

Disasters - be it the cyclical cyclones in Madagascar, Malawi, and Mozambique, or the recurring earthquakes in Japan - affect more than just the mortar and bricks of hospital buildings. They disrupt hospital operations and sever the lifelines that connect the hospital to the outside world. When we ignore these systemic interdependencies, we leave our health systems exposed to cascading failures. A structurally perfect hospital is functionally futile if the access roads are washed away and the municipal water supply is cut off.

CDRI’s Approach

The aforementioned gap is what CDRI works to bridge. CDRI’s contribution to the global health dialogue is not to duplicate the extensive public health emergency management work already being championed by organizations like the World Health Organization (WHO) and the Pan American Health Organization (PAHO). Instead, CDRI brings a specialized infrastructure systems perspective to the table.

By utilizing probabilistic tools like the Global Infrastructure Risk Model and Index (GIRI), CDRI quantifies the risk. GIRI data reveals that across nine critical infrastructure sectors, global annual losses due to disasters range from US$732 to US$845 billion. By identifying exactly where vulnerabilities lie- noting, for instance, that floods account for 65% of health infrastructure losses, followed by cyclones and earthquakes- CDRI helps governments transition from reactive scrambling to proactive, data-driven planning. CDRI builds upon the existing body of global knowledge, adding an essential layer of engineering, systems mapping, and infrastructure finance.

A Practical Framework for Resilient Health Infrastructure

To make infrastructure resilience actionable, CDRI, with active technical support from WHO India, developed a comprehensive Resilient Health Infrastructure Framework.

The framework revolves around maximizing the ‘Resilience Dividend’. This is achieved by strengthening three core capacities:

• The Capacity to Absorb: Designing infrastructure robust enough to withstand the initial shock of a hazard without catastrophic failure.
• The Capacity to Respond: Ensuring that backup systems (like alternative power or water reserves) and operational protocols can be immediately activated to maintain critical care functions.
• The Capacity to Recover: Having the plans, financing, and coordination in place to rapidly restore full functionality. The shorter the recovery period, the greater the resilience dividend.

To build these capacities, CDRI’s framework operates across three intersecting layers:

• The Hospital Building: The structural and non-structural integrity of the facility itself.
• Hospital Operations: The internal management, emergency protocols, and continuity plans that govern how the facility functions under extreme stress.
• System-Wide Critical Infrastructure Services: The external municipal and national networks—power, water, transport, telecommunications—that sustain the hospital.

Crucially, the framework emphasizes asset lifecycle thinking, ensuring that resilience is factored into the initial design, continuous maintenance, and eventual retrofitting of facilities. Further, it explicitly outlines the need for coordination between health sector professionals and infrastructure professionals. 

From Framework to Field: The Sikkim Experience

Frameworks are only as good as their application on the ground, and CDRI approaches its framework as an iterative, evolving tool. In 2022, CDRI piloted the framework in Sikkim, a mountainous state in northeastern India highly susceptible to seismic activity and climate-induced hazards.

The importance of this pilot was brutally underscored in 2023 when Sikkim was struck by a devastating Glacial Lake Outburst Flood (GLOF). Because the foundational work of the resilience pilot had already begun, the state was uniquely positioned to test and leverage the framework in real-time, resulting in extraordinary traction and ultimate national recognition for both the State Disaster Management Authority and the Health Department of Sikkim.

The intervention in Sikkim comprised six major elements, providing a blueprint for holistic health infrastructure resilience:

• Model Hospital Disaster Management Plan: CDRI assisted the government in developing and understanding a comprehensive disaster management plan tailored to the unique vulnerabilities of hill state hospitals.
• Cross-Sector Capacity Building: Acknowledging that health resilience is a whole-of-government responsibility, CDRI convened officials from the health department, disaster risk management authorities, and critical infrastructure departments (power, water, revenue). This broke down traditional silos and fostered collaborative planning.
• Rapid Hospital Safety Assessment Training: Stakeholders were trained to quickly and accurately assess the safety and functionality of health facilities post-disaster, ensuring that unsafe buildings were not occupied and that critical repairs could be prioritized.
• Multi-Departmental Mock Drills: Preparedness was tested through rigorous mock drills that evaluated the coordination between the health department and supporting infrastructure agencies under simulated crisis conditions.
• Post-Disaster Damage and Needs Assessment (PDNA): In the aftermath of the 2023 GLOF, CDRI supported the Sikkim government in conducting a PDNA. This data-driven report was instrumental in securing recovery allocation funds from the national government. 
• Mapping Sustained Financing: Recognizing that pilots fade without funding, CDRI helped the government map out various domestic and international funding sources to ensure that investments in health infrastructure resilience could be sustained long-term.

The Sikkim model demonstrated that when health and infrastructure departments plan together, a crisis can be managed systematically rather than chaotically. Today, this model is being closely studied and replicated by other hill states across India.

Beyond Sikkim: Global Application in Diverse Contexts

CDRI’s framework is adaptable across geographies and institutions, with a particularly strong focus on countries facing high climate and disaster risk. Building on its survey of more than 3,000 infrastructure professionals, CDRI is supporting targeted work in several contexts: in Nepal, hospital safety assessments across seven hospitals; in the Marshall Islands, resilience gap assessments for coastal and health infrastructure; in Haiti, work on operational continuity and backup lifeline systems; and in Honduras, vulnerability assessments for primary healthcare facilities. Together, these efforts show how the framework can be tailored to local needs while strengthening health infrastructure resilience at scale.

Key Takeaways for Health Systems Leaders

Crises create political traction, but systems work must begin beforehand. As seen in Sikkim, the occurrence of a disaster (the GLOF) accelerated political will and resource mobilization. However, it was the baseline assessment and capacity-building work done before the flood that allowed the government to respond effectively and secure national recovery funds. We cannot wait for the next crisis to begin mapping our vulnerabilities. Investing in disaster-resilient health infrastructure may not always yield the immediate political visibility of opening a new hospital wing. 

• Expand the Definition of Health Infrastructure: Move beyond beds and clinical equipment to actively assess the resilience of power, water, sanitation, and telecom dependencies.
• Bridge the Professional Divide: Create formal coordination mechanisms between health department officials, disaster management authorities, and municipal infrastructure engineers.
• Quantify the Risk to Unlock Funding: Utilize probabilistic risk modeling (like CDRI's GIRI data) to translate potential climate and disaster impacts into financial metrics. Finance ministries respond to economic data.
• Focus on the Resilience Dividend: Invest in systems that shorten the recovery time. The faster a health facility can absorb a shock, respond, and bounce back to full operational capacity, the more lives and resources are saved.

As climate change accelerates the frequency and severity of extreme weather events, the stress placed on our health infrastructure will only intensify. The projected US$12.5 trillion in economic losses by 2050 is a warning.