From a crisis response to institutional capacity building: Experiences from on outbreak

From a crisis response to institutional capacity building: Experiences from Zimbabwe on cholera outbreak

Zimbabwe WHO/AFRO Library Cataloguing – in – Publication

From a crisis response to institutional capacity building: experiences from Zimbabwe on cholera outbreak

1. Cholera – prevention and control 2. Disease outbreaks – prevention and control 3. Emergencies – supply and distribution 4. Capacity building 5. Organizational Case Studies

I. World Health Organization. Regional Office for Africa

ISBN: 978-929023261-2 (NLM Classification: WC 264)

© WHO Regional Office for Africa, 2013

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Disclaimer: This report was prepared by the Ministry of Health and Child Welfare and the World Health Organization for sharing experience with participants at the 2011 World Conference on Social Determinants of Health. The opinions expressed in this report are those of the authors, based on experience gained in managing the cholera outbreak, in-depth interviews with key informants and discussions undertaken for the purposes of developing this report. Abstract Acknowledgments...... Contents 6. References...... 5. Cost...... 4. Results...... 3. Methodology. 2. Context...... 1. Introduction...... 12 iv 9 4 4 3 1 v

iii From a crisis response to institutional capacity building: Experiences from Zimbabwe on cholera outbreak iv From a crisis response to institutional capacity building: Experiences from Zimbabwe on cholera outbreak An of prioritypublichealthconditions. determinants the keysocial aimed ataddressing actions intersectoral experiences inusing documentation ofcountrylevel of health.Itsupports and economicdeterminants social role ofMinistryHealthtoaddressing SDH istostrengthenleadershipandstewardship of theWorld HealthOrganization.TheoverallaimofSpanishCoreContributionGrantfor of Health(SDH) was madeavailablethroughtheSpanishCoreContributionGrantforSocialDeterminants of Determinants the Social Health and prepared jointlybytheMinistryof case studywas This Acknowledgments level, The Midzi, WHOCountryOffice,Zimbabwe. Miller, (Consultant);MrLaxonChinhengo, Ministry ofLabour&SocialServices;DrStanley Director, However, the drafting teamincludedDr Davies Dhlakama,Dr Portia Manangazira, on which waswidelydisseminatedduringtheWorldactions on intersectoral Conference Cluster; Africa The address socialdeterminantsofhealth. to actions on implementingintersectoral stakeholder policyandstrategydiscussions through theMinistryofHealthtoconductthisactivity. not least,weexpressgreatappreciationforthesupportreceived from theGovernment but who cannotbementionedbyname.Last valuable inputsthroughouttheprocess in WHOHQ,Coordinator Geneva. We the manypeoplewhomade indebted to are Risk Factors;Dr ChandralallSookramandMrPeter Phori;andDrEugenioVillar, SDH Health earlier Social overall final the are Dr Disease product draft Unit, review gratefully Determinants guidance Davison of World receivedbytheDepartmentofEthicsandSocialDeterminantsHealth this process is Control acknowledged, a case Health and Munodawafa, result of leading study and technical Health of Organization, Prevention, collective was held to namely: inputs included Programme the in finalization efforts Rio Regional Ministry to Dr in de the Tigest a of Janeiro, special project Area many of of Office Ketsela, Health the Coordinator, collection from individuals Brazil case for & Director Africa. WHO in Child study 2011. of Regional and global Determinants Welfare; Financial Health generated At organizations. experiences the Promotion Office Dr support country multi- Anna and for 2008/09 was of eventually resultedinthecontrol efforts study revealedthatthecombinedmultisectoral the socialandotherdeterminantsthatcausedand/orpropagatedoutbreak.The contributed toaddressing collaboration study alsoassessedwhetherthemultisectoral have beendonedifferently.what could suggest well as experiences oftheoutbreakas The A prevailing contextofpovertyandnationalsystemicconstraints,wereneeded. given the the SDHdrivingoutbreak,particularly to address actions intersectoral spheres. Italsoshowedthat,inordertoinstituteacomprehensiveemergencyresponse, of healthconsequencesemanatefromsocial,economic,politicalandenvironmental drivers in thatmost of healthareimportant the evidencethatdeterminants provides driving theoutbreak,inparticular,were waterandsanitation,addressed.Thestudy health (SDH) of determinants the social which examines theextentto Zimbabwe and cholera outbreakin This paperevaluatesthemultisectoralresponseto2008/09 Abstract measures thereafter,outbreaks sporadic of reports multisectoral and buttheconcertedefforts emergency atthesametimeasSDH. the health to anoutbreakrequiresaddressing outbreak demonstratedthatresponding country.Subsequently, This reported. being cases without cholera year elapsed a almost the and deathsacross cases in bothcholera reductions the countrytorealizedramatic comprehensive the cholera put undertaken. in outbreak place desk since review which Key December was of informants documented declared 2009 were officially to response identified address over efforts the and in identified July interviewed to 2009. the cholera SDH There to have provide outbreak have enabled been their of

