Hospital Resilience in a Multi-Hazard Era: Water Security Planning in Northern Thailand

Abstract

Hospitals require continuous access to water to sustain essential health services, especially when resources are taxed when drought conditions are compounded with other public health emergencies. In mid-2020, we conducted a rapid assessment of 71 hospitals in northern Thailand to evaluate water use and resilience during the concurrent 2019–2020 drought and the early phase of the COVID-19 pandemic in Thailand. While most hospitals reported adequate water availability, many depended on short-term measures such as shallow wells and improvised storage. Water use per bed often exceeded international benchmarks, reflecting broader usage patterns that extend beyond potable consumption. Community hospitals, in particular, reported more limited backup supply and planning capacity. Drawing on both our findings and international guidance, we propose the Hazard Management Model, involving a set of recommendations to strengthen hospital water resilience, including hazard-specific planning, protected infrastructure, emergency storage, and improved efficiency. These insights contribute to the growing body of work on climate-adaptive healthcare, particularly in resource-constrained settings facing intensifying multi-hazard risks.

1. Introduction

1.1. Global Context

Hospitals and other healthcare facilities rely heavily on continuous access to clean, reliable water to support essential clinical and operational functions, particularly in times of crisis [1,2,3,4,5,6]. Interruptions in water supply—whether due to internal system failures or external hazards such as drought—can severely compromise vital healthcare functions and damage critical infrastructure, including fire suppression systems, water-cooled medical-gas compressors, radiology equipment, and HVAC units [7,8,9]. In drought-prone regions, such water shortages potentially coincide with other hazards—such as floods, earthquakes, landslides, tsunamis, extreme temperatures, or public health emergencies like the COVID-19 pandemic—resulting in increased patient loads, heightened water demand, and added strain on hospital resilience systems [8].

Globally, hospital water shortages linked to disasters are documented. A review of acute-onset disasters in the United States found frequent interruptions of hospital water supplies during hurricanes, earthquakes, volcanic eruptions, and floods [1]. One notable example occurred during the 1993 floods in the Midwestern United States, when inundation of the primary water treatment facility in Des Moines, Iowa, left six hospitals without water for nearly three weeks. In drought-prone regions, such disruptions can be equally severe [8].

In 2019, for example, during the drought in Chennai, India, private hospitals became entirely dependent on tanker deliveries, while smaller clinics faced a fourfold increase in water costs [10,11]. Similar challenges were reported in Manila, Philippines, where at least five public hospitals relied on emergency tanker deliveries until the arrival of monsoon rains [11]. In Australia, dialysis units raised concerns that extended dry spells could jeopardize their ability to meet the substantial water requirements for treatment—estimated at 3000 to 4000 L per patient per week [12].

Hospital water resilience involves not only ensuring sufficient water quantity but also safeguarding water quality and sanitation. In 2010, Kenya’s Kakamega Provincial District faced a severe water crisis during which the general hospital was forced to rely on bucket-collected supplies, often contaminated with harmful pathogens. This situation directly contributed to outbreaks of cholera and typhoid and was linked to an increase in maternal-care mortality rates. The case underscores the critical importance of maintaining both adequate water volumes and assured water quality in healthcare settings [13].

1.2. Thailand Context

Thailand, the setting of this study, is a rapidly developing nation with marked seasonal rainfall variability, which faces recurring threats to hospital water security from frequent dry spells, and occasional droughts. In January 2020, during a drought described as the most severe in four decades, nine hospitals in Surin and Chaiyaphum provinces reported critical water shortages due to historically low reservoir levels [14,15]. Although the Ministry of Public Health assured emergency water deliveries, hospitals were strongly urged to conserve existing supplies, implement contingency storage systems, and prepare for potential water quality risks [14]. This situation echoed earlier warnings from July 2019, when weak seasonal rains left facilities such as Surin Hospital—normally requiring 800 m³/day—with access to just 80 m³/day. The shortfall prompted urgent measures, including military-supported tanker deliveries, private donations, and emergency well drilling [16,17,18].

Similar drought-driven shortages have occurred during previous dry periods, such as in February 2016, when five hospitals in northern and northeastern Thailand reported water supply disruptions. These issues were attributed to high sediment loads and salinity levels that exceeded safety thresholds at major facilities, including Siriraj Hospital [19]. By March 2016, some hospitals were temporarily reliant on daily military-supported tanker deliveries until new wells could be installed. San Patong Hospital in the northern region, in particular, continued to experience shortages due to its dependence on an upstream water source within a heavily irrigated area. These recurring, reactive responses reveal a systemic gap in proactive planning and underscore the urgent need for resilient, multi-source water supply systems that can withstand both seasonal variability and long-term climate pressures.

Although much of the discourse on hospital preparedness focuses on physical infrastructure and logistics, emerging research shows that drought can directly affect public health [4,6,8]. For instance, in the western United States, droughts have been linked to elevated mortality among older adults [20], emphasizing the need to frame drought not only as an environmental issue but also as a public health threat.

