THE
FRONTLINE
SCORECARD
An Assessment Tool for Climate and Disaster
Risk Management in Health Systems
With a case study for Belize
Mersedeh Tariverdi, Daniel Thompson, Christoph Klaiber,
Jun Rentschler, Keiko Sakoda, Nadezda Leonova, Seti Rahmani,
Chloé Desjonquères, Laura Di Giorgio, Tomas Plaza Reneses
© 2024 International Bank for Reconstruction and Development / The World Bank
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C, Di Giorgio, L., Plaza Reneses, T. 2024. The Frontline Scorecard: An Assessment Tool for Climate and Disaster Risk Management in Health Systems.
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Cover: Map of Belize city. © Kostiantyn Levin | Dreamstime.com
Design by ULTRAdesigns.
1
Contents
Acknowledgements.........................................................................................................................................2
Executive Summary........................................................................................................................................3
Country application: Belize....................................................................................................................................3
Acronyms...........................................................................................................................................................5
➊ Introduction...............................................................................................................................................6
1.1 The expanding frontier of health shocks................................................................................................ 6
1.2 Quality of and access to health care: two dimensions of resilience to shock............................7
1.3 Building health systems that are resilient to natural hazards and climate change................7
➋ The Frontline Scorecard: a new assessment tool..............................................................................9
2.1 Two levels of sophistication....................................................................................................................... 10
2.1.1 The rapid assessment...................................................................................................................... 11
2.1.2 The deep dive assessment............................................................................................................. 11
2.2 Scoring...............................................................................................................................................................12
2.2.1 Indicators............................................................................................................................................. 12
2.2.2 Indicator categories........................................................................................................................... 13
2.3 Limitations.........................................................................................................................................................15
➌ Country application: Belize.................................................................................................................. 17
3.1 Country context..............................................................................................................................................17
3.2 Disaster risk exposure in Belize.................................................................................................................18
3.2.1 Exposure of public and private buildings................................................................................. 20
3.2.2 Exposure of the health system................................................................................................... 20
3.3 Assessment results......................................................................................................................................22
3.3.1 Rapid assessment............................................................................................................................22
3.3.2 Deep dive assessment....................................................................................................................24
3.3.3 Analysis by indicator category................................................................................................... 26
3.4 Recommended future actions...................................................................................................................26
3.5 Discussion.........................................................................................................................................................28
➍ Outlook.....................................................................................................................................................31
Appendix A. Overall results from Belize rapid and deep dive assessments..................................... 33
References.......................................................................................................................................................41
THE FRONTLINE SCORECARD An Assessment Tool for Climate and Disaster Risk Management in Health Systems
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Acknowledgements
This report is the result of a collaboration between the World Bank’s Urban, Disaster Risk
Management, Resilience and Land Global Practice (GPURL) and the Health, Nutrition and
Population Global Practice (HNP). It is part of a wider effort to mainstream risk management and
emergency preparedness in the World Bank’s operational engagements in client countries.
This report was prepared by a team led by Mersedeh Tariverdi, Jun Rentschler and Keiko Sakoda.
Team members were Daniel Thompson, Christoph Klaiber, Chloé Desjonquères, Nadezda Leonova,
Seti Rahmani and Jonathan Rigby. The work was done in collaboration with the World Bank
country health team led by Laura Di Gorgio and included Tomas Plaza Reneses and Mikhael
Gabriel Iglesias Luzardo with inputs from Manuela Villar Uribe and Irene Lorinado Indalao. The
overall effort was overseen by Niels Holm-Nielsen.
World Bank peer reviewers, Gabriel Aguirre Martens, Gabriel Sergio Arrisueño Fajardo, and Elif
Ayhan provided valuable comments and suggestions on the scorecard. Helpful suggestions,
comments, and inputs were also received from Stephane Hallegatte and Keishi Abe.
We are grateful to officials of the Government of Belize’s Ministry of Health and Wellness for
their support throughout the study. In particular, we thank Dr. Javier Zuniga, Greg Cabral, and
Dr. Melissa Diaz-Musa, Dr. Philip Castillo and Lizett Bell for providing valuable feedback and
support. We also thank members of the National Emergency Management Organization and of
the National Engineering Maintenance Center. This work was also supported by Lealou Reballos
and John Bodden of the Pan American Health Organization.
Lucy Southwood was the production editor. ULTRAdesigns designed the report. Erika Vargas
supported its production and dissemination.
This report was made possible with the financial support from the Japan-Bank Program for
Mainstreaming Disaster Risk Management in Developing Countries under Global Facility for
Disaster Reduction and Recovery (GFDRR).
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Executive Summary
The Frontline Scorecard is the World Bank’s new country assessment tool that evaluates the
resilience of a country’s health system to natural hazards (disasters) and climate change.
Introducing the scorecard and presenting the results of its application in Belize, this report provides
a detailed explanation of how countries can use the scorecard as a systematic assessment tool
to identify focus areas for building more resilient health systems and strengthening their climate
and disaster risk management (CDRM) capabilities.
Based on the five pillars of resilient health systems first outlined in the Frontline report (Rentschler
et al. 2021)—health foundations, health facilities, network of health facilities and service
modalities, integrated emergency response, and lifeline infrastructure—the scorecard uses a
traffic-light scale to help policy makers create a high-level assessment of the CDRM capabilities
of their country’s health system. This is an essential first step for directing in-depth technical
assistance, as well as policy change and investments towards shock resilient health systems.
The scorecard has two levels of sophistication. The first, a rapid assessment, is based on readily
available information and provides a holistic, high-level analysis of a health system’s key CDRM
capabilities. It uses publicly available data, information from country governments, and prior
assessments from the World Bank, WHO, and other International Organizations. Given its low
resource requirements, a rapid assessment can be delivered in under 3 weeks for most countries.
It is being rolled out for national assessments of health systems and to guide the direction for
more in-depth technical assistance, which in turn can inform investment operations, including
contingent financing instruments such as the World Bank's Catastrophe Deferred Drawdown
Options (CAT DDOs). The rapid assessment has been conducted in 8 small and medium sized
countries as of January 2024.
The second, complementary level, is a more sophisticated deep dive assessment that uses
semi-structured expert interviews and additional research to form a better understanding of
the implementation of health system capabilities on the ground. Relying on data collection site
visits, and expert interviews, this type of assessment is more resource intensive. As such, it is
well suited for small countries; in larger countries, it can be tailored for use in subnational regions
or focused on specific issues with a narrower scope. For a small country like Belize, it takes 3-4
months. Time needed for larger countries may be longer, depending on the country context and
scope of the assessment.
THE FRONTLINE SCORECARD An Assessment Tool for Climate and Disaster Risk Management in Health Systems
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Country application: Belize
Belize is a small country with high exposure to natural hazards and resource shortages in its health
service. Due to the size of its health system, it was possible to match the rapid assessment’s
countrywide scope with a deep dive.
The rapid assessment identified 10 discrete focus areas in the health system’s CRDM response.
A deep dive assessment and in-country validation mission expanded this to 18 discrete focus
areas across five categories from which government stakeholders prioritized the following areas
for investment: routine maintenance for health facilities, supply chain and storage concerns
connected to the national medical storage facilities, standardized nationwide implementation of
DRM trainings, and standards and procedures for medical personnel.
The deep dive assessment confirmed the results of the rapid assessment and added some focus
areas and deepened the understanding of others. Although no information from experts and
documents conflicted with the information the team collected during the in-country mission,
the latter emphasized some of the focus areas more strongly than assessments provided in the
interviews. For example, although interviews revealed the importance of strengthening investment
in routine maintenance across Belize’s hospital network, the in-country mission clarified the need
for strengthening investment in maintenance before implementing other actions, such as building
new hospital facilities.
THE FRONTLINE SCORECARD An Assessment Tool for Climate and Disaster Risk Management in Health Systems
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Acronyms
CDRM climate and disaster risk management
DRM disaster risk management
GDP Gross Domestic Product
GFDRR Global Facility for Disaster Reduction and Recovery
ICT information and communications technology
KHMH Karl-Heusner Memorial Hospital
MoHW Ministry of Health and Wellness
NEMC National Engineering and Maintenance Center
NEMO National Emergency Management Organization
PAHO Pan American Health Organization
PPE Personal Protective Equipment
WHO World Health Organization
▲ PAHO/WHO |
Moving towards
universal health
with integrated care
services in Belize.
Photo: © HR@PAHO/
WHO
THE FRONTLINE SCORECARD An Assessment Tool for Climate and Disaster Risk Management in Health Systems
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1
Introduction
Health care systems are at the frontline of delivering critical care during emergencies, mitigating
illnesses and deaths. Yet many countries struggle to meet even routine demands for health care.
Climate change, disasters, pandemics, and demographic changes are bound to increase pressures
on already strained health systems (Rentschler et al. 2021).
Preparing and equipping health systems to adequately respond to crises are vital to ensure
sustained access to health services and to provide reliable essential health care that protects
people’s well-being. Having a robust assessment of their country’s health system’s climate and
disaster risk management (CDRM) capabilities allows policy makers to make these systems
more resilient against shocks. This policy note introduces the Frontline Scorecard, a new rapid
diagnostic tool that decision makers can use to conduct a high-level assessment of the CDRM
capabilities of their health system, and illustrates its application in a case-study country, Belize.
▲ Photo: Everett
Atlas / iStock
1.1 The expanding frontier of health shocks
Around the world, health systems are exposed to different kinds of shocks, from natural hazards
and climate change to pandemics and human conflict. As well as having a devastating impact on
THE FRONTLINE SCORECARD An Assessment Tool for Climate and Disaster Risk Management in Health Systems
7
people’s individual health and socioeconomic well-being, shocks can overwhelm health systems,
by simultaneously increasing demand and restricting access to both resources and services.
Many factors—including climate change, unplanned urbanization, population growth, and
displacement—will increase the burden on health systems (WHO 2019). Climate change is
expected to increase the frequency of extreme weather events, such as flooding, heatwaves,
cold spells, and severe storms (IPCC 2022), and therefore the demand for disaster response
management capabilities in health systems. The changing climate is likely to alter transmission
patterns of infectious diseases and place additional burdens on health systems by affecting food
availability, food quality, and environmental stress factors, such as air and water pollution. To
provide reliable access to health services, health systems will need to adapt to changing risk
patterns.
