**2. Methods**

## **2.1. Defining resilience**

Health systems must have the capacity to effectively respond to crises and maintain core functions before, during and after crises. Resilience refers to patterns of positive adaptation in the context of significant risk or adversity [14]. A range of definitions for resilience have been proposed including a stable trajectory of healthy functioning after a highly adverse event; a conscious effort to move forward in an insightful and integrated positive manner as a result of lessons learned from an adverse experience; the capacity of a dynamic system to adapt successfully to disturbances that threaten the viability, function, and development of that system; and a process to harness resources in order to sustain well-being [15]. Resilient health systems are defined as health systems that are aware of inherent strengths and weaknesses; diverse with the capacity to respond to a broad range of challenges; self-regulating with the ability to isolate health threats while continuing to deliver core health services; integrated, and bringing in diverse actors from health and non-health actors as well as local and international players in a smart dependence; and adaptive with the ability to transform in ways that improve function in adverse situations [4]. In all these definitions resilient is understood in terms of a continuum of positive response in the face of adverse events.

#### **2.2. Approach to the review**

Four of the authors were involved in the response efforts and their insights are provided here along with the review of important literature on the outbreak. The literature yielded information on the nature and trend of cholera response activities between 2008 and to date, and provided insights into changes in the health system over the same period that may have had an effect on the response to epidemics. The review took place between February and May 2018.

on an annual basis to date with varying magnitudes. Remarkably, from 2012, all the outbreaks have been controlled at source without further spread to other districts. Chiredzi and Chipinge districts remained as hot spots with cases coming from these two districts for most

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Responding to Cholera Outbreaks in Zimbabwe: Building Resilience over Time

http://dx.doi.org/10.5772/intechopen.79794

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Since 2008, most of the cholera outbreaks in Zimbabwe were in urban settlements where the main drivers of cholera included the overloaded and dilapidated water and sanitation infrastructure which has been deteriorating over the years, inadequate water, contaminated water sources and poor water storage [18, 19]. In addition, cultural practices such as unsafe handling of corpses during burials add to the list of risk factors. In most of the reported outbreaks a great number of cases had been associated with deaths and reported to have attended a funeral [17].

Zimbabwe's health system is built under the principle of primary health care, with a district health system anchored on a district hospital and a network of rural health centers (RHC) or clinics providing first line health services. The district health system is supported by provincial hospitals at tertiary level and central hospitals at national level stationed in the two major

The first line health facilities are serviced by nurses, for curative services and environmental health technicians (EHT) to support public health preventive services in the community. In addition to nurses, for curative services, the district level has doctors, laboratory scientists and

years. **Table 2** shows cholera cases and deaths in Zimbabwe from 2008 to March 2018.

Source: National Health information and surveillance, Ministry of Health and Child Care, Zimbabwe.

**Year Cases Deaths Number of districts affected**

2008/2009 98,592 4288 60 2010 1022 22 4 2011 1140 45 4 2012 22 1 1 2013 2 0 1 2014 0 0 No 2015 42 0 6 2016 4 1 2 2017 6 3 3 2018 111 4 2

**Table 2.** Cholera cases and deaths in Zimbabwe between 2008 and March 20181

**4. Response to cholera outbreaks overtime**

**4.1. The period from 2008 to 2009**

*4.1.1. The health system*

1

cities of the country.