To date, limited information exists on how hospitals in Thailand address water supply resilience in the face of recurrent dry spells—or indeed, any hazard. Climate change is expected to intensify both droughts and extreme rainfall events across the region [21]. In 2020, several parts of Thailand experienced a rapid transition from severe drought to localized flooding by August, underscoring the volatility of the hydroclimate and the urgent need for integrated, multi-hazard water management strategies. This sequence was particularly evident in the northeast and northern provinces such as Phrae, where below-normal rainfall persisted through July, followed by heavy rains and flooding in August and September driven by tropical storms [22].

Such abrupt hydroclimatic shifts exemplify the growing risk of sequential hazards occurring within a single season. Simultaneously, the COVID-19 pandemic illuminated the broader challenge of managing compound risks. Amid ongoing drought conditions, the pandemic—responsible for approximately 3300 confirmed cases in Thailand by 1 September 2020, including 41 in Chiang Mai [23]—highlighted the need to systematically evaluate hospital preparedness and resilience in the face of increasingly complex, multi-hazard scenarios.

1.3. Objectives

This study aims to assess the water security status and preparedness of hospitals in northern Thailand under conditions of drought and compound hazard stress. Specifically, we evaluated hospital water use patterns and identified supply vulnerabilities during the 2019–2020 drought, which coincided with the early phase of the COVID-19 pandemic. Through this rapid assessment, we sought to document institutional responses, planned adaptation measures, and critical gaps in water system resilience. Our broader objective is to inform water security planning by developing practical benchmarks and recommendations tailored to resource-constrained healthcare settings.

This study is guided by the following research questions:

• What are the typical patterns of water use in hospitals across northern Thailand, and how do they compare with international benchmarks?
• To what extent did hospitals experience water shortages during the 2019–2020 compound drought–pandemic period?
• What preparedness and adaptation strategies are needed to improve hospital water security and resilience?

These questions frame our analysis and support a set of policy-relevant recommendations for strengthening water security in healthcare systems. A key component of this effort involved identifying metrics to estimate how much emergency water reserve is needed to maintain essential operations during disruptions.

2. Background

2.1. Water Availability

Thailand’s water availability is shaped by its geography and seasonal climate dynamics. Located in tropical Southeast Asia, the country spans several Köppen–Geiger climate zones: tropical rainforest (Af), tropical monsoon (Am), and—predominantly—tropical savanna (Aw). The Aw zone, which dominates the northern region (Figure 1), is marked by a pronounced dry season and is particularly vulnerable to extended dry spells [24].

Rainfall follows a monsoonal cycle with three seasons: a hot, dry period (mid-February to mid-May), a wet monsoon season (mid-May to mid-October), and a cooler, drier season (mid-October to mid-February). While average annual rainfall is approximately 1700 mm, its distribution varies considerably across space and time. This variability is influenced by regional synoptic systems and large-scale climate phenomena, notably the El Niño–Southern Oscillation (ENSO), which tends to suppress rainfall during El Niño phases, and the Indian Ocean Dipole (IOD), which can either reinforce or counter ENSO effects. These interactions often lead to sharp transitions between drought and flood within a single year—as seen in 2020, when a severe drought was followed by localized flooding from tropical storms. Such volatility is especially pronounced in the Aw zones, underscoring the need for water management strategies that account for both intra- and inter-annual variability and compound hazard risks.

Despite receiving roughly 800 billion m³ of rainfall annually, Thailand experiences significant spatial and temporal mismatches in water availability. National water budget estimates indicate that only about one-quarter of rainfall becomes streamflow, with just over half of that (approximately 44 billion m³) classified as baseflow sustaining rivers during dry periods. The rest is quickly lost as runoff. Although total freshwater demand is estimated at 152 billion m³ per year—mainly for agriculture—only about 102 billion m³ is considered reliably accessible for use [24].

2.2. Drought and Flood Risk

Thailand’s precarious water balance is further strained by growing demand and limited storage capacity, particularly in drought-prone Aw regions. High water usage continues to stress reservoirs, resulting in persistent challenges maintaining adequate supply during dry periods [24]. Areas facing the greatest drought risk often coincide with densely populated, agriculturally intensive lowlands. Thus, vulnerability is driven not only by climatic variability but also by chronic inefficiencies in water resource management and allocation [25].

The World Resources Institute’s Aqueduct Project [26,27] ranks Thailand 45th globally for “medium-high” baseline water stress, defined as the ratio of total water withdrawals to renewable supply, accounting for upstream consumption and dam operations. Among 3011 global provinces analyzed, two in northern Thailand fall within the top decile for water stress: Lamphun (291st) and Lampang (309th). Other northern provinces also rank high: Chiang Mai (370), Phrae (596), Phayao (640), Chiang Rai (1016), Nan (1161), and Mae Hong Son (1417). These eight provinces form the geographic scope of this study.

