Pan American Health Organization · 1st edition, 2023 · 38 pages
A systematic methodology for health facilities to identify, assess and prioritize multi-hazard risks as the foundation for emergency preparedness planning.
- Issuer
- Pan American Health Organization
- Edition
- 1st edition, 2023
- Audience
- Health facility personnel responsible for management, planning, response coordination, and incident command; facility governing bodies; disaster risk management committees
- Evidence
- Expert consensus methodology adapted from WHO STAR toolkit
- Reviewed
- 17 Oct 2026 · GMJ
What this guideline says
GMJ summary
STAR-H is a comprehensive risk assessment toolkit developed by PAHO to help health facilities systematically evaluate their exposure to both external hazards (earthquakes, floods, pandemics) and internal hazards (fires, infrastructure failures, violence, cybersecurity breaches). The methodology uses a quasi-quantitative approach combining likelihood of occurrence with impact severity, vulnerability, and coping capacity to generate prioritized risk scores for strategic planning.
The tool is designed for facilities of any size and produces automated reports that classify risks as very low, low, moderate, high, or very high. Results feed directly into Emergency and Disaster Response Plans (EDRP-H) and complement the Hospital Safety Index (HSI) by providing hazard-specific risk analysis that the HSI does not offer. The methodology follows a seven-step cycle from hazard classification through impact determination to generation of management recommendations.
STAR-H emphasizes a multi-hazard approach that allows facilities to develop response frameworks applicable to any type of hazard, regardless of scale or frequency, while establishing clear roles and responsibilities. The tool stores historical data to enable national or subnational risk profiling when applied systematically across target facilities.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Risk level determined by formula: Risk = likelihood × [(severity + vulnerability + coping capacity)/3], scored on 1–25 scale with five risk categories
- Likelihood scored 1–5: very unlikely (<5% in 12 months) to almost certain (≥95% in 12 months), based on historical occurrence patterns
- Impact severity assessed across three dimensions: occupants' lives, facility damage, and operational disruption (each scored 1–5)
- Operational disruption classified from minor (≤4 hours) to critical (≥2 weeks or irreparable loss of function)
- Vulnerability scored 1–3 (high/medium/low) based on structural, nonstructural, and administrative elements; HSI score <0.36 = high vulnerability, 0.37–0.65 = medium, >0.66 = low
- Coping capacity inversely weighted: high (all required capacities available/sustainable) = 1, medium (some available, not tested) = 2, low (mostly unavailable) = 3
- External hazards include geophysical (earthquakes, tsunamis), hydro-meteorological (floods, storms), biological (COVID-19, measles, antimicrobial resistance), technological (chemical spills, structural collapse), and societal (violence, armed conflict)
- Internal hazards include healthcare-associated infections, infrastructure disruptions (power outage, oxygen supply failure), fire, cybersecurity attacks, occupational injuries, and labour disputes
Scale for determining the risk level in STAR-H
Table extracted from the guideline
| Level of Risk | Risk Score (Likelihood × Impact) |
|---|---|
| Very low | 1 to 3 |
| Low | 4 to 6 |
| Moderate | 7 to 11 |
| High | 12 to 16 |
| Very high | 17 to 25 |
Source: Pan American Health Organization, STAR-H: Strategic Toolkit for Assessing Risks in Health Facilities. Reproduced in summary form.