v From a crisis response to institutional capacity building: Experiences from Zimbabwe on cholera outbreak vi From a crisis response to institutional capacity building: Experiences from Zimbabwe on cholera outbreak Figure 1: frequent outbreakssince1998asshowninFigure1. 1 Previous Source: MinistryofHealthandChildWelfare, 2009 outbreak Between 1. place inthecommunity well abovetheacceptableWHOlevelofallreporteddeathstook 4.3%, of1%.61.4% (89%) were Zimbabwe’s 62districtsaffected.Theoverallcrudecase-fatalityratewas workers limitingearlydetection,reportingandmanagementoftheoutbreaks. of shortage with anongoing in thespread, became majorfactors areas, rural to urban from and areas, urban within populations of Themobility areas. rural and urban hygiene inboth andpoorpersonal poor sanitation inadequate andunsafewatersources, had deteriorated had infrastructure decline wherewaterandsanitation with heighteningsocioeconomic and affectedfarfewerpeople.Notably,duration thisunprecedentedoutbreakcoincided

Interventions (CEPHI),Department OfCommunityMedicine,UniversityofZimbabweandtheWorld HealthOrganization. Health Evaluation oftheHealthCluster Response totheCholeraOutbreakinZimbabwe,Centre for theEvaluationofPublic virtually Introduction outbreaks August which Cholera occurrenceinZimbabwe,1975-2010 to collapsed. its ultimately 2008 worst had and 1 . This outbreak took place against a backdrop of increasingly a backdrop outbreak tookplaceagainst . This been level. Several resulted July confined Additionally, 2009, risk in factors Zimbabwe to 98 discrete all 592 were six cases building identified experienced geographical and blocks in 4288 this a zones, of catastrophic deaths. outbreak, the health were Fifty-five of including systems cholera limited of

1 From a crisis response to institutional capacity building: Experiences from Zimbabwe on cholera outbreak 2 From a crisis response to institutional capacity building: Experiences from Zimbabwe on cholera outbreak that there was nosurgecapacity;aseverely depleted anddemoralizedhealthworkforce 2 to residents water forced of The severeshortage related diseases. and diarrhoeal of spread compounded bydilapidatedseweragesystems,createdfertilegroundforthe shortages, spread toadjacentHararewhereofchronicsevere the factorswater predisposing The outbreakbeganinChitungwizamunicipality,and quickly suburb, ahigh-density Source: MinistryofHealthandChildWelfare, 2009 Figure 2: of deaths. Thisaffectedtimely and adequatedocumentationofallcasesatthe beginning stretched andnottrainedtodealwiththe increasing numbersofcholeracasesand over-were also the ground on health workers Theremaining inadequate transport. and erratic electricitysupplies,lackofradionetworking context ofpoortelecommunications, system wasseverely effective response.Thehealthinformationaffectedbytheprevailing Experienced healthworkerswerefewandpoorlymotivatedtodeliveraprompt weakened in termsoftheabilitytomountatimelyandadequateresponseoutbreak. It isalsoimportanttonotethatthesixbuildingblocksofhealthsystemswere severely burst sewersystems. prompt an understandingoftheoutbreakandmaking completeness, furthercomplicating control. Welfare (MOHCW) policy andimplementationframeworksforepidemiology anddisease The initialresponsetothe outbreak wasbased onexistingMinistryofHealthandChild and assistedinstrengtheningdatacollectiontransmission. hoc previous outbreak in 1999 reporting a total of 4081 cases insixprovinces reportingatotal of 4081 previous outbreakin1999 the outbreakhadexceeded whattheMOHCW hadexperiencedbefore,withtheworst reported innineoutofthe tenprovincesofthecountry.500, to over15 Thescaleof Fromthe number hadquicklyescalated September 2008, of by the1st cases of 30 a total