Thailand also ranks 12th globally in flood risk, with an estimated 250,000 people exposed annually [26,27]. In northern Thailand, exposure is concentrated in floodplains along the Ping, Nan, Wang, and Yom rivers, while mountainous areas face localized flash flood hazards. Flooding is typically triggered by intense monsoonal rainfall and is often exacerbated by tropical storms [28]. During the study period, flood events linked to tropical cyclones were recorded throughout the study area [29].

2.3. Water Supply Management in Thailand

Municipal water supply systems in Thailand draw from a diverse set of sources, including large regional reservoirs, smaller district-scale reservoirs, deep groundwater wells (often managed at the district or village level), and private or institutional wells tapping multiple aquifer layers. In rural areas, shallow hand-dug wells or mixed-depth systems are also common. Drinking water is frequently obtained from commercial vendors who operate reverse osmosis (RO) systems using groundwater or surface water as input. However, untreated shallow groundwater is widely considered non-potable due to risks of chemical and microbial contamination—particularly fluoride and nitrate pollution, as documented in northern provinces like Chiang Mai and Lamphun [30].

Water distribution mechanisms in Thailand range from open irrigation canals to underground piped networks, with treatment levels varying significantly. Municipal systems may provide only basic filtration—such as sand or charcoal—while others employ more advanced treatment processes, including coagulation, clarification, filtration, and disinfection with chlorine, lime, or alum. However, in practice, smaller or decentralized systems frequently suffer from inconsistent treatment standards and aging infrastructure, particularly in peripheral or rural areas, where technical capacity and regulatory oversight may be limited [31].

Hospitals across Thailand are embedded within this patchwork of water systems. A survey of healthcare facilities in Bangkok revealed significant disparities in both source type and treatment protocols, with only 38% of hospitals maintaining access to high-quality municipal water and 23% depending on groundwater sources, some of which were unfiltered [31]. These disparities are magnified in northern and rural areas, where groundwater quality issues are more pronounced and public infrastructure is often underdeveloped.

As climate variability intensifies, these supply vulnerabilities pose growing risks to health service continuity. Droughts, floods, and system outages may compromise water availability, particularly in hospitals reliant on unregulated or decentralized sources. The absence of nationally enforced hospital water standards further exacerbates these challenges, forcing many facilities to adopt ad hoc strategies that may fall short of clinical needs during hazard events [32].

Recognizing these systemic limitations is essential for developing effective resilience strategies. For hospitals, resilience depends not just on source availability but also on water quality, infrastructure reliability, backup power and pumping systems, and governance mechanisms linking public health and water management. Improved coordination, standardized emergency protocols, and investment in climate-adaptive water technologies—such as decentralized treatment units and water reuse systems—are urgently needed across Thailand’s health sector.

2.4. Overview of the Thai Hospital System

Thailand’s healthcare system operates as a mixed public–private model with a pluralistic and entrepreneurial structure. The Ministry of Public Health [33] plays a central role in overseeing public healthcare delivery, managing an extensive network of government hospitals, district health systems, and primary care units throughout the country. Public hospitals continue to serve as the primary source of care for most Thai citizens, with service coverage extending to over 90% of subdistricts. These institutions operate under the Universal Health Coverage (UHC) framework established in 2002, which has significantly expanded healthcare access and financial protection nationwide.

Private hospitals, primarily located in major urban centers, are regulated by the Medical Registration Division of the MoPH [33] and cater to wealthier domestic populations and international patients seeking specialized or expedited services. While private facilities offer advanced care options, they constitute a smaller portion of the national healthcare infrastructure [34].

As of 2018, the Office of the Permanent Secretary of the MoPH reported 895 public hospitals, categorized into three tiers [33]: 34 regional hospitals (≥500 beds), 85 general hospitals (200–500 beds), and 776 community hospitals (typically 10–150 beds). Community hospitals form the majority and function as primary care and referral nodes within district health systems. Their capabilities range widely, with larger facilities offering surgical and inpatient services, while smaller ones provide outpatient and preventive care [35].

Thailand’s 77 provinces are organized into 12 health service regions, each serving a population of 3 to 6 million. This study focuses on two upper northern regions: (1) Chiang Mai, Lamphun, Lampang, and Mae Hong Son; and (2) Chiang Rai, Nan, Phayao, and Phrae. These provinces participate in integrated public health networks and referral systems, including condition-specific coordination centers such as the Chiang Mai University Craniofacial (CMU CF) Center.

3. Materials and Methods

3.1. Data Collection

In July 2020, operational and water-use data were solicited from hospitals across eight northern provinces of Thailand: Chiang Mai, Chiang Rai, Lampang, Lamphun, Mae Hong Son, Nan, Phayao, and Phrae. These provinces fall within Thailand’s Upper Northern Health District, part of the national regionalized health system. Data were collected through administrative channels and included information on facility capacity, patient volume, water consumption patterns, supply sources, and operational challenges under both normal and drought conditions (see Appendix A). Hospitals were also asked to report any impacts on water use related to the COVID-19 pandemic, offering additional context on concurrent system-level stressors.

