**4. Response to cholera outbreaks overtime**

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

#### *4.1.1. The health system*

**2. Methods**

48 Current Issues in Global Health

**2.1. Defining resilience**

**2.2. Approach to the review**

**3. History of cholera in Zimbabwe**

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

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.

The first recorded cholera case in Zimbabwe was in Mashonaland East Province (Mudzi district) in 1972. In the same year another outbreak was reported in Mashonaland Central (Mt Darwin district) [16]. Thereafter outbreaks occurred every 10 years until 1992. More frequent outbreaks occurred in the late 1990s, with the largest being recorded in 1999 when 4081 cases were reported in low lying border areas covering six provinces. Since the year 2000, cholera outbreaks were reported on an annual basis, with unprecedented outbreaks occurring in 2008/2009, when 60 of the 62 districts in the country were affected, and by the time the outbreak was declared over in May 2009, 98,592 cases and 4288 deaths had been reported [17]. The 2008/2009 cholera outbreak tested the strength of the Zimbabwe emergency preparedness and response at a time when the country was ill prepared for emergencies. Smaller outbreaks occurred in 2010 and 2011 each covering four districts and recording 1022 and 1140 cases respectively but these were controlled in reasonable time given the built response capacity from the 2008/2009 outbreak. After 2011, the country continued reporting cholera outbreaks

terms of a continuum of positive response in the face of adverse events.

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 cities of the country.

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 other clinical and public health experts. The ideal for the country is two to three nurses and one EHT for every RHC. The district hospital is ideally supposed to be supported by 50–100 nurses, and three to eight doctors depending on the size. From independence, the supply of health workers improved up to about year 2000, when almost all the district hospitals had at least one doctor. Nurses' coverage at RHC level had been improving up to a time when every RHC had at least one nurse.

Protection Committee at all levels of the system, chaired by the local government ministry. Although this committee remained functional, due to the poor economic performance all actors' roles in responding to the outbreak were constrained. Although international players were eager and willing to provide support, the country did not declare the cholera outbreak as an emergency in sufficient time to allow inflow of such support. This is evidenced by the fact that although the first official report of the outbreak was on 22 August 2008, unofficial reports had been circulating in the media much earlier. Since the first official report of the outbreak became public, the Government was silent on the issue until December 2008, when the Minister of Health and Child Welfare eventually declared the cholera outbreak a state of emergency. After this declaration of a state of emergency, donors responded immediately and provided financial support through UN agencies and NGOs to fight the cholera outbreak.

Responding to Cholera Outbreaks in Zimbabwe: Building Resilience over Time

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

51

The International Health Regulations (2005), or IHR (2005), represents a binding international legal instrument involving 196 countries across the globe, including all the WHO Member States. The purpose and scope of the IHR (2005) is "to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade." The IHR (2005), to which Zimbabwe is a signatory, has shaped the country's preparedness [26], prevention and response efforts to public health

The IHR (2005) sets guidelines for core capacities which must be implemented in order to prevent or respond to disease outbreaks and other public health events of international concern. This includes strengthening of core capacities at ports of entry to prevent exit or entry of infectious hazards. Alongside this is enabling legislation, establishment and strengthening IHR national focal points for the coordination of stakeholders and reporting of diseases of

The 2008/2009 cholera outbreak occurred outside the period of implementation of IHR (2005) for the country which was to start in 2011 with discussions and base-lining of country capacities for implementation of IHR (2005). State parties, in line with IHR (2005), are required to strengthen capacities in preparedness and response efforts. This requires countries to have multi-hazards national public health emergency preparedness and response plans which have to be periodically tested, including identification of hot spots and developing mechanisms for resource pooling and deployment during times of emergencies. This kind of plan

Integrated Disease Surveillance and Response (IDSR) was adopted as a tool for detection and response to epidemics by the WHO Regional Committee for Africa in 1998. In Zimbabwe, training modules were developed between 2001 and 2007, national adaptation carried out, training of trainers and training of health workers conducted. Although the training of trainers covered the whole country, cascade training of health workers was at a slower pace because of the limited financial resources. This capacity in IDSR was later to be negatively affected by the health worker attrition. With the coming of IHR (2005) AFR member states agreed that the

*4.1.2. Status on IHR and IDSR*

public health importance to WHO.

risks, but only after the 2008/2009 cholera outbreak.

did not exist before the 2008/2009 cholera outbreak.

implementation of IHR (2005) in Africa was going to be through IDSR.