1.2 Quality of and access to health care: two dimensions of resilience
to shocks
Reliable access to adequate and affordable health services is foundational to countries’ long-term
socioeconomic development prospects (Rentschler et al. 2021). From a planning perspective, for
a health system to be resilient to climate change and disasters, both quality and access matter.
First, for people to be able to rely on health services, they require a certain level of quality in terms
of health facilities and staffing levels. But no matter the quality or reliability of the service delivery
itself, if people— especially vulnerable populations—cannot access these services, they cannot
rely on them.
Accessibility is influenced by both physical and financial factors. For example, physical access
requires a good road network and health service availability in remote areas, while financial
access means ensuring both health services and the transportation to reach them are affordable.
The Frontline Scorecard assesses the accessibility of health services and factors that impact
accessibility, such as physical damage to facilities, roads, and supply chains, and socioeconomic
obstacles.
1.3 Building health systems that are resilient to natural hazards and climate
change
After a climate or disaster shock, it is a priority for health systems to maintain public access to
its services. The ability to do so relies on multiple factors, connected to the system’s resilience
to disasters and climate change, and its ability to cooperate with other stakeholders, including
private and public emergency response units, military personnel, international organizations
providing disaster relief, and community preparedness groups.
To systematize individual factors that determine a health system’s ability to respond to shocks,
the World Bank’s Frontline report (Rentschler et al. 2021) identifies five essential pillars for
analyzing a system’s functionality during a pandemic or a disaster, and thus detecting potential
breaking points that can cause severe disruptions. These are:
THE FRONTLINE SCORECARD An Assessment Tool for Climate and Disaster Risk Management in Health Systems
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➊ Foundations of the health system, including baseline service quality
➋ Individual health facilities, including their exposure and preparedness to shocks
➌ Network of health facilities, including ability to flexibly manage surge demand across facilities
➍ The network of emergency response systems surrounding health systems, including
emergency response agencies
➎ Lifeline infrastructure systems, such as roads, water and electricity, that health facilities
depend on.
These five pillars form a framework for analyzing a health system’s disaster risk management
capabilities. Each pillar can help detect breaking points and hidden weaknesses in individual
areas that can carry over and affect the whole system. Being able to identify weaknesses at
different levels in this way is crucial for improving the overall disaster response. For example, to
be able deal with shocks as a whole, a health system needs individual facilities that can respond
to shocks (Pillar 2).
Cooperation between facilities (Pillar 3) is also vital to avoid the magnitude of surge demand
overwhelming a single facility. Integrating individual facilities into the health facility network is
an essential element of disaster and pandemic-resilient health systems, and identifying gaps in
one pillar that affect the other pillars will effectively increase resilience to shocks. One strength of
the five-pillar approach is that it can combine a climate and disaster risk management (CDRM)
analysis at facility level that includes baseline demand with a macro analysis of health systems
that consider their integration and interdependence with disaster response systems and lifeline
infrastructure.
THE FRONTLINE SCORECARD An Assessment Tool for Climate and Disaster Risk Management in Health Systems
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2
1
The Frontline Scorecard:
a new assessment tool
The Frontline Scorecard uses this five-pillar structure to conduct a high-level assessment of a
country’s ability to integrate CDRM into its health system. This novel approach provides helpful
insights to assess the most effective starting points for more detailed analysis, which can identify
the most efficient ways of reducing a system’s vulnerability to climate and disaster shocks.
The scorecard is based on a mixed-methods approach, using both quantitative (indicators,
empirical data1) and qualitative (text analysis, semi-structured expert interviews) measures. Its
three-tiered traffic light scoring system currently uses 84 indicators across Pillars 2–5 (around
20 in each pillar) to evaluate health system capabilities related to each pillar’s focus area. All
indicators receive a traffic light score, based on an evaluation of their capabilities, which are then
aggregated to generate an overall score for each pillar and one for the overall assessment.
The initial analysis for Pillar 1 (foundations of the health system) is based on country-level
statistics rather than indicators, due to the differences across health governance models and
foundational factors. Although the scorecard assesses a country’s fundamental primary health
care capabilities in Pillar 1, it does not score them on the traffic light scale.
The scorecard results assess the state of a country’s health facilities, health system, and high-
level policies and disaster response standards. Analyzing these results provides a unique DRM
perspective of the system’s functionality and integration into the wider disaster response ▲ First Aid Hut
mechanisms. The scorecard’s results also can provide insights into a health system’s potential on Star Fish
weaknesses and breaking points, its linkages to lifelines infrastructure, and its ability to Island, Belize.
Photo: © Raycan |
cooperate with disaster response agencies. This can help policy makers identify essential nodes Dreamstime.
for strengthening the health network to increase its resilience to climate change and natural
E.g. World Bank, 2022
1
THE FRONTLINE SCORECARD An Assessment Tool for Climate and Disaster Risk Management in Health Systems
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hazards. This, in turn, enables them to prioritize budget allocations and actions to improve CDRM
in the health sector, creating a foundation for future engagements.
2.1 Two levels of sophistication
The scorecard has two levels of sophistication. It starts with a rapid assessment, which is
based on readily available information, such as country level indicators, public documentation
of country laws surrounding DRM, and country profiles that capture exposure to natural
shocks. This can be complemented by a more sophisticated deep dive assessment, which builds
on the initial results to form a better understanding of the implementation of health system
capabilities on the ground. Using semi-structured expert interviews, site visits, and additional
research, the deep dive assessment takes a more detailed look at how a country implements
laws and standards. An overview of the scorecard structure, inputs, and approximate timeline is
presented in figure 1.
Figure 1. Overview, inputs, outputs and timeline of the Frontline Scorecard
Rapid assessment2 Deep dive assessment3**
Potential
Phases Rapid assessment
➜ Data collection
➜ Focus areas
➜ implementation
actions
Collect relevant data Derive potential
Gather information Develop key areas
Develop rapid results implementation
to validate and for strengthening,
Overview for scorecard based actions to
calibrate rapid based on validation
on easily accessible address focus
results assessment assessment results
information areas
Results from previous Expert interviews
World Bank projects Additional data and Survey of other
Validation
Publicly available information from the DRM and health
assessment
Input(s) information government investments
Key stakeholder
Guidance from World In-country mission Key stakeholder
input
Bank country team or input
Surveys,
key stakeholders questionnaires
Timeline < 3 weeks >2 months* >2 weeks* >2 weeks*
WB team + minimal
Team
support from local WB team + support from local expert for 4 weeks
composition
experts
Validated and expanded indicator analysis to include implementation of
indicators
Outputs Rapid results scorecard
Identified focus areas
Priority actions developed from focus areas
*Timelines can overlap
2
Given the scope of the analysis and resource requirements, this assessment can be conducted for any state and any size of health system
3
Given the scope of the analysis and resource requirements, this analysis is recommended for small states or individual regions of larger states
only
THE FRONTLINE SCORECARD An Assessment Tool for Climate and Disaster Risk Management in Health Systems
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2.1.1 The rapid assessment
The standalone rapid assessment provides a holistic, high-level analysis of a health system’s key
CDRM capabilities. By examining relevant legislation and policies that concern health and health
legislation, the scorecard presents an overview of how health and CDRM interact. It scores each
indicator using readily available information from online databases and government websites,
complemented with a written explanation to substantiate the score with evidence. The results
allow policy makers and other stakeholders to identify key areas in need of strengthening to
increase resilience to climate and disaster shocks across and expose vulnerabilities within the
health system. Where appropriate, it can also function as the basis for a deep dive assessment.
Given its low resource requirements, conducting a rapid assessment is quick and easy for most
countries.
The rapid assessment was first piloted in Peru. Results from this assessment were cross
validated with a multi-year GFDRR assessment of Peru. Alignment of results from both methods
suggested that the rapid assessment could identify strengths and gaps across a national-level
health system’s capabilities (e.g., facilities, committees, personnel, plans) and across the health
system’s dependency on emergency response and lifeline infrastructure.
2.1.2 The deep dive assessment
The deep dive assessment expands on the rapid assessment results by gathering additional
information for most indicators4 using semi-structured expert interviews, surveys, and
questionnaires (existing or individualized). It provides a second score, which may differ from
the rapid assessment result. As well as revealing critical areas for strengthening by identifying
gaps between existing policy mandates and regulations and their implementation in emergency
situations, it can help identify issues in everyday operations that impact a health system’s
resilience to climate and disaster shocks.
Relying heavily on data collection and expert interviews, this type of assessment is more time
intensive. It can be adjusted to individual country characteristics and project needs and context.
Depending on country size, it might be more suitable to focus the deep dive assessment on one
region, rather than the entire country. To date, the deep dive assessment has been conducted
in Belize (chapter 3) where, due to its size, it was possible to match the rapid assessment’s
countrywide scope with a deep dive.
The deep dive assessment allows for a more detailed examination of a country or region’s
foundational capabilities (Pillar 1), or to focus on evaluating the implementation of CDRM laws
and regulations in the health sector (Pillars 2 and 3). For example, while the rapid assessment for
Pillar 2 looks at legislative and regulatory frameworks to evaluate the disaster preparedness of
individual health facilities, the deep dive assessment measures the performance of previously
identified rules and regulations on the ground and can therefore identify potential gaps between
the existence of regulatory frameworks and their actual implementation. It can also be tailored
to assess any of the other pillars in greater detail than the rapid assessment.
The deep dive assessment does not re-evaluate indicators that are based on up-to-date data metrics on the health
4
system, such as population ratio of doctors or nurses.
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This detailed assessment can inform focus areas, providing suggestions for further engagement
and actions to strengthen the CDRM aspects of a health system. Depending on its agreed
scope and the level of detail of the data used, the results allow for tailored next step guidance
for decreasing vulnerabilities across the health network under each pillar. This could include
strengthening systems at facility and network levels, strengthening the intersection with other
emergency response agencies, and creating a deeper understanding of the interdependencies
between health system and lifelines infrastructure during and after a shock. The results highlight
the importance of considering multisectoral effects in planning decisions and can illustrate how
infrastructure decisions in other sectors can impact health systems.
2.2 Scoring
The rapid assessment does not provide an evaluation of Pillar 1 (foundational capabilities).