This study did not involve human participants, personal data, or identifiable information. All information was provided by hospital administrators in response to a formal request from the Regional Hospital Director’s Office, as part of routine administrative duties. Data were aggregated at the institutional level and concerned only operational aspects of hospital functioning. To ensure confidentiality, hospital names were anonymized during data handling and analysis. As no individual patient, staff, or interview data were collected, informed consent and ethical review were not required by the author-affiliated institutions, and Institutional Review Board (IRB) approval was not necessary.

3.2. Response

Of the 124 hospitals contacted, 71 provided responses, yielding a response rate of approximately 57%. The highest number of responses came from Chiang Rai (15 of 23) and Chiang Mai (15;32), followed by Lampang (11;18), Nan (11;16), Mae Hong Son (6;8), Phayao (5;8), Lamphun (5;10), and Phrae (4;9).

The majority of respondents (58 hospitals) were community facilities located in rural districts. In addition, four were general hospitals and five were specialty hospitals. Across all hospitals, the number of beds ranged from 10 to 1400, with a median of 40. Community hospitals reported the smallest bed counts—median 30 [range: 10–130]—while the specialty hospitals ranged from 15 to 1400 beds (median: 99). The four general hospitals reported the highest bed counts, with a median of 425 (range: 120–5020). This variation allowed for stratified analysis by hospital size, although not by hospital type due to limited numbers in some categories.

Because the sample was dominated by small community hospitals—reflecting both the healthcare system’s structure and the moderate response rate—findings may be biased toward lower-resource settings. Larger, urban institutions were underrepresented. Notably, 4 of the 71 hospitals reported having only one to three beds; these were excluded from water use analyses due to concerns about representativeness and the potential to skew results. Water use analyses were thus conducted on 67 hospitals, while all other analyses include the full sample of 71 hospitals.

4. Findings

4.1. Hospitals Reporting COVID-19 Activity

Of the 71 hospitals included in the analysis, the majority (n = 54) had been officially designated as screening sites for COVID-19. At the time of the survey, 46 hospitals had managed at least one patient under investigation (PUI) for the virus. Furthermore, 59 hospitals reported having the capacity to admit confirmed COVID-19 patients, reflecting a relatively broad level of regional preparedness for isolation and treatment—despite the low overall case burden during the early phase of the pandemic. As of 1 September 2020, a total of 67 confirmed COVID-19 cases and 6415 PUIs had been recorded across the eight northern provinces. Chiang Mai, the region’s most populous province, reported the highest number of confirmed cases (n = 41), followed by Chiang Rai (9), Mae Hong Son (5), Lampang (4), and Lamphun (4). Phayao recorded three cases, Phrae recorded one case, and Nan Province reported no confirmed cases during this period. While these numbers do not suggest a major epidemiological burden, some hospital responses indicated that the pandemic introduced notable strain on staffing, infrastructure, and water resource management.

4.2. Water Use Patterns

Reported weekly water usage across the 67 hospitals varied substantially, ranging from 69 m³ to 14,960 m³ (

Table 1. Weekly water use (m³).

	Median	Min	Max	IQR
All Hospitals (67)	460	69	14,959	306–777
Community Hospitals (58)	414	69	2992	269–621
General Hospitals (4)	2301	921	3797	1093–3538
Specialty Hospitals (5)	1202	312	14,959	513–5341

Values in parentheses are number of hospitals; IQR is the interquartile range. Four hospitals with 1–3 beds are excluded from this analysis. Weekly values were determined from reported monthly values.

). Medians ranged from 414 to 2301 m³ (Table 1). Extreme values in the table should be interpreted with caution due to inconsistencies in reporting—including uncertainty whether the volumes represent consumption, in-hospital use, or include broader facility demands like garden irrigation. With this issue in mind, the interquartile range (IQR) likely provides the most reliable estimate of range of typical usage.

The IQR for all hospitals was 306 to 777 m³ per month (Table 1). This IQR range is similar to that of community hospitals (269–621 m³), which dominated the dataset (58 of 67 hospitals). In contrast, the ranges for general hospitals (1093–3538 m³) and specialty hospitals (513–5341 m³) were much larger with higher maximums (Table 1). Specialty hospitals include regional hospitals, medical centers, and medical school hospitals—often having advanced services. Notably, the highest reported usage came from the largest facility, which has 1400 beds.

In

Table 2. Weekly water use per bed (m³/bed/week).

