From a crisis response to institutional capacity building: Experiences from Zimbabwe on cholera 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 Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. All rights reserved. Copies of this publication may be obtained from the Library, WHO Regional Office for Africa, P.O. 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Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization or its Regional Office for Africa be liable for damages arising from its use. 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. Contents Acknowledgments ............................................................................................................ iv Abstract ............................................................................................................................. v 1. Introduction .................................................................................................................1 2. Context ........................................................................................................................3 3. Methodology ...............................................................................................................4 4. Results ........................................................................................................................4 5. Cost .............................................................................................................................9 6. References ................................................................................................................12 From a crisis response to institutional capacity building: a crisis response From Zimbabwe on cholera outbreak Experiences from iii Acknowledgments This case study was prepared jointly by the Ministry of Health and the Social Determinants of Health Unit, World Health Organization, Regional Office for Africa. Financial support was made available through the Spanish Core Contribution Grant for Social Determinants of Health (SDH) received by the Department of Ethics and Social Determinants of Health of the World Health Organization. The overall aim of Spanish Core Contribution Grant for SDH is to strengthen leadership and stewardship role of Ministry of Health to addressing social and economic determinants of health. It supports documentation of country level experiences in using intersectoral actions aimed at addressing the key social determinants of priority public health conditions. An earlier draft of this case study was included in a special collection of global experiences on intersectoral actions which was widely disseminated during the World Conference on Social Determinants of Health held in Rio de Janeiro, Brazil in 2011. At the country level, the review process leading to the finalization of the case study generated multi- stakeholder policy and strategy discussions on implementing intersectoral actions to address social determinants of health. The final product is a result of collective efforts of many individuals and organizations. However, the drafting team included Dr Davies Dhlakama, Dr Portia Manangazira, Director, Disease Control and Prevention, Ministry of Health & Child Welfare; Dr Anna Miller, (Consultant); Mr Laxon Chinhengo, Ministry of Labour & Social Services; Dr Stanley Midzi, WHO Country Office, Zimbabwe. The overall guidance and technical inputs to the project from WHO Regional Office for Africa are gratefully acknowledged, namely: Dr Tigest Ketsela, Director Health Promotion Cluster; Dr Davison Munodawafa, Programme Area Coordinator, Determinants and Risk Factors; Dr Chandralall Sookram and Mr Peter Phori; and Dr Eugenio Villar, SDH Coordinator in WHO HQ, Geneva. We are indebted to the many people who made valuable inputs throughout the process who cannot be mentioned by name. Last but not least, we express great appreciation for the support received from the Government through the Ministry of Health to conduct this activity. From a crisis response to institutional capacity building: a crisis response From Zimbabwe on cholera outbreak Experiences from iv Abstract This paper evaluates the multisectoral response to the 2008/09 cholera outbreak in Zimbabwe and examines the extent to which the social determinants of health (SDH) driving the outbreak, in particular, water and sanitation, were addressed. The study provides the evidence that determinants of health are important in that most drivers of health consequences emanate from social, economic, political and environmental spheres. It also showed that, in order to institute a comprehensive emergency response, intersectoral actions to address the SDH driving the outbreak, particularly given the prevailing context of poverty and national systemic constraints, were needed. A comprehensive desk review of documented response efforts to the cholera outbreak of 2008/09 was undertaken. Key informants were identified and interviewed to provide their experiences of the outbreak as well as suggest what could have been done differently. The study also assessed whether the multisectoral collaboration contributed to addressing the social and other determinants that caused and/or propagated the outbreak. The study revealed that the combined multisectoral efforts eventually resulted in the control of the cholera outbreak which was declared officially over in July 2009. There have been reports of sporadic outbreaks thereafter, but the concerted efforts and multisectoral measures put in place since December 2009 to address the identified SDH have enabled the country to realize dramatic reductions in both cholera cases and deaths across the country. Subsequently, almost a year elapsed without cholera cases being reported. This outbreak demonstrated that responding to an outbreak requires addressing the health emergency at the same time as the SDH. From a crisis response to institutional capacity building: a crisis response From Zimbabwe on cholera outbreak Experiences from v vi From a crisis response to institutional capacity building: Experiences from Zimbabwe on cholera outbreak 1. Introduction Between August 2008 and July 2009, Zimbabwe experienced a catastrophic cholera outbreak which ultimately resulted in 98 592 cases and 4288 deaths. Fifty-five of Zimbabwe’s 62 districts (89%) were affected. The overall crude case-fatality rate was 4.3%, well above the acceptable WHO level of 1%. 61.4% of all reported deaths took place in the community1. This outbreak took place against a backdrop of increasingly frequent outbreaks since 1998 as shown in Figure 1. Figure 1: Cholera occurrence in Zimbabwe, 1975-2010 Source: Ministry of Health and Child Welfare, 2009 Previous outbreaks had been confined to discrete geographical zones, were of limited duration and affected far fewer people. Notably, this unprecedented outbreak coincided with heightening socioeconomic decline where water and sanitation infrastructure had deteriorated to its worst level. Additionally, all six building blocks of the health systems had virtually collapsed. Several risk factors were identified in this outbreak, including inadequate and unsafe water sources, poor sanitation and poor