Rather, it highlights some key health statistics for the country compared to its regional peers
and includes recently enacted policies for strengthening the health system that focus on the
quality and availability of health services as they impact CDRM. Depending on country needs and
project scope, it is possible to conduct a deep dive assessment to focus on primary health care
standards, health system governance, and basic workforce needs.
Pillars 2–5 are scored on a traffic light scale with four categories: green, yellow, red, and gray
(table 1). This builds on similar scoring techniques used in other World Bank publications, first
introduced in the Adaptation Principles report (Hallegatte et al. 2020) and applied in Caribbean
countries (Rozenberg et al. 2021).
Table 1. Scoring logic of the Frontline Scorecard
Category Description
Green l Meets all, or almost all, of the capabilities in an indicator
Capabilities in this indicator are emerging; meets some elements but lacks some
Yellow l
critical elements
Red l Capabilities in this indicator are nascent or nonexistent
Gray l Unknown, due to insufficient evidence to provide a score
2.2.1 Indicators
The assessment evaluates indicators for each pillar based on quantitative or qualitative
boundaries. In the rapid assessment, approximately 15 percent of the indicators use quantitative
measures as input. Quantitative boundaries are derived by identifying a country’s capability
compared to a global dataset of performance, with the lowest third of global performers assigned
red, the middle third, yellow, and the upper third, green. For example, in Pillar 4 for the indicator
access to internet, the top 33 percent of countries with the best internet access according to a
global database score green. The deep dive assessment complements quantitative evaluation
metrics with survey results or other qualitative inputs, based on information availability and
assessment focus.
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Qualitative indicators are evaluated on a three-part normative scale. Although the boundaries
for the scale vary by indicator, a common scale is that indicators score red if a capability is
nonexistent or nearly nonexistent, yellow if some of the qualities assessed by the indicator are
present, and green if it has a nearly complete or a full array of capabilities. For hazard-resilient
building codes under Pillar 2, for example, if a country has no hazard-resistant building codes for
health facilities, it would score red, if it has codes for earthquakes but not for other high-impact
hazards, such as floods or landslides, it would score yellow, and if it has a full set of building codes,
it would score green. Table 2 provides an overview of the number of indicators per pillar of the
health system.
Table 2. Number of indicators per pillar of the health system
Pillar General description Number of indicators
1 Foundations of health care not applicable
2 Health facilities 18
3 Health systems 21
4 Integrated emergency response 24
5 Lifeline infrastructure 21
Note: The number of indicators may change as the assessment evolves.
2.2.2 Indicator categories
Indicators for Pillars 2–5 are divided into nine categories, according to CDRM capabilities and
policy areas at different levels of the health system (table 3). Each indicator falls under a pillar
and a category according to its best fit. This enables a crosscutting analysis of CDRM according
to pillar and capability. For example, an analysis of Pillar 2 might highlight the personnel needs
in individual facilities but cannot account for the same needs across other pillars. However, a
categorical analysis looks at indicators across pillars to complete the picture.
Using individual indicator scores, it is possible to calculate aggregate scores for both pillars and
categories. This involves averaging scores across pillars and categories, giving 3 for a green score,
2 for a yellow, 1 for a red, and 0 for unknown. The resulting aggregated score takes on a value
between 1 and 3 and translated back to a traffic light score.
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Table 3. Nine indicator categories for CDRM capabilities
Indicators
Category Covers issues related to: (number) Pillar
Codes, regulations, Existence and enforcement of standards to reduce the
18 2–5
and laws incidence or severity of an impact
Financing and Developing, distributing, and accessing funding and
9 3–5
funding funding mechanisms
Networks for organizing, storing, and communicating
Information systems 8 2,3
critical data
Written documents or processes for achieving objectives
Plans and planning related to health care security, public health, emergency 15 2–5
management, or related fields
Constructions or physical systems that deliver or help
Physical assets 9 2–5
deliver health care services
Health care and response staff (competency, capability,
Personnel 13 2–5
numbers, etc.)
Population or social characteristics related to capabilities
Public health 5 3,5
or gaps for health care shocks
Public
Ability to communicate with the public digitally, cellularly,
communication and 4 4
and in writing (i.e. literacy)
warning capacity
Items that are used explicitly for treatment and therapy
Supplies and
or to assist in treatment and therapy during emergencies 3 3
distribution
and the supply networks used to distribute these items
Note: The number of indicators shown are for the deep dive assessment. The number may change as the
scorecard evolves.
One significant difference between the two assessment levels is that a rapid assessment can
identify high-level strengths and weaknesses in a health system’s capability to manage shocks,
while a deep dive assessment can focus on specific aspects identified in the rapid assessment
and identify specific actions to strategically strengthen CDRM efforts. Through a data-driven
process of examining existing protocols and procedures against a backdrop of best practice
examples, a deep dive assessment allows countries to identify the focus areas, by category and
by pillar, which need to be strengthened most. From this, a deep dive assessment can develop
concrete suggestions for moving forward in cooperation with local counterparts. Figure 2 shows
a schematic overview of this process. In countries with resource constraints—for example, due to
size or geography—it is possible to implement individual restrictions for the analysis, limiting the
scope of a deep dive assessment to particular subregions or issues.
THE FRONTLINE SCORECARD An Assessment Tool for Climate and Disaster Risk Management in Health Systems
15
Figure 2. Exemplary output for scored indicators, incorporated feedback, and resulting focus
actions
Cross-Pillar Analysis Organizational Category Analysis
Codes, regulations, and laws
Pillar 2 3
2.75
ID201: Existence and Public communication and
warning
Personnel
2.5
enforcement of building codes 2.25
ID202: Hazard-specific 2
considerations for building 1.75
1.5
codes and land use Supplies and distribution
Physical assets
networks 1.25
ID203: Codes specific for 1
medical facilities
ID204: Health facilities have
adequate backup water system
Financing and funding Information Systems
Pillar 3
ID313: Deployment of mobile
hospitals and related resources Public health Plans and planning
ID314: Emergency operations
centers for health
Pillar 5
ID513: Power supply reliability
Key Stakeholder Input
Recurring comments about building conditions, lack of standards of maintenance, etc., which is also
supported through numeric measurements (e.g. 8 of 10 respondents listed the focus area as a concern)
Focus Area
Highlight age and condition of facilities, along with growing Validation from
population. Present risk scenarios during several hazard events, Ministry of Health and
which can be bolstered by histyorical incidence other stakeholders
Potential Implementation Action(s)
Action(s) to develop building code standardization, implementing Validation from
maintenance SOPs, having sufficient staff to maintain hospitals, Ministry of Health and
financing projects other stakeholders
2.3 Limitations
The Frontline Scorecard is not without its limitations around the accuracy, quality and availability
of input data, context, and comparability.
Input data can vary in quality and age, and almost all indicator scores are based on qualitative
judgements of a country’s capabilities, which can be prone to additional subjectivity. It is
important, therefore, to consider the rationale behind individual scores when interpreting the
Frontline Scorecard results.
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Results are also mostly based on country-level indicators, and so, while they present an accurate
high-level assessment of CDRM capabilities at national level, they do not reflect regional
disparities within a country fully. Although a deep dive assessment could include a focus on
regional disparities, this may impact the speed of delivery, depending on the overall scope of the
regional analysis.
With indicator scores based on qualitative measures and built as a traffic light metric, and the
composition of indicators subject to change based on individual analysis needs and country
contexts, assessments are only comparable within a specific country context and not necessarily
across countries.
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3
Country application: Belize
This chapter presents the background and results of the rapid and deep dive assessments in
Belize. It provides a detailed explanation of how countries can use the Frontline Scorecard to
identify focus areas for increasing their health system’s resilience to natural hazards (disasters)
and climate change, and potential future actions for strengthening their CDRM capabilities.
3.1 Country context
Belize is a small Central American nation, bordering Mexico to the north, Guatemala to the west
and south, and the Caribbean Sea to the east, with a shoreline that is roughly 400 kilometers long.
It has a population of roughly 400,000 in 2020 (PAHO 2020) and is the only Central American
country without access to the Pacific Ocean. Despite its size, it has a diverse landscape and
geography, and is exposed to many natural hazards, including hurricanes, floods, storm surges,
landslides, wildfires, and extreme heat (Morath-et al. 2022).
To understand how the country’s health system meets its population’s needs, it is important to
look at its structure. Belize is divided into four health regions – Northern, Central, Western, and
Southern – which cover the country’s six administrative districts of Corozal, Orange Walk, Belize,
Cayo, Stann Creek and Toledo Districts. The Northern and Southern Health Regions each serve
two districts while the Western health region serves Cayo district. The Central Health region
serves the Belize District including the Cayes (San Pedro and Caye Caulker). Each catchment
area has a public regional or community hospital and multiple health centers and posts; some
also have polyclinics.
The Ministry of Health and Wellness (MoHW) is responsible for regulating, managing, supervising,
and providing public health services. It manages seven public regional and community hospitals, ▲ Belize City.
10 polyclinics, 32 health centers and all health posts connected to the public health centers. The Photo: Mindaugas
Dulinskas/
only public hospital not directly managed by MoHW is the country’s only tertiary care facility, iStock.com
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the Karl-Heusner Memorial Hospital (KHMH) in Belize City. KHMH has been a statutory authority
since 1999, and management decisions on resource use remain with the hospital’s chief executive
officer and statutory board, on which MoHW holds two seats. The Belize health system aims
towards a universal health care system to increase equitable access to health services as part
of the government’s Health Sector Strategic Plan 2014–24. It is likely that the National Health
Insurance, which operates independently of MoHW, will take a greater role in the coming years.
The private health sector also plays a significant role in delivering health services in Belize. As
of May 2022, there were 191 private health facilities in the country, operating independently of
MoHW and with little quality oversight. Although there is no recent publicly available data on
what share of the population relies on the private sector, the share of public-to-private health
facilities is highest in Toledo District, where roughly 64 percent of all facilities are public, and
lowest in Belize and Cayo Districts, with 16 and 14 percent, respectively.