	Median	Min	Max	IQR
All Hospitals (67)	9.2	2.6	28.8	6.9–12.1
Community Hospitals (58)	9.2	3.5	28.8	6.9–12.4
General Hospitals (4)	7.3	2.6	9.6	5.8–8.1
Specialty Hospitals (5)	10.6	5.3	20.8	9.2–15.2

Values in parentheses are number of hospitals; IQR is the interquartile range. Four hospitals with 1–3 beds are excluded from this analysis. Weekly values were determined from reported monthly values.

, weekly water use is determined based on the number of beds. Median weekly water use per bed ranged from 7.3 to 10.6 m³/bed/week. Specialty hospitals reported slightly higher water usages (10.6 m³/bed/week) than community hospitals (9.2 m³/bed/week) and general hospitals (7.3 m³/bed/week). The interquartile range (IQR) for all hospitals was 6.9–12.1 m³/bed/week, which matches the IQR for community hospitals—again, that dominates the dataset. This range is slightly narrower than that observed for specialty hospitals and broader than that for general hospitals.

When compared to international studies, weekly water use per bed in northern Thai hospitals generally exceeds values reported elsewhere (

Table 3. Comparison of water use in a variety of hospitals worldwide.

Country	Hospital Count	Bed ** Number	Water Use ** (m3/Bed/Week)	Study Focus	Hospital Type
Thailand *	67	34 (10–1400)	9.6 (2.6–28.8)	Total water usage	Various
Germany [37]	19	396 (45–1003)	2.7 (2.2–4.3)	Water consumption	Various
Germany [38]	64	NA	2.8 (1.0–4.8)	Water consumption	Unknown
Germany [39]	1	1709	5.7	Water consumption	University
India [40]	1	183	7.8	Filtered water use	Cancer
Italy [41]	36	383	8.8	Water use	Public
Mauritius [42]	1	435	4.5	Water audit	Unknown
Portugal [43]	1	776	8.3	Water consumption	Regional
Spain [44]	20	39 (193–1075)	4.1. (1.2–7.6)	Water consumption	Mixed
Spain [45]	13	~30–500	5.0	Water consumption	Unknown
Spain [46]	14	20–194	2.2	Water consumption	Private
Turkey [47]	13	169 (5–810)	3.7	Total water usage	Public

* Thailand is this study. ** Values for bed number and water use are medians and ranges, which we derived from reported data. Singular values are derived from summary values reported in the corresponding study.

) [36,37,38,39,40,41,42,43,44,45,46,47]. While consumption levels in countries such as Italy (8.8 m³/bed/week), India (7.8 m³/bed/week), and Portugal (8.3 m³/bed/week) are broadly consistent with values observed in this study [40,41,43], they still fall at the lower end of the interquartile range (7–13 m³/bed/week) found across northern Thai hospitals (Table 3).

Notably, many lower-consuming hospitals—such as those in Germany (2.7–2.8 m³/bed/week), Spain (2.2–5.0 m³/bed/week), and Mauritius (4.5 m³/bed/week)—fall outside the IQR for the northern Thailand study (Table 3). We believe our elevated water use volumes are partly attributable to the scope of the data reported, total water usage versus various types of consumption (potable, filtered, and treated). We also are unsure at times if our respondents used the terms interchangeably.

Finally, the best-fit regression curve relating water use to the number of beds (Figure 2) closely aligns with the interquartile range (IQR) values presented in Table 2, indicating that a water reserve of approximately 9 to 12 m³ per bed per week may be appropriate. The observed spread in the data reflects both facility-level variability and inherent uncertainty in the estimate. These values should be treated as indicative benchmarks and validated through detailed audits at individual hospitals. Although relatively high compared with the studies summarized in Table 3, similar benchmarks are used in countries such as the USA and Canada, where recommendations reach up to 12 m³/bed/week for hospital water supplies [48,49].

4.3. Water Sufficiency, Quality, and Planning

A large majority of hospitals (n = 61 of 71, 86%) reported having sufficient water supplies under both normal and dry-season conditions. Ten hospitals (14%) indicated difficulties maintaining supply during the dry season. This figure is comparable to findings in Sri Lanka, where 19% of the hospitals reported insufficient drinking water and 14% lacked adequate water for other uses [8].

Water sourcing patterns also varied. A total of 58 hospitals had access to their own water sources, with 46 of these fully self-reliant. Among them, 37 relied on local wells, while others used small reservoirs. Twelve hospitals supplemented their supply from external systems—eleven from the district and one from the local community—while thirteen relied entirely on district-level supply.

Water quality issues were infrequently reported, with only five hospitals indicating problems in the past year. However, just 24 hospitals (34%) had infrastructure in place to recycle greywater for non-potable uses such as gardening or maintenance, highlighting a key opportunity to enhance water-use sustainability.

Regarding adjustments in water management practices during the combined pressures of drought and the COVID-19 pandemic, 17 hospitals (24%) reported implementing additional measures, such as expanding storage, increasing monitoring, or altering usage protocols. The remaining 54 hospitals (76%) reported no changes to their normal water management routines.