Health Organization. Interventions (CEPHI), College ofHealthSciences,DepartmentCommunityMedicine, UniversityofZimbabwe;andtheWorld Health Evaluation oftheHealthCluster Response totheCholeraOutbreakinZimbabwe,Centre for theEvaluationofPublic the the basis. water outbreak. action Additional Trends incholeracasesanddeathsover time However, from difficult. As shallow support such by In 10th response, the wells coming December surveillance which in donors from were 2008, data health and contaminated the partners were situation partners initially with with had on of the the sewage deteriorated very means ground low flowing complemented timeliness was 2 . It was clear significantly. on from an and the ad of through faecally-contaminatedperiod incubation Cholera hasaveryshort waterorfood. by thebacterium disease caused diarrhoeal a Cholera is 2. The information andcompromisedlogisticsbecauseoftheprevailingnationalcrisis. with nopreviouscholeraoutbreakmanagementcapacity, very limited resources, Additionally, levels. educational and sex, race andoccupational group, in placesofresidence,wealth and highlightedanumberofkey cities,provincesanddistricts inequities to varyacross of patientsdyingfromcholera,wasreported rate(CFR),ortheproportion The case-fatality progressive dilapidationofinfrastructure,including thewaterandsewagesystems. and closureofmanyhealthfacilities of medicalsuppliesandcommodities, shortages failures, transport incomes, reduced household commodities, basic of shortages insecurity,food experienced healthworkers, skilled and of unemployment, attrition high contributed toanumberofseverechallengesforthecountry,factors additional including against Zimbabwe.Thesecombined unresolved governmentstatusandsanctions challenges includedarecently of resources.Socio-politicaldisputedelectionwith negative prevailing attheonsetofoutbreakincluded The macroeconomiccontextualfactors address thesesocioeconomicparameters. with stakeholderswhowill approach the controlofcholerademandsamultisectoral where water supply, sanitation, foodsafetyandhygiene are inadequate.For thisreason, in environments Outbreaks occur can leadtodehydrationanddeathwithinhours. salts soap forhandwashing, lackofawarenessandaccesstoadequate information and athome, lack ofcommoditiessuch assugarandsalttomake salt sugarsolution (SSS) access, suchaslimited geographical of deathsoccurredinthe communityduetofactors appearedtocompoundcholeramortality.and malnutrition conditions Themajority(61%) building government security a within location its and facilities sanitation not havefunctional did However,have beentheMOHCW/HQpremises. atthattime,theMOHCWpremises centre should command of this Centre (C4).Thelocation Control and Cholera Command the mechanism, a jointcommandandcoordinating the MOHCWandWHOtoestablish to theemergencyled for allstakeholdersresponding platform The needforacoordination Government ofZimbabwe,throughtheMOHCW. the declaration ofthe outbreak asaNationalEmergency on 6thDecemberbythe 2009 especially WHOandUNICEF.workers anddevelopmentpartners, culminated in This fatality rate(CFR) increased anxiety and createdpanicwithinthe population, healthcare WHO possible. quickly andeffectivelyas as at fullcapacity meant thatthecentrewasabletofunction that resourcesforC4didnotcomedirectlytobuildingcapacityintheMOHCW, italso 2 increasing hours Office Context presented gross to Annexe the 5 severity days, domestic underlying difficulties was and of selected the if product left prevalence situation in untreated, the to host and necessary typified of the massive the co-morbid C4 by severe coordination round-the-clock high hyper-inflation, loss numbers conditions , usually transmitted usually cholera, Vibrio of meetings. large of access. such cases amounts with While as and a As HIV, severe of high this such, fluid cardiac meant case- lack and the