Human resources is one of the biggest concerns for health service provision in Belize. Poor
retention rates in underserved areas, high mobility and migration, precarious working conditions,
and low productivity are factors hindering the progressive expansion of health services (MoHW
2021). This problem is aggravated at the primary health care level. With 10.8 doctors available
per 10,000 population in 2018, Belize is below many of its regional peers—such as Barbados (24.9
in 2017), Costa Rica (28.9), Dominica (11), Guyana (18.2), Mexico (24.2), Panama (16), and Trinidad
and Tobago (54)—but above Jamaica (5.3) and Suriname (8.2) (WHO 2023). With 23.4 nurses and
midwives per 10,000 people, Belize places better in this respect than Guatemala (12.8), Guyana
(10.4), and Jamaica (9.4), but places below Barbados (30.6), Costa Rica (34.1), Dominica (60.9),
Mexico (28.5), Panama (30.7), Suriname (27.6), and Trinidad and Tobago (41.4) (WHO 2023).
A MOHW assessment of public health facilities (MoHW 2021) found significant gaps in the
delivery of health services resulting from shortages of doctors and nurses, particularly in rural
areas. Some clinics have no permanently placed medical officers and visiting physicians have to
cover large areas. In a small number of rural areas, nurses are shared between multiple clinics,
impacting the delivery and quality of the public health program, including screening and birth
control. When human resources are available, they do not always have the appropriate profile
and competencies. The sector also struggles with a lack of equipment and medical supplies.
The Belize Health Information System (BHIS) is a digital health record system currently utilized;
however, the effective use of data for meaningful analysis is lacking and requires human resource
expertise and ongoing training.
3.2 Disaster risk exposure in Belize
The GFDRR classifies Belize’s risk exposure to hurricanes, urban floods, river floods, extreme heat,
and wildfires as high and to earthquakes, landslides, and coastal floods as medium (Thinkhazard
2020). While these risks vary slightly between regions, given its small size, all the country’s
regions are exposed to significant risk from at least one source.
The threat from hurricanes is severe across the country (figure 3), which cause damage due to
high wind speeds, heavy rain, flooding, and storm surges along the coast and further inland.
These could be devastating in the most populous city, Belize City, and other settlements along
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the coast. GFDRR recommends considering this high exposure to hurricanes in all project
planning decisions, designs, and construction methods. In addition to the continued threats from
hurricanes and other hydrometerological hazards, climate models project that Belize will face
more seasonal droughts in the future.
In a worst-case scenario, multiple disasters could coincide. This increases the challenges faced
by the DRM community in Belize, because disaster preparedness cannot focus on just one or
two types of disasters; rather, it must plan for multiple hazards simultaneously. By far the most
severe risk in terms of population exposure is posed by hurricanes.
Box 1 Disaster response and recovery in Belize
In terms of preparing for and responding to disasters, and managing both disaster
response operations and recovery efforts, the main actor at national level is the
National Emergency Management Organization (NEMO). Founded in 1999, it was
established as a government department led by a national emergency coordinator
in 2000 through the Disaster Preparedness and Response Act. This Act regulates the
general response of the Government as it relates to emergency and disaster mitigation,
preparedness, response, and recovery in Belize. Although current legislation includes
costs for some recurrent operational expenditures, NEMO does not receive funding
for disaster management activities such as structural improvements to buildings,
hurricane relief and emergency management, which must be provisioned for through
the NEMO Advisory Committee, where the Prime Minister (Minister of Finance) leads.
(Morath et al. 2022). As one of the main actors for disaster relief, the health system
relies heavily on cooperating with NEMO. When a disaster is declared by the Prime
Minister, all disaster relief funding from external agencies as well as from government
emergency funds must be channeled through NEMO and the Office of the Prime
Minister. Therefore, MoHW will seek support from this office to respond to shocks.
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Figure 3. Exposure to hurricanes in Belize Figure 4. Exposure of buildings to hurricane
and earthquake damage in Belize
Corozal Corozal
Orange Orange
Walk Walk
Belize Belize
Cayo Cayo
Stann Stann
Creek Risk level Creek Building exposure
Very low (in percentage of total)
Low 5%
Medium 9%
High 11%
Toledo 15%
Toledo
22%
38%
0 25 50 km 0 25 50 km
Source: Thinkhazard 2020 Source: GFDRR 2017
3.2.1 Exposure of public and private buildings
As part of the country risk profile, GFDRR modeled and estimated the exposure of Belize’s
public and private buildings to hurricane and earthquake risks. This was based on real damages
sustained from Hurricane Iris in 2001, adjusted to project economic losses from a similar storm
in 2016. The equivalent losses adjusted for 2016 would have resulted in damages of $105 million,
or roughly 6 percent of Belize’s GDP (GFDRR 2017). Depicting the percentage of at-risk buildings
at district level, figure 4 shows that, in one district, at least 38 percent—that is, more than one
in three buildings—are exposed to hurricane and earthquake damage. In another, the figure is 22
percent, or more than one in five buildings. This highlights the vulnerabilities of the population,
infrastructure, and health system to natural hazards.
3.2.2 Exposure of the health system
Exposure to natural hazards poses concrete challenges for Belize’s health system, as the country’s
frequent disasters impact the service delivery in the sector. In late 2022, Category 2 Hurricane
Lisa forced many private health practices to shut down in Belize City, increasing demand for
services from the public and private-public sectors. Patients and procedures mostly were moved
to Karl Heusner Memorial Hospital (KHMH) in Belize City, the country’s only tertiary health facility,
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putting additional strain on already scarce resources. As part of the hurricane response plan for
KHMH, this hospital cannot withstand a hurricane stronger than a category 2. The entirety of
Belize City is below sea level, and KHMH is in a flood zone. The hospital must be evacuated for
a category 3 storm or stronger with all patients transferred to the Western Regional Hospital
or the Northern Regional Hospital. Hurricane Lisa only caused minor disruptions to power and
telecommunication services, but outpatient services in KHMH were suspended (PAHO 2022b).
The threat of evacuation from a higher category hurricane also places additional burden on the
health system. Roughly 80 kilometers away in Belmopan, the nearest referral hospital is Western
Regional Hospital, a secondary health facility that does not offer all the services available at
KHMH. Western Regional Hospital is inland and may be secured from a storm surge; however,
it is not elevated and remains at risk to flooding. It is important to note, however, that in case
of hurricane Lisa, primary health centers and policlinics were operational within hours after the
Hurricane had passed, enabling the health system to begin returning to its normal operational
capacities.
Box 2 The impact of COVID-19
The COVID-19 pandemic also had severe impacts on Belize’s health sector, as well as more
widespread effects on the people and the economy. As a result of pandemic preparation
and response actions, the government suspended fiscal adjustment measures and the
acquisition of new debt. Belize’s GDP dropped by 14 percent in 2020 alone, mainly from
the decline of secondary services. In the public health sector, the Government of Belize
was forced to cut spending on routine health service delivery to create fiscal space
and counter the negative macroeconomic climate. At the same time, income losses
experienced by households likely adversely impacted the delivery of health services, as
private sector substitutions for public sector services that were no longer offered are
typically paid privately out of pocket. The impact COVID-19 had on people directly and
indirectly can be seen in the decline of the life expectancy at birth, which declined during
the pandemic from 73.93 years in 2019 to 70.47 years in 2021, reversing recent progress.
Life expectancy started to increase again in 2022 (PAHO 2022a).
Resource scarcities in terms of personnel and technical equipment can severely impact a health
system’s ability to effectively respond to shocks (Rentschler et al. 2021). Given both the Belize health
sector’s resource shortages and the country’s high exposure to disasters, a high-level assessment
of strengths and weaknesses of the system’s CDRM capabilities can identify problem areas to
effectively reduce vulnerabilities and provide an informed starting point for further analysis.
3.3 Assessment results
This section shows how countries can use the Frontline Scorecard to assess the CDRM capabilities
of their health systems. The scorecard provides valuable insights into strengths and potential
gaps of service delivery, emergency response, and emergency preparedness, in individual health
facilities and across integrated emergency response operations. As a first step in ensuring
continuity of service delivery and access to health services for the population in case of shocks,
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this analysis of the current state of DRM in the Belize health sector is a crucial step. It also
complements existing efforts to strengthen the capability of the health sector to respond to
shocks, including lessons learned from the COVID-19 pandemic.
There were four phases to implementing the assessment in Belize, one in the rapid assessment
stage and three in the deep dive assessment (figure 5). Overall, the results show that conducting
both levels of assessment is useful for small states and can help to inform future investments for
the health system. Direct commentary on the efficacy of the study can be found in section 3.4.
Figure 5. Overview and timeline of the Belize scorecard
Rapid assessment Deep dive assessment
Recommended for health Recommended for health systems in small states or regions of
systems in all states larger states
Potential
Rapid
Phases Data collection Focus areas implementation
assessment
actions
Expert interviews
Results from Additional data Validation Survey of
previous World and information assessment other DRM and
Input(s) Bank projects from the Key stakeholder health investments
Publicly available government input Key stakeholder
information In-country input
mission
September 2022 December 2022 –
Timeline August 2022 January 2023
– January 2023 January 2023
3.3.1 Rapid assessment
The Belize rapid assessment was completed in August 2022, as shown in figure 5, and results
were presented to a health team at the World Bank and key stakeholders from MoHW in January
2023. The rapid assessment provided a score for all indicators with sufficient data (77 out of 79)
and for Pillars 2–5 of the health system.
Table 4 presents a written summary of the key findings (see table A.1 in Appendix A for detailed
scores5). Although the results show that there has been some progress in strengthening emergency
response and infrastructure projects, they also highlight staff shortage issues and difficulties
streamlining national policies and enforcing and updating rules and regulations.
Following the presentation of results, the health team at the World Bank and MoHW stakeholders
decided to move forward onto a deep dive assessment to complement and expand some of the
results from the rapid assessment and test the implementation of capabilities on the ground.
5
The number of indicators in the Frontline Scorecard has changed since the application in Belize. At the time of the as-
sessment in Belize, the scorecard consisted of 79 indicators. Table A.1. contains 84 indicators. The five new indicators
were added as a result from updates and feedback received during the application of the scorecard assessment. It is
expected that the exact list of indicators will evolve as more applications are conducted and new datasets and infor-
mation sources become available.