Drought was commonly perceived as a threat, with 39 hospitals (55%) reporting some negative impact during drought events. In contrast, only six hospitals cited water supply challenges directly linked to the COVID-19 pandemic, suggesting that the pandemic likely did not inflate the elevated water use figures reported. Nonetheless, 21 hospitals indicated that they had modified their water management plans in response to COVID-19, reflecting a limited degree of adaptive planning for multi-hazard scenarios (

Table 4. Planned actions by hospitals to address potential water shortages.

n	Planned Action
20	Build a water reserve system (tanks or reservoir) *
15	Drill a well
5	Connect to Provincial Water Authority system
3	Request a water vehicle from the municipality
2	Connect with municipal water supply system
2	Request raw water from the municipality (e.g., via tank truck)
1	Drill a well and connect with the Provincial Water Authority system
1	Drill a well and request a water truck from the municipality
1	Build a water reserve system and request a water truck from the municipality *
1	Build a rainwater collection system

n is the number of different hospitals indicating a particular action. The “*” signifies that some of the responses were potentially linked to the COVID-19 pandemic (based on individual responses).

). While overall crisis preparedness appeared adequate, it is important to note that the number of COVID-19 cases in northern Thailand at the time of the survey was relatively low compared to other countries.

Looking ahead, 51 hospitals (72%) reported having plans to improve water security in the future (Table 4). The most common strategies included constructing new storage infrastructure—either tanks or small reservoirs (n = 20)—and drilling additional wells (n = 15). Other strategies included connecting to external supply systems and developing on-site resources. One hospital reported intentions of designing a rainwater harvesting system for non-clinical use. Notably, the existence of a plan does not guarantee the availability of funding or institutional capacity for implementation—these issues may be a reason for infrastructure differences among the hospitals surveyed.

5. Discussion

5.1. Efficiency, Strategic Planning, and Risk Reduction

Despite widespread recognition of the importance of hospital-level preparedness, systemic governance and funding constraints may hinder the implementation of effective water resilience measures—particularly in multi-hazard contexts. Institutional barriers commonly include fragmented responsibilities between health and water agencies, the absence of standardized protocols, and limited financial autonomy—especially among smaller community hospitals with fewer administrative resources [4,50,51,52]. The limited and inconsistent responses to our survey reinforce these concerns, highlighting variability in preparedness approaches and the lack of shared operational standards across facilities in the region.

Building on these findings, it is clear that institutional and governance-related factors constrain efforts to improve hospital water resilience. Decentralized management structures, inconsistent local government support, and restricted budgeting autonomy limit the ability of hospitals—particularly smaller community facilities—to implement proactive measures such as emergency storage or well installation [3,4,6]. Broader systemic challenges, including poor coordination between sectors, legal ambiguity, and chronic underfunding, have been documented across diverse national contexts. Even high-income countries often lack clear contingency protocols and operational standards for emergency water supply. In addition, structural and cultural constraints—such as rigid hierarchies, weak staff engagement, short-term governance cycles, and the marginalization of water planning—further hinder innovation and sustained preparedness [50,51,52]. These interlocking constraints typically must be addressed through integrated planning and institutional reform to ensure reliable water access in times of crisis.

An illustration of these institutional and operational challenges comes from Cape Town, South Africa, where hospitals were severely affected during the 2018 drought. A recent study found that provincial emergency response plans were too generic to ensure continuity of care at the facility level [53]. In response, they developed a hospital-specific, six-step water risk management framework for Somerset Hospital, incorporating ISO 31000:2009 guidelines, infrastructure audits, and business impact analysis to identify and prioritize essential services [53]. This case highlights the value of devolving resilience planning to the facility level and demonstrates how tailored, site-specific strategies can help bridge the gap between broad policy frameworks and operational preparedness in multi-hazard contexts.

Our survey indicates that water use in most northern Thai hospitals exceeds the volumes reported in several other hospital water-use studies (Table 3). Although “water use” and “water consumption” are not strictly synonymous, the elevated values underscore the need to improve water-use efficiency—particularly given the region’s vulnerability to recurring dry spells. Hospital water demand is influenced by multiple factors, including patient volume, facility size, infrastructure age, service complexity, and dependence on water-intensive systems such as sterilization units, autoclaves, HVAC, sanitation, diagnostic imaging, laundry, and food services [36,40,54,55].

Breakdowns of hospital water use vary across contexts but show consistent patterns across key operational domains. For example, a detailed assessment at a cancer hospital in India reported that water was used primarily for HVAC systems (36%), toilet flushing (24%), handwashing (18%), showering (6%), hot water (5%), central sterilization (4%), housekeeping (4%), kitchen (2%), and drinking (1%) [40]. These patterns align with broader reviews of healthcare facilities, which consistently identify HVAC systems, sanitation, laundry, kitchens, and medical equipment as major water-consuming functions [36]. A literature review of healthcare water management strategies further noted that cooling towers alone can account for up to 30–40% of a facility’s water use, with additional significant demand from sterilizers, dialysis systems, and other water-intensive equipment [55].