From the guideline
Verbatim
“Health facilities must be prepared to respond well to such disasters. An effective disaster risk management program in a health facility saves lives, reduces damages, and ensures continuity of service.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As a WHO consultant who has witnessed the impact of the 2002 Spitak earthquake legacy on Armenian hospitals and Georgia's own seismic vulnerabilities, I recognize STAR-H as an essential planning tool for our region. The methodology's multi-hazard approach is particularly valuable for Georgian health facilities that must prepare simultaneously for earthquakes, floods in low-lying areas like western Georgia, and biological threats demonstrated by COVID-19. I would stress to Georgian colleagues the importance of the vulnerability assessment component—many of our facilities inherited Soviet-era infrastructure that scores poorly on nonstructural safety (medical equipment anchoring, utility system resilience) even when structural retrofitting has occurred. The practical caveat is that effective implementation requires genuine multidisciplinary teams including structural engineers and infection control specialists, not just administrative designation of a committee; half-measures in the assessment phase will produce unreliable risk prioritization that undermines the entire planning process. The tool's capacity to generate subnational risk profiles could support Georgia's Ministry of Health in evidence-based resource allocation across the hospital network, but this requires standardized implementation with proper training, which the document correctly identifies as a prerequisite for all assessment team members.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 17 Oct 2026
Applicability
Georgia and the South Caucasus
For Georgia and the South Caucasus, STAR-H addresses critical vulnerabilities in a region exposed to seismic hazards (Georgia lies on active fault lines), seasonal flooding, and increasingly frequent extreme weather events due to climate change. The methodology is particularly relevant given the need to strengthen health facility resilience in countries where many hospitals were built during the Soviet era without modern seismic standards. The tool’s emphasis on internal hazards—including infrastructure failures, cybersecurity threats, and healthcare-associated infections—aligns with challenges facing Georgian health facilities as they modernize under the Universal Health Coverage programme. National health authorities would need to integrate STAR-H findings with existing emergency preparedness frameworks and ensure multidisciplinary assessment teams include structural engineers, infection control specialists, and risk managers. The Excel-based tool’s compatibility with limited-resource settings and its capacity to generate subnational risk profiles make it suitable for systematic implementation across Georgia’s network of public and private health facilities.
Questions this guideline answers
Quick answers
How does STAR-H differ from the Hospital Safety Index?
STAR-H analyzes and prioritizes specific hazards that the HSI identifies but does not assess. While HSI evaluates structural, nonstructural, and functional vulnerabilities to determine overall facility safety (scored 0–1), STAR-H conducts hazard-specific risk assessment using likelihood, impact, vulnerability, and coping capacity to generate prioritized risk scores (1–25). The two tools are complementary: HSI vulnerability scores can inform STAR-H vulnerability ratings, and STAR-H results guide strategic planning to address the specific hazards identified during HSI assessment.
Who should conduct the STAR-H assessment?
An interdisciplinary committee with decision-making authority, disaster risk management experience, and planning responsibilities should conduct the assessment. The team must include professionals whose profiles contribute to risk assessment (structural engineers for structural vulnerability, infection control specialists for biological hazards, IT specialists for cybersecurity, etc.). All committee members must complete online risk assessment training before implementation. The facility's governing body should coordinate activities as part of a continuous improvement process.
How is the 12-month likelihood of hazards determined?
Likelihood is scored 1–5 based on historical occurrence patterns: very unlikely (1) = <5% probability, occurred ≤1 time in 20 years; unlikely (2) = 5–29%, occurred 1–3 times in 20 years; likely (3) = 30–69%, occurred 2–3 times in 10 years or 1–2 times in 5 years; very likely (4) = 70–94%, occurs every 2–3 years or twice in 5 years; almost certain (5) = ≥95%, occurred ≥3 times in 5 years or ≥5 times in 10 years. Assessors should consult local information sources, national risk management and climate reporting institutions, and collaborate with technical government agencies and scientific institutions rather than rely solely on their own experience.
When should STAR-H assessment be updated?
Ideally at the beginning of the disaster risk management cycle to inform preparedness planning, but it can be conducted at any stage, including during an emergency. The methodology should be part of continuous improvement, with assessments updated when new hazards emerge, after significant events that test facility response, when major infrastructure changes occur, during EDRP-H review cycles, or when vulnerability or coping capacity substantially changes. The tool stores historical data to enable tracking of risk profiles over time.
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- Issuer
- Pan American Health Organization
- Type
- Procedures, manuals, guidelines
- Edition
- 1st edition, 2023
- Status
- Current
- Published
- 2023-01-01
- Languages
- English, Spanish
- Scope
- Health facilities of any size and capacity in the Americas and globally
- Audience
- Health facility personnel responsible for management, planning, response coordination, and incident command; facility governing bodies; disaster risk management committees
- Pages
- 38
- Licence
- CC BY-NC-SA 3.0 IGO
- ISBN
- 978-92-75-12558-8 (PDF)
- Evidence
- Expert consensus methodology adapted from WHO STAR toolkit
- Record history
- Created 17 Oct 2026 · updated 17 Oct 2026 · next check Apr 2027
Pan American Health Organization. STAR-H: Strategic Toolkit for Assessing Risks in Health Facilities. Washington, D.C.: PAHO; 2023. Available from: https://doi.org/10.37774/9789275125588GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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