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Table 4. Key findings of the rapid assessment for Belize
Overall assessment 77/79 indicators scored
Many studies have noted Belize’s higher-than-average exposure to disasters. Belize has made substantial
progress in curbing the severity of the impact of disasters on health care systems and services over
the last 20 years. Improvements include new laws and regulations, developing enforcement arms,
strengthened emergency response, and infrastructure projects. Belize has strengthened partnerships
with multinational agencies—such as the World Health Organization (WHO), the Pan American Health
Organization (PAHO), and the World Bank—and with bilateral partners. The health care sector recently
collaborated with PAHO on several notable projects for training and healthcare facilities. With the aid
of some of these organizations, the government has also conducted assessments of hazards, response
operations, hospital risk, and other topics. But it has not been implemented or legislatively mandated
some resilience measures, such as design standards. Belize also has a large disparity in publicly available
information, and rural and urban area capabilities, which should be assessed further. These issues may be
exacerbated by lack of access to some rural areas and lower numbers of health care personnel per capita
than its urban counterparts.
Pillar 1. Health foundations Unscored
The rapid assessment scorecard analyzes national-level statistics only, so no writeup is provided (but it
can be provided upon request).
Pillar 2. Health facilities 14/17 indicators scored
Of all the pillars, this has the most capability gaps. Although Belize has made strides to protect its health
facilities through retrofits and studies with external partners, many of these upgrades do not seem to be
codified in law or policy, which could produce imbalances in resilience across different hospitals. Although
there are health personnel with emergency and disaster response training, hospitals would benefit from
having staff with these capabilities, which can be ensured via mandate.
Pillar 3. Network of health facilities 19/19 indicators scored
Belize has a strong response and coordination network. But despite improvements in recent years,
its healthcare information systems could benefit from further strengthening. It has a strong initial
foundation for planning, and this could be expanded through further integration with emergency response
and infrastructure services. Cybersecurity was identified as a notable gap, but the country’s recent
cybersecurity plan identified the need to protect critical infrastructure services, which may improve this
capability in the future.
Pillar 4. Integrated emergency response 22/22 indicators scored
This pillar shows similar trends to Pillar 3. Belize has strong DRM capabilities, possibly as a result of the
volume of disasters it faces. The country has developed and strengthened partnerships with its neighbors
and other entities but could benefit from strengthening internal coordination mechanisms during
emergency periods and determining additional ways to reach the public during disaster events, especially
in rural areas.
Pillar 5. Lifeline infrastructure 19/21 indicators scored*
Belize has identified and executed key infrastructure projects over the last decade and is expected to
continue this trend. Integrating MoHW with water and wastewater delivery is a notable advancement for
the country’s resilience to disasters and climate change. Despite implementing recent roadway projects
that have improved resilience to flooding and other weather events, transportation infrastructure could use
additional investment and mandated design standards. The country’s reliance on hydropower may also
expose its power generation systems to greater power uncertainty due to climate change.
Note: The two unscored indicators under Pillar 5 are related to railways, which Belize does not have.
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3.3.2 Deep dive assessment
The deep dive assessment was conducted from September 2022 to January 2023. To complement
the analysis of the rapid assessment, additional information was collected through semi-structured
interviews with stakeholders from MoHW and other government agencies. After contacting more
than 40 experts for interview, 15 interviews were conducted (table 5). In line with the semi-structured
approach, each expert received a different set of questions related to their area of expertise and
had an opportunity to share additional information and highlight areas of greatest need. All the
questions were open-ended. In addition to data analysis and interviews, members of the World Bank
team also validated some indicators during an in-person mission to Belize in January 2023.
Table 5. Experts interviewed, by sector
Organization Number of experts interviewed
MoHW 8
Central Building Authority 1
Belize Electricity Limited 1
National Engineering and Maintenance Center (NEMC) 1
Ministry of Works 1
NEMO 2
National Meteorological Service 1
In the validation phase, the scores of 26 indicators were adjusted, with 20 indicators receiving a
higher score and 6 a lower score (see table A.1, appendix A, for the overall scores for each indicator).
As well as scoring by indicator, the scorecard results included summary writeups for the overall
scorecard and all pillars. These, and a summary of the initial qualitative assessment of Pillar 1,
were made possible through engagement with experts from Belize and are presented in table 6.
Table 6. Summary results of the deep dive assessment
Overall assessment 77/79 indicators scored
As outlined in table 4, the Government of Belize has strengthened its legal and political DRM
frameworks, and its international partnerships. But despite notable improvements in DRM for health
systems, recent shocks, including Hurricane Lisa and the COVID-19 pandemic, highlighted some areas
that require strengthening. A cross-evaluation of the pillars and organizational categories reveals
five focus areas that are crucial to improving resilience of the health system: facilities (including
maintenance and medical supply chains), training and simulations, planning and allocation, information
and communications technology (ICT), and whole-of-government collaboration. A comprehensive list of
these areas is outlined in table 8.
Pillar 1. Health foundations Assessment not based on indicators
Unlike the other pillars, Pillar 1 does not follow a set of pre-established indicators, considering instead a
range of issues that affect healthcare systems and delivery during shocks. It is only assessed in the deep
dive assessment.
There is a critical need for more health system personnel at all levels and in all roles, from doctors and
nurses to critical support personnel, such as ICT and maintenance. This problem has been aggravated
by constraints on the health system from the recent COVID-19 pandemic, which have prompted a
wave of retirements. MoHW also consistently loses personnel to the private health sector, due to more
lucrative offers or a better work-life balance.
The decentralization of Belize’s health system, which allows the elements of the system to respond more
quickly to adverse events, has introduced fragmentation across the health system, which in turn
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Table 6. Summary results of the deep dive assessment (cont.)
Pillar 1. Health foundations (cont.) Assessment not based on indicators
contributes to a lack of DRM and preparedness standards across health facilities, districts, and regions.
With many processes and plans remaining the purview of health system administrators and individual
facilities, the result is an ad-hoc system with varying capability levels, where institutional knowledge
is assumed rather than formalized. This differs from MoHW’s approach to health financing, which is
generally centralized, but lacks a strategic and performance-based plan to implement the ministry’s
goals, such as universal health care.
Pillar 2. Health facilities 17/17 indicators scored
Many codes have not been standardized or are not implemented uniformly throughout Belize, leading
to an imbalance across hospital facility capabilities. A lack of standards is compounded by a historical
lack of code enforcement for public health facilities, and several of Belize’s most critical health
facilities, especially Western Regional Hospital, are in need of significant renovation. MoHW’s supply
and distribution facilities are also at risk from several hazards, including flooding. At the facility level,
personnel training in DRM and emergency response planning seems to vary widely, partly due to a lack
of resource allocation and mandate for these activities. Based on current goals and trajectories, major
health facilities are expecting retrofits or new constructions, and enhancements to lifeline infrastructure
redundancies (e.g., better water storage). Planning, personnel, and other emerging capabilities, such as
cybersecurity, would benefit from increased attention.
Pillar 3. Health system 19/19 indicators scored
The MoHW has strengths at the national level regarding planning and foreign aid coordination. But
it also found that a lack of personnel across all levels of the system has limited disease surveillance
capacity, the deployment of medical personnel (especially during surges), and other capabilities. A lack
of financial resources has limited MoHW’s ability conduct standardized trainings, respond to disasters
and health shocks, and move personnel and goods through its supply chain. The health system would
benefit from enforcing standards and increased planning, to strengthen capacities related to continuity
and emergency response planning, the ability to use telemedicine, and other capacities developed in
response to the COVID-19 pandemic.
Pillar 4. Integrated emergency response 22/22 indicators scored
Belize has strong coordination at district, regional, national, and international levels when it comes to
disaster response. But there is room for improvement in coordination and communication efforts across
agencies, especially with the public. Many communication channels rely on digital or cellular technologies
without any redundancy in place. Existing backup systems, like radios, are not regularly maintained
and checked. Planning and recovery efforts are a secondary priority after response efforts, reflected in
a comparative lack of resource allocation to these stages of DRM, especially at local level. Nonetheless,
planning, response, and recovery are expected to continue their trajectory of improvement moving forward.
Pillar 5. Lifeline infrastructure 19/21 indicators scored*
Transport (roads), electricity, and water face varied levels of exposure to natural hazards and risk,
impacting the health sector in several ways. Of all the infrastructure components surveyed, frequent
transport disruptions are the biggest disruptor of health services.
Despite the implementation of recent projects that have improved major roadways’ resilience to flooding
and other weather events, Belize’s transport infrastructure remains vulnerable to natural shocks,
impacting health service delivery. The transport network could benefit from additional investment and
mandated design standards, especially in secondary and tertiary road networks. Frequent disruptions
to transport infrastructure have shaped health delivery, especially in rural areas, as accessibility issues
mean it is often more resource-efficient to have providers and other personnel travel to these locations
following a natural disaster than have people visit health facilities.
Belize’s electricity system is generally well-prepared to mitigate and respond to shocks, including larger
shocks such as hurricanes. However, the country relies on power supply from Mexico, especially during
failure events to its own power network. Its reliance on hydropower may also expose these power
generation systems to greater supply uncertainty in the future due to climate change and changing
precipitation patterns and water flows.
Additional research is needed to deliver a more complete assessment of the impacts of the exposure of
Belize’s water and wastewater network on the health system, as expert interviewees were not available
during the research period.
Note: The two unscored indicators under Pillar 5 are related to railways, which Belize does not have.
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3.3.3 Analysis by indicator category
To complement the results of the rapid and deep dive assessments, the Scorecard analyzed the
indicators by category, as outlined in section 2.2.2. Table 7 shows the average scores for each of
the nine categories. The analysis finds that the country’s capabilities are emerging—that is, that
it meets some of the indicator’s elements but lacks some critical elements—for all categories
except physical assets strengthening, for which its capabilities are nascent or nonexistent. These
findings allow for a deeper understanding of strengths and weaknesses that are common at
distinct levels of the health system.
Table 7. Overall scores for the Belize health system, by category
Organizational categories
Codes, regulations, and laws ●
Financing and funding ●
Information systems ●
Plans and planning ●
Physical assets ●
Personnel ●
Public health ●
Public communication and warning capacity ●
Supplies and distribution ●
This additional analysis and categorical scoring process identified five focus areas of the Belize
health system, based on recurring themes from the rapid and deep dive assessments—facilities,
training and simulations, planning and allocation, ICT, and whole-of-government collaboration—
which the World Bank and the Government of Belize representatives discussed during a workshop
at MoHW in Belmopan in January, 2023. Table A.2 (appendix A) outlines detailed findings for
these focus areas and provides further insights into the challenges Belize faces in increasing its
health sector’s resilience to disasters and climate change.