Improving efficiency in these areas is critical not only to reduce operational demand but also to strengthen resilience in water-scarce or hazard-prone settings. As emphasized in multiple national guidelines, including those cited in the Sri Lanka review, routine water audits, sub-metering, and preventive maintenance are key strategies for identifying inefficiencies and promoting conservation [55]. Reducing unnecessary water use lowers costs and enhances hospital preparedness for droughts and infrastructure disruptions.

5.2. Hazard Management Team Model

A valuable resource for emergency preparedness is the Emergency Water Supply Planning Guide for Hospitals and Health Care Facilities [56]. The guide advocates for the formation of a multidisciplinary emergency water supply planning team. Drawing on that resource, we propose a Hazard Management Model as a guide for better water use management in hospitals (

Table 5. Hazard Management Model.

A. Governance and Planning

Establish a multi-actor Hazard Management Team (HMT) to oversee water preparedness and coordination.

Develop a Hazard Management Plan (HMP) that integrates water and multi-hazard risk management.

Convene the HMT regularly, especially before the flood and drought seasons.

Assign a dedicated water systems manager to oversee maintenance and coordination.

Conduct hazard mapping to assess facility exposure to plausible risks.

Provide regular training and simulation exercises for staff on water management and emergency protocols.

B. Infrastructure and Systems

Ensure access to a reliable primary water source (e.g., borewell or on-site reservoir).

Establish backup supply agreements with district water providers or local partners.

Create an emergency water reserve based on calculated demand (see Table 2).

Install a backup power supply to operate water systems during outages.

Protect critical infrastructure (e.g., tanks, pumps) from flood exposure and contamination.

Install on-site potable water systems (e.g., reverse osmosis, other) where feasible.

Incorporate rainwater harvesting and greywater reuse for non-potable use.

C. Data and Monitoring

Develop water-use budgets by collecting disaggregated, activity-specific data.

Conduct periodic water audits to identify inefficiencies and track improvements.

Update preparedness plans based on audit findings and evolving climate risks.

D. Operational Preparedness

Plan for increased demand during prolonged or cascading crises.

Avoid reactive, last-minute strategies by proactively implementing risk-reduction measures.

Establish communication protocols with local authorities and communities for coordinated responses.

).

The HMT should include both internal and external stakeholders [57]. Internal members typically represent departments such as facilities management, administration, infection control, clinical services, environmental services, and security. External stakeholders may include representatives from public water utilities, drinking water agencies, local health and fire departments, and critical governmental or infrastructure partners—such as the Royal Irrigation Department, the Provincial Waterworks Authority, or the military in the context of Thailand.

The HMT should be responsible for developing and maintaining the water component of the hospital’s disaster protocol, auditing water use, identifying emergency water supply alternatives, and conducting routine training to ensure preparedness. Crucially, this process should be iterative, data-informed, and grounded in principles of efficiency and resilience—addressing both anticipated and unforeseen hazards.

Drought and dry spells—though often overlooked—must be formally integrated into hospital risk assessments, as their exclusion can jeopardize the continuity of essential services [8]. Building on this insight, and drawing from recent studies [50,51,54] as well as our findings from 71 hospitals in northern Thailand, the proposed set of recommendations in the model (Table 5) are intended to strengthen hospital water resilience—particularly in settings where access is already limited or prone to disruption. These recommendations aim to support hospitals in developing comprehensive, proactive, and context-sensitive water management strategies.

Before specific resilience measures can be implemented, it is important to classify hospital utilities—such as water systems—based on their criticality and exposure to hazard risks [58]. This step is foundational for effective water security planning and the development of targeted, risk-informed preparedness frameworks. Although nearly one-quarter of surveyed hospitals reported implementing additional water management actions during the concurrent drought and COVID-19 emergency, most did not. This limited response likely reflects deeper structural constraints, including institutional rigidity, funding limitations, and the absence of integrated planning frameworks capable of addressing compound hazard scenarios [4,6,8,51,59].

5.3. Sustainability Issues

Beyond general efficiency improvements, addressing water sufficiency under multi-hazard stress reflects a broader sustainability imperative. At least one of the surveyed hospitals expressed interest in greywater reuse systems—a promising yet underutilized strategy in healthcare infrastructure. Hospitals generate substantial volumes of lightly contaminated water from sinks, showers, and laundry, which can be repurposed for non-potable uses such as toilet flushing, cooling systems, or landscape irrigation [60,61]. When properly designed and managed, greywater reuse can significantly reduce freshwater demand, lower operational costs, and support broader goals of sustainability and climate adaptation [62,63].

Greywater reuse systems also align with the growing push toward climate-resilient health facilities, as emphasized in WHO frameworks that identify sustainable water and sanitation services as core pillars of health system resilience [64]. Their adoption can also support compliance with green building standards and sustainability certifications [65,66].