3 From a crisis response to institutional capacity building: Experiences from Zimbabwe on cholera outbreak 4 From a crisis response to institutional capacity building: Experiences from Zimbabwe on cholera outbreak As • • • • • determinants ofhealth,whichincluded: These inequitiescanbeunderstoodtohave arisen fromtheunaddressedsocial communications andafailedreferralsystem. EHTsand doctors, seen duetolownumbersofnurses poor andVHWsontheground, Representation included: and Permanent Secretaries) toprovidepolicydirectiononthe response totheoutbreak. secretariat, theTask Force brought togetherhigh-level leadership (includingMinisters Ministry ofLocalGovernmentandUrbanDevelopment withtheCivilProtectionUnitas thegovernment response tothesituation.Chairedby established tocoordinate WelfareCabinet-levelDecembera 9th 2008, on Task multisectoral Force immediately was Followingemergency bytheMinisterofHealth andChild ofanational thedeclaration 4. the socialandotherdeterminantsthatcausedpropagatedoutbreak. contributed toaddressing collaboration study alsoassessedwhetherthemultisectoral their experienceswhatcouldhavebeendonedifferently. oftheoutbreakandsuggest The cholera to the efforts study followsacomprehensivedeskreviewofdocumentedresponse This 3. lack ofknowledgeabouthowcholeraspreads at alllevels. stakeholders multiple of collaboration and with thecooperation response multisectoral required a spread the outbreakandpreventingongoing clear thatcontrolling it was such, comprehensive services. trust intheestablishedhealthcaredelivery system that wasnolongeroffering Poor perception of health delivery systemby communities sanitation; poorpersonalhygiene. improved water and Living andtosafe working access conditions –declining areas; belongingtoareligioussectwhichdiscouragesseekingmedicalattention. handshaking atfunerals;historyoffrequenttravellingincludingtocholera-affected gatherings; traditionalpracticesofpreparingthe dead forburial;practiceof Social and atfuneral community food networks –consumptionofcontaminated in viewofthescarcitywaterandbasicfoodsuppliescountry. and consumption storage unhygienic foodpreparation, unsafe waterconsumption, coverage, sanitation poor practices, hand-washing Individual lifestylefactors–poor AIDS, andpoornutritionalstatus. weakened outbreaks ofcholerahadbeensporadic,immunesystemsduetoHIVand Individual factors –nocholeraimmunitywithinthegeneralpopulationasprevious Results Methodology outbreak while the of outbreak 2008/09. became Key informants known initially were 2 . Lateresponsestoclinicalcaseswere to identified the MOHCW and as interviewed –communitieslost a health emergency, to provide Government Figure 3: government andnongovernmentalagenciesas showninFigure3. government Task Forcea widerange of of allactionsacross toensurecoordination The MOHCWactedasthe focal pointbetween both the C4 andthe multisectoral Canada andtheUSA. Response the were including mobilized fortheworkofC4anditspartnersfromavarietydonors, and of implementation for support providing critical NGOs and agencies of very widerange difficult decisions the meetingswereinfrequentandoftenlackedaquorum,makingbinding effectiveness with varioussubcommitteestotakeforwardthework.Unfortunately, theTask Force’s for the US Centers Bangladesh, in Research Diseases Diarrhoeal Centre for the International from the inputsofkeytechnicalexpertise,including coordinated The C4also sundries. to by theMOHCW Command andControlCentre),co-chairedWHO, wasestablished Cluster chairedbytheWorld Food Programme(WFP).Thenewentity, the“C4” (Cholera by UNICEF,and Hygiene)Clusterchaired Sanitation new Logistics a of formation and of “Cluster” system Humanitarian WHO simultaneouslystrengthenedtheUnitedNations For governments werereluctanttoprovidefundsdirectlytheGovernmentofZimbabwe. the country,context in given theprevailing But commodities. other and donors some This MinistryofForeign Affairs • MinistryofDefence • MinistryofTransport • MinistryofHomeAffairs • andPublicity MinistryofInformation • MinistryofEnergyandPower Development • MinistryofFinance(ReserveBankZimbabwe) • MinistryofWater Development ResourcesandInfrastructural • ChildWelfare MinistryofHealthand • OfficeofthePresidentandCabinet • facilitate responding the Disease African this Russia was response or reason, impossible. supported Relational contextofthemultisectoral coordination mechanisms Fund, the Development responded Control of was to scaling Greece, and in emergencies, limited United the and after by Several form up with Republic by the and Communications a Kingdom Bank, being of lack working donations of Global interventions countries finance, of with officially AusAid, of resources Department Outbreak a group Korea, Health in equipment, including cash Government approached to of SIDA, to fight Cluster and Alert meet senior for Namibia, cholera OFDA/USAID, kind, and all manpower, International chaired by officials of of including Response the , the and South identified Government by and coordinate medicines WHO, World Development, IV Africa, Network. a Central fluids, needs. command a Vision , WASH of the bicycles and Emergency Zimbabwe, In Resources work Australia, addition, medical ECHO, (Water, centre China of and a