3.4 Recommended future actions
This analysis of the Belize health sector’s CDRM capabilities identified potential future actions
to strengthen the health system’s ability to respond to climate and disaster shocks and increase
its resilience. The Frontline Scorecard’s CDRM focus enables the recommendation of actions
to improve the delivery of health services during surge demand situations where additional
constraints are placed on the health system. A co-benefit of the identified measures is that they
also improve routine accessibility and access to health services.
Table 8 provides an overview of components for future action under the five focus areas, based on
a review of best practice examples from other countries and of past and ongoing engagements in
the country and the wider region.
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Table 8. Critical areas for strengthening in the Belize health system
Focus areas Components for future action
Facilities Storage and distribution
Hospitals and clinics
Training and simulations Standards and training
Emergency simulations and stress tests
Planning and allocation Disaster preparedness plans
Resource allocation
ICT Communication redundancies
Cybersecurity
Whole-of-government collaboration Workforce planning
Infrastructure
Concrete next steps were developed for each of these focus areas shown in table 8 as the final
step of the scorecard analysis. Four key challenges identified by this study were subsequently
prioritized by MoHW, NEMC, and the Ministry of Finance during the January 2023 workshop:
routine maintenance demands for health facilities, supply chain and storage concerns connected
to the national medical storage facilities, the need for standardized nationwide implementation of
DRM trainings, standards, and procedures for medical personnel, and the need to widen disaster
plans to include updated flood risk exposure of health facilities.
Table 9 provides an example for potential further actions to address specific challenges of CDRM
in the Belize health system, with a time dimension to provide a high level of guidance. This is just
one of the four prioritized implementation actions identified in the workshop. Table A.3 (appendix
A) shows the remaining three actions not presented in this section.
Table 9. Potential implementation actions for facilities
Facilities: storage and distribution
Description MoHW may consider strengthening the storage and distribution of medical
supplies
Short-term Conduct a scoping study to determine actions to improve medical storage
(< 2 years) locations and reserve supplies of medical equipment, pharmaceuticals, and related
items
Include supply chain considerations and travel time estimations for medical
supplies, and relate potential synergies with laboratory services—for example, in
the distribution and logistics network
Medium-term Upgrade or retrofit medical storage centers to reflect hazard exposure, where
(< 5 years) necessary
Long-term If upgrading is economically not sensible, move and rebuild storage buildings,
(> 5 years) according to distribution needs and hazard exposure
Workshop outcome The January 2023 Belmopan workshop identified the storage and distribution of
medical supplies as a strategic element of interest for rapid strengthening and
budget allocation
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The identified actions presented in this case study provide an illustration of the Frontline
Scorecard’s practical applicability strengths. The high-level nature of the analysis identifies
critical breaking points that can have cascading effects on service delivery in the health system,
which require further analysis, and that can be the focus of subsequent investment decisions.
It provides a guideline of where to look first when improving the health sector’s resilience to
disasters, climate change, and pandemics. Consequently, many of the suggested implementation
actions identify the need for in-depth analyses of vulnerable elements of the health system that
can hinder the delivery of health services during a shock. This case study also shows that some
of the areas identified as being in need of strengthening also severely impact the routine delivery
of health services.
As table 9 shows, countries can use the scorecard to identify and prioritize concrete next steps
for strengthening the CDRM capabilities of their health systems. Its high-level analysis helps
to present a holistic overview, identifying gaps through data-driven analysis. This allows policy
makers to identify and rank future actions according to impact and facilities or actors affected.
It also highlights the interdependence between the health and other sectors—for example,
the physical accessibility of health facilities via the road network. The facility-level analysis
conducted in Belize identified storage and distribution of medical supplies as a key issue, with
bottlenecks occurring during surge demand situations and in underserved communities. Based
on these results, the next step would be to analyze the supply chain further to improve its climate
and disaster resilience, thus decreasing overall vulnerabilities in the health sector.
3.5 Discussion
Belize is one of six country rapid assessments completed as of December 2023, all of which were
conducted within the expected resource and timeframe allocation. The Belize rapid assessment
took the equivalent of 1.5 weeks of one team member’s time. In all countries assessed, search
queries were undertaken in the official national language. English is Belize’s official language
so all publicly available documents relevant to the indicators were written in English or had an
English translation. Assessment languages for the other country scorecards included Spanish,
Filipino, French, and Tajik. If a country’s official language is not within the Frontline team’s native
or professional proficiency, the scorecard assessment may require translation or similar support
services.
Although the Belize rapid assessment identified more than 10 gaps in the health system’s CRDM
response, it did not pinpoint all 18 implementation actions across the five focus areas identified
in the deep dive assessment. Findings include the need to strengthen physical supply storage
locations against natural hazards and improve supply chain management, which formed one of
the recommended future actions.
However, results of the rapid assessment did hint at some of the gaps later identified through
interviews during the deep dive assessment, providing a helpful foundation for additional analysis.
For example, under Pillar 1, the rapid assessment indicated that resource constraints for staffing
and financing hindered the effectiveness of the sector’s disaster response; this was confirmed
during the deep dive assessment, which found that human resource issues directly impact one-
third of the focus areas identified.
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The rapid assessment could not, however, predict the priority or scale of many of the gaps
highlighted by the deep dive assessment. For example, it noted that Belize’s digital health
system had improved in recent years but needed some upgrades in relation to cybersecurity and
information management. The deep dive assessment clearly showed the linkages between digital
health and other areas that require strengthening, such as human resources, and emphasized
the need to strengthen the digital health system from a risk management perspective, such as
cybersecurity and network failure.
Unlike the rapid assessment, the deep dive assessment has more extensive resource requirements.
The recommendation to use it for small states or regions within larger states is due to the resource
requirements needed to understand implementation, including broad disparities, throughout the
health system. The expert interviews, which formed the backbone of the deep dive research in
Belize, took hours to establish, execute, and analyze. Although the report would have benefitted
from additional interviews, 15 were sufficient to understand the implementation of—and some of
the disparities between—regulatory frameworks and their enactment.
Belize has a small health system, comprising seven hospitals and approximately 50 facilities
in total. Based on this experience, analyzing a health system with several thousand facilities
would make a similar deep dive assessment significantly more resource intensive. Although the
CDRM4H team is determining avenues to automate some aspects of information gathering,
which may expand the speed or scope of the scorecard, this development is at an early stage and
depends on too many assumptions—such as sufficient uptake from an expert pool—to draw any
conclusions as of this writing.
Results from Belize, confirmed by feedback from country representatives, suggest that the
deep dive assessment can highlight focus areas for strengthening health systems’ capabilities
to prepare, respond, and recover from shocks. Aspects of the assessment overlapped with
observations from other recent reports, such as PAHO’s BAT and SMART assessments for Pillar
2 (van Alphen et al. 2017) and the Belize National Disaster Preparedness Assessment (Morath et
al. 2022) for Pillar 4.
The deep dive assessment also identifies co-benefits and opportunities from cross-sectional
cooperations, with the Belize research identifying significant overlap with other projects,
especially for Pillar 5. Finally, the assessment stands as the first World Bank engagement to
analyze Belize’s capabilities to deal with shocks at public health system level.
Despite the general success of the deep dive assessment, several biases may skew its results. Its
flexible approach to data collection means it is possible to use a variety of methods—including
interviews, additional documents, analysis, electronic surveys, and missions—depending on
country context. Biases in collection methods differ, as demonstrated in Belize’s case. Although
no information from experts and documents conflicted with the information the team collected
during the in-country mission, the latter did emphasize some of the focus areas more strongly
than assessments provided in the interviews. For example, interviews revealed the importance of
strengthening investment in routine maintenance across Belize’s hospital network, while the in-
country mission in January 2023 clarified the need for strengthening investment in maintenance
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before implementing other actions, such as building new hospital facilities. This highlights the
importance of using different data sources.
While the results of the deep dive assessment highlight the accuracy of the rapid assessment in
capturing general trends with limited resources, the accuracy of the latter can vary significantly
between countries and pillars, depending on the public availability of information. This can explain
some of the discrepancies in the scoring of indicators between the rapid assessment and the
deep dive assessment shown in Table A.1.
The deep dive assessment highlights the successful implementation of the methodology, primarily
using expert interviews. Despite the benefit of expert interviews, the use of other sources, including
an in-country mission, highlight the benefits of complementary data sources. In larger countries
and where there are resource and time constraints, limiting the deep dive assessment to a region
rather than covering the whole country can help increase the efficacy of the analysis.
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4
Outlook
The Frontline Scorecard is an assessment tool that allows countries to identify focus areas for
increasing their health system’s resilience to natural hazards (disasters) and climate change, and
potential future actions for strengthening their CDRM capabilities.
Based on the five pillars of resilient health systems—foundations, facilities, network of facilities,
integrated emergency response, and lifeline infrastructure—the scorecard uses a traffic light
scale to create a high-level assessment of the CDRM capabilities of a country’s health system.
Its two levels of sophistication mean the scorecard can be applied quickly to any country and
has the flexibility to be adapted, depending on country size, needs and data availability. Based
on publicly available information, the rapid assessment typically has low resource requirements,
is quick and easy to conduct, and can identify high-level strengths and weaknesses in a health
system’s capability to manage shocks. The optional deep dive assessment—better suited to small
countries or subnational regions—can then focus on aspects identified in the rapid assessment
to provide a better understanding of the implementation of health system capabilities on the
ground.
By revealing critical areas for strengthening, the scorecard can help policy makers identify gaps
between existing policy mandates and regulations and their enforcement or implementation in
emergency situations and identify potential actions and areas for investment to strategically
strengthen CDRM efforts.
Ongoing scorecard applications also highlight the opportunity to use the rapid assessment
scorecard for continuous monitoring of the progress in health system resilience. Converting the
scorecard into a monitoring tool takes place in three stages. First, the team validates some of
the key indicators in the scorecard with local knowledge and calibrates potential targets (e.g.,
▲ Mother and child
yellow and green) to the government’s goals and historical trajectory of strengthening. The team in Belize City. Photo:
also validates resources for monitoring and the frequency that the tool will be updated. Second, © Ivan Kokoulin |
Dreamstime.
the team confirms the targets with government stakeholders, along with the resources and
monitoring frequency. Lastly, the team reconsolidates all the finalized information into an excel
tool and holds training sessions with the operational team and government counterparts on how
to use the tool.