However, translating these ideals into practice presents significant challenges—particularly in resource-constrained settings. Common barriers include water quality concerns, regulatory uncertainty, and the lack of dedicated infrastructure for greywater separation and treatment [67]. In hospital environments, where hygiene and patient safety are paramount, the tolerance for risk is exceptionally low. Meeting safety standards typically requires advanced treatment systems and continuous monitoring, making such initiatives both technically complex and financially demanding.

Institutional and organizational limitations are equally critical. Many hospitals lack dedicated water management personnel, and decisions about infrastructure upgrades often fall outside local administrative control or rely on centralized budget allocations. Even when technical capacity is available, low prioritization of environmental sustainability in day-to-day hospital operations can stall progress [67,68].

Thus, while greywater reuse holds considerable promise for enhancing hospital water security and sustainability, its implementation must be tailored to the operational realities of each facility. Bridging the gap between vision and practice will require demonstration projects, clear regulatory frameworks, and accessible technical guidance. Without addressing practical constraints—such as funding limitations, staffing shortages, and limited institutional autonomy—these systems risk remaining aspirational rather than actionable. Moreover, water reuse initiatives are most effective when integrated into broader facility planning and maintenance frameworks—alongside leak detection, usage monitoring, and staff engagement—rather than treated as standalone sustainability measures [69].

5.4. Limitations

This study began as a rapid assessment of the combined impacts of drought and the COVID-19 pandemic on hospital water supplies in northern Thailand. The survey was intentionally designed to be simple and time-efficient, enabling hospital staff—already under pressure during this multi-hazard period—to respond quickly (Appendix A). Only after analyzing the results alongside emerging literature did we recognize the broader comparative value of the findings, particularly given the scarcity of published work on this topic at the time. Since then, global attention to hospital water sustainability has grown, contributing to a more nuanced and evolving body of literature.

As with any survey-based research, several limitations must be acknowledged. All responses were self-reported by hospital staff or administrators, introducing the potential for estimation errors, incomplete records, and reporting bias. Water use figures were not independently verified, and disaggregated data by department or activity were unavailable. Moreover, the survey captured a single time point during an ongoing drought and the early phase of the COVID-19 pandemic, limiting its ability to reflect seasonal variability or long-term trends. Of the 124 hospitals contacted, only 71 responded, raising the possibility of non-response bias if non-responding institutions systematically differ in water use practices, infrastructure, or preparedness.

Given the rapid nature of the assessment, we did not develop formal hypotheses, conduct site visits, or perform in-depth interviews—approaches that would likely have yielded richer, more contextualized insights. Additional information on infrastructure governance, institutional decision-making, and funding mechanisms would also have helped explain variation in preparedness across facilities. Appendix B outlines supplemental data categories that could improve future assessments of hospital water resilience.

Our sample was dominated by small- and medium-sized public hospitals, with limited representation from larger urban or private institutions. This underrepresentation may obscure important differences in infrastructure capacity, management practices, and water demands, potentially leading to an underestimation of total regional use. Many private hospitals, particularly in urban centers, follow distinct operational models and contribute substantially to healthcare-related water consumption. Their absence limits the generalizability of our findings and may overlook alternative strategies employed within the broader healthcare system. Furthermore, while the study spans eight provinces, the results may not be transferable to regions with different hydrological or institutional contexts.

Despite these constraints, the dataset offers important insights into hospital water resilience under compound stress and highlights key areas for policy attention, investment, and future research.

6. Conclusions

This study provides a snapshot of how hospitals in northern Thailand navigated water-related challenges during the concurrent 2019–2020 drought and early phase of the COVID-19 pandemic. While most hospitals reported having sufficient water at the time of the survey, many depended on short-term measures—such as emergency deliveries and improvised storage—rather than making long-term infrastructure upgrades. These findings underscore the distinction between immediate coping capacity and deeper systemic resilience.

Water use volumes in northern Thai hospitals appeared higher than those reported in several international studies. However, these comparisons should be interpreted cautiously, as our estimates reflect total water use—including clinical operations, support services, facility-wide systems, and external uses—rather than strictly defined consumption metrics. Additionally, the self-reported nature of the data, the simplified survey design, and a low response rate of 57% (71 of 124 hospitals) introduce uncertainty and the potential for non-response bias.

Despite these limitations, this study contributes to a growing body of work on hospital water use and resilience, particularly in the context of multi-hazard scenarios where drought can severely tax water supply systems. The dataset highlights key areas for further research to improve the understanding of water demand patterns, planning capacity, and infrastructure performance in healthcare settings. Future studies incorporating field verification, longitudinal tracking, and broader institutional representation—including more private hospitals—would enable more comprehensive assessments. As water-related stressors and compound hazards intensify globally, strengthening the monitoring and management of hospital water use will be essential for climate-resilient and hazard-ready health systems.