5 From a crisis response to institutional capacity building: Experiences from Zimbabwe on cholera outbreak 6 From a crisis response to institutional capacity building: Experiences from Zimbabwe on cholera outbreak the Action their diseasecontrolcommittees, civil protectioncommittees or formationofnew Cholera the responsetoanoutbreakthroughrevitalizing for mobilizingresourcesandcoordinating plans and maintained theirexistingstructures or levelsestablished district and provincial In theinterim, the roll-outofdecentralizedstructureswasdelayeduntilMarch2009. in lower-levellevel toassist at provincial decentralized structures However, coordination. level,itwasalsoplannedtohave operated atthenational While theC4originally and theWorld HealthOrganization;December2008. Source: Establishment ofCholeraCommandandControlCentre (C4) in Zimbabwe,MinistryofHealthandChildWelfare, Zimbabwe, A were this data, andsohadmore up-to-date datathan the MOHCW. TheC4helped to capture fuel, phones)tocollectandtransmit had readilyavailableresources(transport, partners of choleraasanationalemergency.although thischangedfollowingthedeclaration Some initially not readilyavailable outbreak was Dataonthecholera Surveillance/laboratory: then developedlocalplanstomanagetheoutbreak. The within whichtofighttheoutbreak. framework model, havingbeenchosenbytheMOHCWandWHOasmainstrategic Figure 4: below: the C4, withthe key objectives / tasksoutlinedwithineachpillarasshowninFigure4 outbreak officers, and surveillance unitofthe health techniciansonmotorbikes andthehealthinformation number challenges information core the Committees interventions nursing was provincial of Cholera CommandandControlCentre’s organizationalstructure different through and and and staff, Disease these (CACs) medical use processes the decided district it are Minister to composed Control described guide directors, medical upon were of action. Directorate. Health were required officers, of under environmental all based Key and organizations the provincial to people designated Official around five take thematic place involved health communication five and operating offices main simultaneously district areas officers, in pillars the of of at the health surveillance the that identified on PMDs environmental C4 level, the information to response address and cholera which within data city each testing, providingemergency a rapidresponseteamin water supplies,and establishing water quality for of materials the availability assessing aquatabs), items (buckets,soap, CTCs,assessing ofEHTs training within CTCs,control ininfection of non-food provision contributed totheimprovementandhealthfacilities, of safewatersuppliesinschools level. Themembers and hygieneimprovementsatalllevels,especiallygrass-roots with water,who wereengagedinassisting partners by over100 participation sanitation At tothehealthfacilityandcholeratreatmentcentresunits. developed anddisseminated case guidelines. Followingoutdated and old on based instances, appropriate realization, this in some and, un-standardized initially Case management:managementwas challenge andthereforelimitedthenumberofconfirmedcholeracasesinthisoutbreak. presented anongoing capacity of specimensandgenerallyreducedlab transportation of cholera;however,means, physical challengeswithregardstoavailabilityoftransport Stool the WHOwebsite. on were posted that bulletins the weeklyepidemiological develop to Datafromcholeratreatment statistics. centres(CTC), districts andprovinceswasused cholera and panicthroughuncoordinated health departmentsinordertoreduceconfusion and WASH: these centres. controlling Initially, key protocoltobefollowed. were set up by the MOHCW and, with the support ofpartners,hadinfectioncontrolasa clinics andindependent sites toincreaseaccesscareandsoreducedeaths.These enable safewatertobe providedtoresidents.Thissupportcontinued untilmid-2012. when UNICEF 2009, began donatingwatertreatmentchemicalsto localauthoritiesto Februaryfrom other major citiesas and water safetyinHarare provided toimproveurban also was at thecommunitylevel.Support change behavioural by targeting outbreaks were health educationprogrammes revitalized as akey intervention inpreventingfurther a litter-freea cholera-freeZimbabwe,celebrating Participatory Zimbabwe”. hygiene and fromthe Environment, withsupport Deputy Prime Ministerunderthe theme “Celebrating launching aclean-upcampaigninSeptember 2009 inconjunctionwiththeMinistryof families andcommunitiestopreventcholera, the goalofbuildingcapacityindividuals, assist manpower wasaddressedpartiallywhen some ofthe health workersreturnedtowork of shortage evolved. Theprevailing the outbreak the CFRas decrease in corresponding later improvedwiththe support ofpartnersandthese improvements translatedintoa were notavailableorinadequateinquantityduetothescaleofoutbreak.This amounts care workersmanningthebusyCTCs/CTUs,and partnersprovidedvarying somedonors the few health for allowances pay to While thegovernmentfailed training. experience and due toinadequate Primary CareNurseswerenotcompetenttomanagethecase-load the driving samples province. definitions with height The water and sanitation situation in thecountrywasakeydeterminantcausing situation Thewaterandsanitation essential for the the the daily of were crisis outbreak this A outbreak. and items or joint collected outbreak, but weekly management health-WASH such the and duties, shortage As as from preventing up such, oral to selected and 400 rehydration protocols social of the this skilled CTCs/CTUs future activities patients mobilization caused manpower for outbreaks. solution the to discrepancies of had be the different working (ORS), sent been persisted. water The for established clinical WASH IV group laboratory sector in fluids The the was Cluster scenarios staffing were newly-qualified and confirmation at formed antibiotics hospitals, crucial enjoyed rates were with at in