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In addition to its simplicity of use, the benefit of using the scorecard as a monitoring tool
demonstrates the interconnectedness of health system resilience, as achieving green for some
of indicators requires improving other indicators as well. For instance, many of the indicators in
pillar two (health facilities) rely on improvements to electricity and water supply. The use of the
scorecard as a monitoring tool also allows stakeholders to add indicators to monitor specific
goals or capability gaps, which the team is demonstrating in the scorecard’s ongoing applications.
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1
Appendix A. Overall results from Belize
rapid and deep dive assessments
Table A.1 presents the overall scores for indicators used in the rapid (left) and deep dive (right)
assessments, 26 of which were changed in the validation phase. For comprehensibility, the results
and indicators for both levels of the assessment are displayed side by side. Several indicators that
relied on multinational databases were not rescored, as no higher-level or more accurate data
was identified during the research phase of the deep dive assessment; others were not further
assessed due to unavailability of interview partners. The indicators that are based on global
databases are marked with an asterisk (*). Furthermore, note that language of some indicators
has changed since the Belize assessment. The table contains the most recent list of indicators
as of the publication of this report. Some indicators in the list were added as a result of feedback
and consultations with country teams and were not yet included when the assessment for Belize
was conducted. For these indicators, the column with the results of the scores is marked as "new".
▲ Caye Caulker,
Belize pharmacy.
Photo: Everett Atlas
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Table A.1.. Results for each indicator of the rapid assessment (left) and the deep dive assessment (right)
Rapid assessment Deep dive assessment
Pillar 1. Health foundations Pillar 1. Health foundations
Unscored Unscored
Pillar 2. Health facilities Pillar 2. Health facilities
Codes, regulations, and laws Codes, regulations, and laws
ID201: Existence and enforcement of building codes ID201: Existence and enforcement of building codes
ID202: Hazard-specific considerations for building codes and ID202: Hazard-specific considerations for building codes and
land use land use
ID203: Specific building codes for medical facilities ID203: Specific building codes for medical facilities
ID204: Mandated backup water systems for hospitals ID204: Mandated backup water systems for hospitals
ID205: Mandated backup power generation in health facilities ID205: Mandated backup power generation in health facilities
Physical assets (redundancies) Physical assets (redundancies)
ID206: Mandated protection against electrical surges at ID206: Mandated protection against electrical surges at
hospitals hospitals
ID207: Mandated backup fuel storage at hospitals ID207: Mandated backup fuel storage at hospitals
ID208: Existence of emergency operations plans at hospitals ID208: Existence of emergency operations plans at hospitals
ID209: Mandate for internal communications system at ID209: Mandate for internal communications system at
hospitals hospitals
ID210: Mandated emergency space at hospitals for surge ID210: Mandated emergency space at hospitals for surge
demand demand
ID210: Law, code, or other rule for the existence of maintenance ID210: Law, code, or other rule for the existence of
new new
at health facilities maintenance at health facilities
Personnel Personnel
ID211: Existence of disaster education and training for health ID211: Existence of disaster education and training for health
staff staff
ID212: Hospital staff who specialize in disaster or emergency ID212: Hospital staff who specialize in disaster or emergency
management management
ID213: Hospital staff who specialize in disaster or emergency ID213: Hospital staff who specialize in disaster or emergency
new new
management management
Information systems Information systems
ID214: System to track hospital bed capacity in real time ID214: System to track hospital bed capacity in real time
ID215: Cyber security at hospitals and other major health ID215: Cyber security at hospitals and other major health
facilities facilities
Plans and planning Plans and planning
ID216: Existence of an emergency operations plan at hospitals ID216: Existence of an emergency operations plan at hospitals
that considers all relevant hazards that considers all relevant hazards
ID217: Emergency plans for vulnerable populations in catchment ID217: Emergency plans for vulnerable populations in
areas catchment areas
ID218: Availability of risk-based site selection guidance for ID218: Availability of risk-based site selection guidance for
medical facilities medical facilities
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Table A.1.. Results for each indicator of the rapid assessment (left) and the deep dive assessment (right) (cont.)
Rapid assessment Deep dive assessment
Pillar 3. Health systems Pillar 3. Health systems
Codes, regulations, and laws Codes, regulations, and laws
ID301: Regulations for data privacy and protection of patient ID301: Regulations for data privacy and protection of patient
data* data*
Public health Public health
ID302: Vaccination rates (measles, both doses, and foot-and- ID302: Vaccination rates (measles, both doses, and foot-and-
mouth only)* mouth only)*
Financing and funding Financing and funding
ID303: Funding for large-scale health response* ID303: Funding for large-scale health response*
ID304: Funding for health care-specific disaster planning ID304: Funding for health care-specific disaster planning
exercises, drills and or trainings exercises, drills and or trainings
ID305: Funding for personal protective equipment (PPE) and ID305: Funding for personal protective equipment (PPE) and
basic medical supplies basic medical supplies
Information systems Information systems
ID306: Disease surveillance capacity for pandemics (lab ID306: Disease surveillance capacity for pandemics (lab
capacity) capacity)
ID307: Communication between healthcare officials and ID307: Communication between healthcare officials and
healthcare personnel during emergency events* healthcare personnel during emergency events*
ID308: National data collection for communicable diseases ID308: National data collection for communicable diseases
ID309: Telemedicine capacity ID309: Telemedicine capacity
Personnel Personnel
ID310: Committee for integrated response across hospital ID310: Committee for integrated response across hospital
network(s) network(s)
ID311: System to deploy and relocate medical specialists in case ID311: System to deploy and relocate medical specialists in
of emergencies case of emergencies
ID312: Standard DRM training for medical personnel across the ID312: Standard DRM training for medical personnel across the
new new
health system health system
Physical assets Physical assets
ID313: Deployment of mobile hospitals and related resources ID313: Deployment of mobile hospitals and related resources
ID314: Emergency operations centers for health new ID314: Emergency operations centers for health new
ID315: Capacity to isolate patients with communicable
ID315: Capacity to isolate patients with communicable diseases
diseases
Plans and planning Plans and planning
ID316: Business continuity plan for the health care sector in the ID316: Business continuity plan for the health care sector in
event of lifeline failure (transport, electricity, gas, or water) the event of lifeline failure (transport, electricity, gas, or water)
ID317: Existence of emergency plan, for health facility
ID317: Existence of emergency plan for health facility network*
network*
ID318: Health care plan in the event of a cyber attack ID318: Health care plan in the event of a cyber attack
Supplies and distribution networks Supplies and distribution networks
ID319: Capacity for coordinating and receiving foreign aid ID319: Capacity for coordinating and receiving of foreign aid
ID320: Storage capacity of PPE, pharmaceutical, and basic ID320: Storage capacity of PPE, pharmaceutical, and basic
medical supplies medical supplies
ID321: Ability to distribute PPE, pharmaceutical, and basic ID321: Ability to distribute PPE, pharmaceutical, and basic
medical supplies, in a timely manner* medical supplies in a timely manner*
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Table A.1.. Results for each indicator of the rapid assessment (left) and the deep dive assessment (right) (cont.)
Rapid assessment Deep dive assessment
Pillar 4. Integrated emergency response Pillar 4. Integrated emergency response
Codes, regulations, and laws Codes, regulations, and laws
ID401: Civil-military cooperation: military authorization in ID401: Civil-military cooperation: military authorization in
disasters and for the planning and utilization of military disasters and for the planning and utilization of military
resources* resources*
ID402: Existence of disaster aid agreements with geographically ID402: Existence of disaster aid agreements with geographically
proximate neighbors and international community* proximate neighbors and international community*
ID403: Availability of collaboration protocol between ID403: Availability of collaboration protocol between
governmental and nongovernmental entities (including Red governmental and nongovernmental entities (including Red
Cross, CSOs, private sector etc.) Cross, CSOs, private sector etc.)
Public communication and warning capacity Public communication and warning capacity
ID404: Adult literacy rate (as proxy for efficacy of written ID404: Adult literacy rate (as proxy for efficacy of written
messages for early warning systems and emergencies)* messages for early warning systems and emergencies)*
ID405: Mobile cellular subscriptions (as proxy for potential reach ID405: Mobile cellular subscriptions (as proxy for potential reach
of messaging for early warning systems and emergencies)* of messaging for early warning systems and emergencies)*
ID406: Internet access and usage (as proxy for potential reach of ID406: Internet access and usage (as proxy for potential reach
messaging for early warning systems and emergencies)* of messaging for early warning systems and emergencies)*
Physical assets Physical assets
ID407: Existence of local emergency operations centers ID407: Existence of local emergency operations centers
Financing and funding Financing and funding
ID408: funding for mitigation activities new ID408: funding for mitigation activities new
ID409: Funding for emergency drills and trainings for emergency ID409: Funding for emergency drills and trainings for
response emergency response
ID410: Funding for emergency response operations ID410: Funding for emergency response operations
ID411: Funding for recovery operations* ID411: Funding for recovery operations*
Information systems Information systems
ID412: Disaster detection systems for natural hazards ID412: Disaster detection systems for natural hazards
ID413: Protocols for information sharing during onset or early ID413: Protocols for information sharing during onset or early
detection between health and response networks detection between health and response networks
Personnel Personnel
ID414: Committee to plan and coordinate integrated response ID414: Committee to plan and coordinate integrated response
with health sector with health sector
ID415: Regular joint exercises between health-, emergency ID415: Regular joint exercises between health-, emergency
response-, and the private sector* response-, and the private sector*
ID416: Consistency of simulations, trainings, and exercises of ID416: Consistency of simulations, trainings, and exercises of
new new
health care, emergency response, and the private sector* health care, emergency response, and the private sector*
ID417: Protocols for mobilization and deployment of responders ID417: Protocols for mobilization and deployment of
and response equipment responders and response equipment
ID418: Mandate for local or regional emergency management ID418: Mandate for local or regional emergency management
coordinators coordinators
ID419: Existence of specialty units for structural or urban rescue ID419: Existence of specialty units for structural or urban rescue
ID420: Training for local emergency response units ID420: Training for local emergency response units
Plans and planning Plans and planning
ID421: National emergency response plan(s) ID421: National emergency response plan(s)
ID422: Existing health plans can be integrated into emergency ID422: Existing health plans can be integrated into emergency
response plans* response plans*
ID423: clearly defined and integrated roles of health care ID423: Clearly defined and integrated roles of health care
personnel in emergency response plans personnel in emergency response plans
ID424: Emergency plan(s) consider(s) vulnerable populations ID424: Emergency plan(s) consider(s) vulnerable populations
explicitly* explicitly*
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Table A.1.. Results for each indicator of the rapid assessment (left) and the deep dive assessment (right) (cont.)