The health system, during the period 2008–2009, was far from being resilient and being able to absorb shocks whilst maintaining normal functionality. By the time the 2008/2009 cholera outbreak struck, the health system was at its weakest. It was characterized by a critical shortage of skilled as well as motivated health workers; critical shortages of essential medicines and supplies and medical technologies; dilapidated health infrastructure; unreliable health information systems and weak surveillance systems; poor service delivery and poor health stewardship under inexperienced health leadership [20]. In one study on community mortality from Cholera in Zimbabwe, the poor access to health services and limited availability of oral rehydration salts were some of the causes for high community mortality [20].

The health system was dysfunctional as far as promoting provision of core health services because of the nationwide economic decline and staff attrition. For instance, most health workers including nurses, doctors, EHTs and laboratory scientist left for greener pastures either within or outside the country leaving RHCs without nurses and many district hospitals without doctors [21]. This left the health system poorly serviced by human resources [22]. According to the World Health Organization (WHO), the ratio of health workers per 1000 population was 0.162 in 2004 dropping to 0.05 in 2007 for physicians and that for nurses and midwives dropping from 1.491 in 1995 to 1.215 in 2009 [23]. With the country's economy at its worst, affected by hyperinflation, financing for health was at its lowest during this period. Total health expenditure was 8.9% of GDP, with out of pocket expenditure constituting 50.4% of health expenditure [24]. Total health expenditure per capita was estimated at \$16.21 in 2008 [25]. As such, surge capacity was nonexistent. With the lack of confidence in the health system a good proportion of the population was seeking for health care elsewhere which meant that some threats would not be detected by the health system late. Such a system could not adapt, transform and improve performance in the face of an outbreak.

An up-to-date map of human, physical, and information assets that highlight areas of strength and vulnerability was not in place. Real time strategic health information and epidemiological surveillance systems as well as the use of indicator and event based surveillance systems were not in place. Some information was however available on the vulnerabilities of the population to different threats although not well disseminated to impel action. The functionality of the health information network was at its lowest, human resources were poorly motivated and not available at work to record surveillance data, analyze it and use the information for decision making. The surveillance system which was then largely paper based and not real time was severely affected by the transport and communication systems which were also at a low level.

Resilient systems have the ability to harness human, financial and logistical resources from health and non-health fields, coordinate actors and manage partnerships. The strength of the country was the availability of inbuilt structures for coordination including the Civil Protection Committee at all levels of the system, chaired by the local government ministry. Although this committee remained functional, due to the poor economic performance all actors' roles in responding to the outbreak were constrained. Although international players were eager and willing to provide support, the country did not declare the cholera outbreak as an emergency in sufficient time to allow inflow of such support. This is evidenced by the fact that although the first official report of the outbreak was on 22 August 2008, unofficial reports had been circulating in the media much earlier. Since the first official report of the outbreak became public, the Government was silent on the issue until December 2008, when the Minister of Health and Child Welfare eventually declared the cholera outbreak a state of emergency. After this declaration of a state of emergency, donors responded immediately and provided financial support through UN agencies and NGOs to fight the cholera outbreak.