7 From a crisis response to institutional capacity building: Experiences from Zimbabwe on cholera outbreak 8 From a crisis response to institutional capacity building: Experiences from Zimbabwe on cholera outbreak logistics the pumpingcapacity,development programmetoaddress reticulationsystem,andthe NATPHARM, overwhelmed being a resultofsuppliers as where theywerebeingprocured from delayed inarriving in linewiththeseverityofoutbreakaffectedareas.Supplieswere also frequently of suppliesnotalways being deliveredtothemostaccessibleareas,withdistribution and oversightbytheMOHCW,which resultedinresources and fuelshortages transport to allCTCsdistribution inthevicinity. Thispartly resultedfromthe limited governance Department, cholera financial in were bilateral agenciesand NGOs.Donationsreceivedbothin“cash” and“inkind” donors, development partners, Zimbabwe, of Zimbabwe/Reserve Bank Government of Resource allocation:Resourceswere mobilized frommanysources, includingfromthe order toshareresponsibilitiesandavoidduplication ofeffortinmanagingthelogistics. decentralized levelswith district-levelat place in put meeting frequentlyin stakeholders of more donors greatlyimprovedthe situation interms ofsupplies.Logisticsclusterswere before the declaration oftheoutbreakasanemergency. However, thesubsequentarrival not organizedthroughtheMOHCW due toimportdutyonsupplies of supplies costs being with supplies resources, of distribution inequitable challenge was major that a partners were inadequateinthecountry.soap buckets and including supplies noted by Itwas Basic the outbreak. controlling of to thesuccess crucial was support Logistics: Logistical involved thatschoolswerenottobeusedascholeratreatmentcentres. importanceofsustainedcontrol.Communicationwasalsoconveyed given critical toall targeting thecommunitywerecontinuously levels oncholeraissues,andcampaigns if needed. The MinistriesofYouth, LocalGovernment and Educationwere trained atall and sanitationmeasuresknew when to make contact withhealthworkerspromptly were responsivetothewater sector tomakesurethatprimaryandsecondaryschools the education wrote to The MOHCWalso schools. and villages into teams by sending were messages, TVandprintmedia.Massivehealtheducationcampaignsconducted Zimbabwe todevelopandreview the IEC materials, includingradiomessages,cellphone the the outbreak,aimedatsensitizingcommunitiesoncholera,actionstobetakenand Social mobilization:mobilizationinterventionswere conducted duringandafter donors unabletoprovidedirectbudgetarysupportgovernmentforsuchprojects. country Addressing A of socialmobilizationincreasedandonlyscaleddownastheoutbreakcameundercontrol. the emergency,of to thedeclaration place prior the intensity the declaration, andfollowing term developed. However, the implementation ofthese plans requiresresourcesforlong- have been areas, urban for particularly challenges, thesewatersupply addressing for social the preventive financing. delivered form continuing campaign. mobilization support of of adequate the WHO, the and measures commodities. The to was national water one having to This same WASH committee struggle provided specific water committee to situation pharmaceutical determinants insufficient be cluster treatment All in put CTC to was raising resources NATPHARM in representatives, in included rather place. formed stocks. the chemicals. of finance than the storage A country were to officers running This cholera from to provide for the managed was

and large A and C4, requires from district message number outbreak technical further distribution WFP, the capital the hospital National in UNICEF MOHCW a complicated of on the however, projects guidance medium- studies radio first facility. for Healthcare and Health and onward instance and persist, and Logistical other to to by TV some the Promotion proposals the was long-term equitable partners national through with Trust raised major put and the of in Figure 5. Figure cholera casesreportedfromweek23of2011to202012. the country.and deathsacross in bothcholeracases reductions Therehavebeenno put inplacesinceDecemberhaveenabledthecountrytobringaboutdramatic 2009 measures the multisectoral and outbreaks sporadic of been continuedreports have since 3 Source: MinistryofHealthandChild Welfare, Zimbabwe,Weekly DiseaseSurveillance System;August2011 million in2009 estimated atUS$36.2 to theHealthClusterwere of overthreeyears.Contributions time period prolonged in cashandkind,aswellthe stakeholders involved,themixtureofcontributions and donors governments, of number the large expertise considering require will this However,recurrence. of likelihood and determinants given thepersisting important but and theresponseiscomplex Estimating thetotalcostofcholeraoutbreak2008/9 5. cases andotherepidemiologicaldata. to createa“formula”quantifysuppliesneeded byeachCTC basedonnumberof worked together andepidemiologists (MSF). Logisticians frontiers as Medicinessan such The IMPACT 1:Reductionincholeracases MOHCW withsupportfromWHOfollowingthecholeraoutbreak. by the have beentrained that teams response rapid with deploymentof any outbreaks, this systemisusedtoinformareaswhere priority actionisneeded to rapidlycontain integrated diseasesurveillanceandresponse(IDSR) is beingcontinued.Datafrom outbreak. Training ofhealthworkersandcommunities intheWHO-recommended the massive2008/9 following which hasmanagedtodetectothersmalleroutbreaks Monitoring ofcholeracasescontinuesthroughtheroutineMOHCW surveillance system, response is,therefore,expectedtobemuchhigher. of the cost of Zimbabweandothergovernments.Thetotal contribution including actions raged the worst-everof resulted inthecontrol outbreak hit Zimbabwe.This to outbreak cholera