Rapid assessment Deep dive assessment
Pillar 5. Lifeline infrastructure Pillar 5. Lifeline infrastructure
Codes, regulations, and laws Codes, regulations, and laws
ID501: Existence and enforcement of codes for roadway ID501: Existence and enforcement of codes for roadway
networks, especially major roadway networks (slope networks, especially major roadway networks (slope
stabilizations, quick recovery mechanism when damaged, stabilizations, quick recovery mechanism when damaged,
landslide monitoring etc.) landslide monitoring etc.)
ID502: Existence and enforcement of codes for railways (slope ID502: Existence and enforcement of codes for railways (slope
stabilizations, quick recovery mechanism when damaged, N/A stabilizations, quick recovery mechanism when damaged, N/A
landslide monitoring etc.) landslide monitoring etc.)
ID503: Design standards for water distribution network and ID503: Design standards for water distribution network and
wastewater treatment wastewater treatment
ID504: Regulation for water/wastewater plants to have backup ID504: Regulation for water/wastewater plants to have
generation backup generation*
Plans and planning Plans and planning
ID505: Plans that analyze natural hazards and cyber risks to ID505: Plans that analyze natural hazards and cyber risks to
water/wastewater network water/wastewater network*
ID506: Plans that analyze natural hazard risks to electrical
ID506: Plans that analyze natural hazard risks to electrical grid
grid
ID507: Plans that analyze natural hazard risks to transportation ID507: Plans that analyze natural hazards and cyber risks to
network transportation network
ID508: Life cycle asset management policy or plans for ID508: Life cycle asset management policy or plans for
infrastructure (including maintenance and replacement) infrastructure(including maintenance and replacement)
Personnel Personnel
ID509: Cybersecurity teams to protect infrastructure ID509: Cybersecurity teams to protect infrastructure*
Financing and funding Financing and funding
ID510: Government spending on infrastructure ID510: Government spending on infrastructure *
ID511: Operations and maintenance (O&M) spending on ID511: Operations and maintenance (O&M) spending on
infrastructure as a percentage of GDP (calculated by region) infrastructure as a percentage of GDP (calculated by region)
Physical assets Physical assets
ID512: Electrical generation plants are located in an area that ID512: Electrical generation plants are located in an area that
has not been identified as a high-hazard area, particularly has not been identified as a high-hazard area, particularly
related to climate changes (global data base indicator) related to climate changes (global data base indicator)
ID513: WEF report on quality of electric supply* ID513: WEF report on quality of electric supply*
ID514: WEF report on quality of roadways* ID514: WEF report on quality of roadways*
ID515: WEF report on quality of railways* N/A ID515: WEF report on quality of railways* N/A
ID516: WEF report on quality of airports* ID516: WEF report on quality of airports*
ID517: WEF report on quality of ports* ID517: WEF report on quality of ports*
Public health Public health
ID518: Proxy index for an independent air quality grade for ID518: Proxy index for an independent air quality grade for
countries* countries*
ID519: Population exposure to unsafe drinking water and unsafe ID519: Population exposure to unsafe drinking water and
sanitation (sewer)* unsafe sanitation (sewer)*
ID520: Proxy for urban health using population living in slums* ID520: Proxy for urban health using population living in slums*
ID521: Proxy for population health by looking at causes of death ID521: Proxy for population health by looking at causes of
by communicable diseases* death by communicable diseases*
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Table A.2.. Results for the five focus areas identified through the categorical scoring process
Organizational
Description Pillar
categories
Health facilities
Codes, regulations,
and laws
Flooding and damage in current storage location (in Belize City)
Storage and Information systems
Need for reliable supply of medical resources to hospitals and health facilities All
distribution Physical assets
Procurement difficulties highlighted by COVID-19 response
Supplies and
distribution
Many health facilities in Belize, including secondary referral hospitals, are at increased risk
to hazard impacts due to age, building materials used, and layout given the patient flow,
among other considerations Codes, regulations,
Steps to strengthen the resilience of health facilities have already been undertaken in and laws
Hospitals and cooperation with PAHO, specifically PAHO’s SMART (Safe + Green)6 health facility program Information systems
1, 2, 3
clinics
Assessments identified the Western health region in more acute need, given its capabilities Physical assets
and state facilities in light of population expansion in the region and exposure to natural
hazards
Need for health infrastructure maintenance, waste management, infectious disease control
Training and simulations
Codes, regulations,
General need for developing and implementing standard professional training that includes and laws
Standards and emergency and DRM training across hospitals and regions 1, 2, Plans and planning
training Focal points in each referral facility that are familiar with a common command system, such 3, 4
Personnel
as the Incident Command System
Simulations do not seem to be implemented consistently or regularly across the health Codes, regulations,
system and in collaboration with other partners, which can produce DRM capability levels and laws
Simulations The health system may benefit from an enhanced hospital evacuation study and exercise 3, 4 Plans and planning
that considers the combination of access issues from transportation networks and health
Personnel
facility vulnerabilities that could be updated via geographic information system (GIS)
analysis
Planning and allocation
Some plans focus on or consider exclusively the impact of flooding resulting from hurricanes
and not other types of flooding 2, 3, Plans and planning
Plans
Assessments and flood zones for hospitals (and major access roads) should be updated 4, 5
using the most current GIS information and developed around a set of minimum criteria
Plans and planning
Need for optimal resource allocation of healthcare personnel across all levels of care,
Allocation 1, 2, 3 Information systems
specifically for disaster response protocols
Personnel
ICT
Standard modes of communication (such as cell towers) rely on internet, which remain
vulnerable to natural hazard events Codes, regulations,
Although some facilities and regions have standard checks for secondary communication and laws
Communication devices, this is not standardized Information systems
3, 4, 5
Redundancies Telemedicine can help to maximize utility of scarce human resources at MoHW and can Public communication
reduce the impact of access issues in some circumstances and warning
MoHW increased telemedical capacity in response to COVID-19 but has since mostly
returned to in-person visits. No protocol has been established for future shocks
Lack of additional cyber protections at critical facilities makes these facilities more Information systems
Cybersecurity 2, 3, 5
vulnerable to attack Physical assets
For reference, see (PAHO 2017).
6
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Table A.2.. Results for the five focus areas identified through the categorical scoring process (cont.)
Organizational
Description Pillar
categories
Whole-of-government collaboration
Medical students from the country have difficulty securing residency seats abroad, and Belize
currently lacks an in-house training capacity for specialists
Workforce 3, 4, 5 Personnel
Belize has agreements with some countries, including Cuba, for several but not all medical
residencies
Approximately two-thirds of the country’s roadway network (secondary and tertiary) is
unpaved and often washes out during flooding, isolating residents, especially in northern and
southern areas, which are naturally more low-lying than the west. It can also have a secondary
Road and effect of preventing the establishment of public transportation systems. Physical assets
electricity Belize relies on electrical power supply from Mexico (energy sovereignty issue) and has several 3, 4, 5 Public health
infrastructure hydroelectric generation sources, which could shift power capacity and vulnerability due to
climate change
But as all of Belize’s major health facilities have backup electrical power, this is a lower-priority
issue
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Table A.3.. Potential future actions
Facilities: hospitals and clinics
Description MoHW may consider strengthening routine maintenance services along with supply of medical resources and waste
management. Facilities may need further upgrading and retrofitting in accordance with population demand and specific
patient flow models might increase efficiency at facilities.
Short-term Conduct a feasibility (human resources, financing for recurrent costs) and scoping study for potential upgrades to health
facilities or new investment of a tertiary referral hospital in the Western Region
Conduct scoping studies for improved patient flow to ensure optimal allocation of scarce resources, such as operating
theatres and medical staff
Conduct scoping study for waste management (specifically disposal of medical waste) and access to laboratory services for
improving service deliveries through the central medical laboratory, including a supply analysis of the national blood bank
Medium-term Depends on outcome of scoping studies
Continue existing efforts to retrofit facilities under the PAHO SMART health facility program
Long-term In case of severe exposure, it might be more cost-efficient to move facilities or build new ones in safe zones
Workshop Outcome The January 2023 Belmopan workshop identified facility resilience and maintenance as a strategic element of interest for
strengthening of the health sector and budget allocation
Training and simulations: standards and training
Description MoHW may benefit from developing and implementing baseline DRM standards and procedures across the ministry
Short-term Develop and implement a centralized emergency and DRM modules for healthcare officials and providers at hospitals and
primary health care on a national level. Make this course strongly recommended or mandatory for medical care and public
health committee
Include lessons learned from the COVID-19 pandemic response
Medium-term Enforce and update the DRM training in accordance with potentially changing hazard exposure patterns
Regularly update trainings and standards according to lessons learned
Long-term Continue the medium-term strategy
Workshop Outcome The January 2023 Belmopan workshop identified standardized DRM training for medical personnel as an area of key interest
for increasing disaster resilience in the health sector
Planning and allocation: plans
Description MoHW may consider updating the multi-hazard plan to include scenarios of high-frequency low impact hazards, such
as flooding from rain and landslides that may impact hospital functionality and access.
Short-term Adjust subnational and facility plans to include all types of flooding, not just from hurricanes. Identifying flood zones using
the latest data is a necessary first step for contingency planning and should include necessary infrastructure for access to
health facilities, to identify regions where access might be lost in case of a disaster.
Medium-term Update plans according to changing hazard risk exposures.
Long-term Update plans according to changing hazard risk exposures.
Workshop outcome The January 2023 Belmopan workshop identified the storage and distribution of medical supplies as a strategic element of
interest for rapid strengthening and budget allocation
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THE FRONTLINE SCORECARD An Assessment Tool for Climate and Disaster Risk Management in Health Systems
The Frontline Scorecard is a new country assessment tool that estimates the resilience of a
country’s health system to natural hazards and climate change. Introducing the scorecard
and presenting the results of its application in Belize, this report provides a detailed
explanation of how countries can use the scorecard as a systematic assessment tool to
identify focus areas for building more resilient health systems and for strengthening their
climate and disaster risk management capabilities.