## *4.1.2. Status on IHR and IDSR*

other clinical and public health experts. The ideal for the country is two to three nurses and one EHT for every RHC. The district hospital is ideally supposed to be supported by 50–100 nurses, and three to eight doctors depending on the size. From independence, the supply of health workers improved up to about year 2000, when almost all the district hospitals had at least one doctor. Nurses' coverage at RHC level had been improving up to a time when every

The health system, during the period 2008–2009, was far from being resilient and being able to absorb shocks whilst maintaining normal functionality. By the time the 2008/2009 cholera outbreak struck, the health system was at its weakest. It was characterized by a critical shortage of skilled as well as motivated health workers; critical shortages of essential medicines and supplies and medical technologies; dilapidated health infrastructure; unreliable health information systems and weak surveillance systems; poor service delivery and poor health stewardship under inexperienced health leadership [20]. In one study on community mortality from Cholera in Zimbabwe, the poor access to health services and limited availability of

The health system was dysfunctional as far as promoting provision of core health services because of the nationwide economic decline and staff attrition. For instance, most health workers including nurses, doctors, EHTs and laboratory scientist left for greener pastures either within or outside the country leaving RHCs without nurses and many district hospitals without doctors [21]. This left the health system poorly serviced by human resources [22]. According to the World Health Organization (WHO), the ratio of health workers per 1000 population was 0.162 in 2004 dropping to 0.05 in 2007 for physicians and that for nurses and midwives dropping from 1.491 in 1995 to 1.215 in 2009 [23]. With the country's economy at its worst, affected by hyperinflation, financing for health was at its lowest during this period. Total health expenditure was 8.9% of GDP, with out of pocket expenditure constituting 50.4% of health expenditure [24]. Total health expenditure per capita was estimated at \$16.21 in 2008 [25]. As such, surge capacity was nonexistent. With the lack of confidence in the health system a good proportion of the population was seeking for health care elsewhere which meant that some threats would not be detected by the health system late. Such a system could not adapt,

An up-to-date map of human, physical, and information assets that highlight areas of strength and vulnerability was not in place. Real time strategic health information and epidemiological surveillance systems as well as the use of indicator and event based surveillance systems were not in place. Some information was however available on the vulnerabilities of the population to different threats although not well disseminated to impel action. The functionality of the health information network was at its lowest, human resources were poorly motivated and not available at work to record surveillance data, analyze it and use the information for decision making. The surveillance system which was then largely paper based and not real time was severely affected by the transport and communication systems which were also at

Resilient systems have the ability to harness human, financial and logistical resources from health and non-health fields, coordinate actors and manage partnerships. The strength of the country was the availability of inbuilt structures for coordination including the Civil

oral rehydration salts were some of the causes for high community mortality [20].

transform and improve performance in the face of an outbreak.

RHC had at least one nurse.

50 Current Issues in Global Health

a low level.

The International Health Regulations (2005), or IHR (2005), represents a binding international legal instrument involving 196 countries across the globe, including all the WHO Member States. The purpose and scope of the IHR (2005) is "to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade." The IHR (2005), to which Zimbabwe is a signatory, has shaped the country's preparedness [26], prevention and response efforts to public health risks, but only after the 2008/2009 cholera outbreak.

The IHR (2005) sets guidelines for core capacities which must be implemented in order to prevent or respond to disease outbreaks and other public health events of international concern. This includes strengthening of core capacities at ports of entry to prevent exit or entry of infectious hazards. Alongside this is enabling legislation, establishment and strengthening IHR national focal points for the coordination of stakeholders and reporting of diseases of public health importance to WHO.

The 2008/2009 cholera outbreak occurred outside the period of implementation of IHR (2005) for the country which was to start in 2011 with discussions and base-lining of country capacities for implementation of IHR (2005). State parties, in line with IHR (2005), are required to strengthen capacities in preparedness and response efforts. This requires countries to have multi-hazards national public health emergency preparedness and response plans which have to be periodically tested, including identification of hot spots and developing mechanisms for resource pooling and deployment during times of emergencies. This kind of plan did not exist before the 2008/2009 cholera outbreak.

Integrated Disease Surveillance and Response (IDSR) was adopted as a tool for detection and response to epidemics by the WHO Regional Committee for Africa in 1998. In Zimbabwe, training modules were developed between 2001 and 2007, national adaptation carried out, training of trainers and training of health workers conducted. Although the training of trainers covered the whole country, cascade training of health workers was at a slower pace because of the limited financial resources. This capacity in IDSR was later to be negatively affected by the health worker attrition. With the coming of IHR (2005) AFR member states agreed that the implementation of IHR (2005) in Africa was going to be through IDSR.