Health ClusterBulletin No.152009MOHCW, WHO health from Cost Cholera curve,Zimbabwe,fromWeek 5,2010to Week 26,2011 sector-specific end- August 2008 and and combined was 3 declared , butthisdoesnotincludenon-healthcluster multisectoral officially efforts over described on 26 July here 2009. ultimately There

9 From a crisis response to institutional capacity building: Experiences from Zimbabwe on cholera outbreak 10 From a crisis response to institutional capacity building: Experiences from Zimbabwe on cholera outbreak 4 on foodhygiene;andtrainingofRapidResponseTeams atdistrictlevel guidelines including guidelines control Zimbabwe cholera diseases; epidemic diarrhoeal for modules forhealthworkers;casemanagementtraining guidelines; updatedtraining includes development of updatedIntegratedDiseaseSurveillanceandResponse(IDSR) levelstoenablefutureresponsediseaseoutbreaks.This at nationalandsub-national outbreak atthe onset, andmanylessonshave been learned andsystemsestablished outbreak. Itwasclearthatthehealthsystemoverwhelmed by thesheerscaleof The countryhaslearnedandevolved a greatdealasresultofthesevere cholera IMPACT 2:Improvedstateofreadiness unpredictability ofoutbreakspots. and groups, certain religious among in patientswithcholeraseekingcare,particularly However,of thepopulation. areas may beduetodelays this and theCFRremainedhigh some to provided water being quantity of and improved quality in resulted sanitation hygiene including handwashingandimprovedenvironmentintermsofsafewater Improved awarenessbypeopleaboutcholera,improvedbehaviourtowardspersonal institutions Cluster andotherstakeholders,withimprovedmedicalequipmentsupplytohealth The healthsystemwasstrengthenedasaresultoftheactionsMOHCW, theHealth IMPACT 4:Strengtheningofthehealthsystem transition towardsamoredevelopment-oriented modelisanongoingdiscussion. its system, although cluster the ongoing through facilitated is Continued coordination the leadershipofDepartmentEpidemiologyandDiseaseControlinMOHCW. nongovernmental agencies,withallstakeholdersusingthe same setsofguidelinesunder government and both across action of harmonization greater much now There is IMPACT 3:Harmonizedactionbymultiplestakeholders that markers ofpotentialinequity.data of gathering in itselfrevealsthefutureimportance This level orother level, occupational residence butnotbysex,wealthquintile,educational Routine dataoncholeracasesanddeathsaredisaggregatedbyageplaceof Data onchangesinhealthinequitiesarehardtoidentify within availabledocumentation. response totheoutbreakprogressed. of while disposableincomesremainpoor. Fundinglow remains donors private sector government and the central health from for health (human resources, weak inallpillars the systemremains the MOHCWandpartners, there havebeenimprovementsinthehealth system asaresultofconcertedeffortsby the health systemitself. Thegeneralsocioeconomicsituationremainsfragile, andwhile hygiene poverty andthe practices, accesstosafewaterandsanitation, functionalityof Meeting Falls, Zimbabwe. disease. specifically information, on Preparedness, and Key explores an social health increase Detection, determinants potential financing, Alert in and community Response inequities health of health Strategy service confidence through in for Outbreaks, Zimbabwe’s delivery, deeper in 28 the - exploration 29 commodities health April cholera 2009, care Elephant epidemic of 4 . and the system Hills distribution products). Hotel, relate as Victoria the to to ensurenogapinsurveillance orcapacitytorespondquicklyoutbreaks asneeded. (EOC) with fundingfrom ECHO,phase during thetransition continuing withC4 functions Centre Emergency Operations purpose-built the MOHCWwithina C4 to of functions all being of of surveillance mainly insupport The C4–continuestooperatebutnow functions countrywide, althoughthereisstillalongway . Water health. determinants of in thesocial factors alert giventhecontinuedexistenceofpredisposing butstakeholdersremainedonhigh The outbreakwasdeclaredoveron26July2009 A numberofkeyfacilitatorsandbarrierswereobservedintheresponse: Follow-up andlessonslearnt group departments, UNagencies,NGOs,private sector, churches,universities,etc.).This command centretoenableinclusionofallstakeholders inthe response (government in the response modelusedtocontrolcholera,but willincludeanexpandedplatform the standard for will legislate This Management. Risk Disaster Cabinet Committeefor advanced stageontheformulationofapolicy,for anenhanced strategyandlegislation at an also while workis response, and planning both committee for into astanding force of epidemic-pronediseases.Workthis task isatanadvancedstageoftransforming the issues on addressing monthly andnowoncequarterlyhasaparticularfocus The NationalTask Forcegroup continuedtomeet onEpidemic-ProneDiseases–This launch oftheHealthSectorInvestmentCase. and resourcemobilizationthroughthedevelopment Health Strategy2009-2013, of theNational the launch following strengthening seen progressive health systemhas and RapidResponseTeamsThe socialmobilizationcampaigns. (RRT)andongoing Preparedness &Response(EPR),IntegratedDiseaseSurveillance(IDSR) The MinistryofHealthandChildWelfarein Emergency -TheMOHCWsteppeduptraining objectives andthewayworkisdone.For example: a threat.However, therehave been important developmentsofthe and transitioning cholera whichremains outbreak remaintothisdayinaneffortcontinuecontrolling the severecholera to manage put inplace Thestructures areas. in urban particularly the country,over time,withincreasedsuppliesofcleanwaterbeingprovidedacross issues inwhichtherehasbeenanimprovement the waterandsanitation addressing Changeofcurrency:withdollarizationtothe • Changingof • stakeholders Convergenceofpurpose:all • Facilitating factorsintheresponse cases US dollar, logisticalissuesweremadeeasier National Unity 2009 withtheformationofGovernment loss oflife united intheirdeterminationtoavoidfurther scaled has Authority) All and relevant also inFebruary thepoliticalclimate down support been and sectors to working relevant to three the continued people. MOHCW hard ministries with At working for local the to rapid same Barriers intheresponse Thehealthsystemwasatits • Lowcommunitycapacity, knowledgeand • Political oftheoutbreak attheonset situation • Potential withthelargenumberof confusion • improve authorities awareness funding affected communication,collaborationand partners whohadtobewell-coordinated outbreak in everypillar, attheonsetandthroughout to follow-up prevent time, the plans and further water of any ZINWA are and outbreaks, outbreaks, in (Zimbabwe progress sanitation weakest,andweak with in to particular situation National transfer staffing

11 From a crisis response to institutional capacity building: Experiences from Zimbabwe on cholera outbreak 12 From a crisis response to institutional capacity building: Experiences from Zimbabwe on cholera outbreak . Meeting 2. 1. 6. Data • The • Key lessonsonsocialdeterminants ofhealthandcholeraforZimbabwe driving diseaseoutbreaksareaddressedinasustainablemannerthelongerterm. health of determinants social all that ensures comprehensive developmentplatform nationaltransitionfromanemergency is dependentonsuccessful fundingmodetoa While for nowthe cholera situationinthe country isundercontrol,futuresustainability including Haiti). outbreak; theC4modelhasbeendisseminatedandadaptedinanumberoflocations, them intheircholera to support Control CentremodelwasprovidedtoCameroonin2010 level (e.g.Zimbabwe’sCholeraCommandand already beensharedattheinternational response mechanismstobedeveloped, and many of the tools andprocesseshave required innovative the outbreak benotedthattheunprecedentedscopeof It shouldalso The • Without • 3. Responding • coordination. tofutureoutbreaksusingamultisectoralapproachandbetter in responding World HealthOrganization. Sciences, DepartmentofCommunity Medicine, University of Zimbabwe,andthe HealthInterventions(CEPHI),Collegeof Centre fortheEvaluationofPublic Evaluation oftheHealthClusterResponseto theCholeraOutbreakinZimbabwe, contain anepidemic. to possible not is it awareness, community raising and supplies material health, systematically gathered and documented as part of the ongoing work oftheMOHCW.of theongoing gathered anddocumentedaspart systematically 28 -29April2009,ElephantHillsHotel,Victoria Falls, Zimbabwe. identified, need tobe outside thehealthsector time asthedeterminantsofhealth–stakeholders Health Cluster Bulletin No.15, 2009, Ministry of Health&ChildWelfareHealth ClusterBulletin No.15, 2009,Ministryof andWHO. stewardship role. to bemandated/supporteddosobythehighestlevel of thegovernmentinits multisectoral responsetodiseaseoutbreakswith social causes,anditneeds References Ministry emergency on a on health made strong, Preparedness, to of an aware Health became inequities outbreak well-responding of and their an Detection, requires and Child responsibilities opportunity the Welfare health addressing social Alert system to and must and determinants work Response the given take including health towards the a central emergency Strategy lead of human better health role in coordinating for in preparedness resources need responding. at Outbreaks, the to same for be a

ISBN 978-929023261-2

978- 929023261- 2