Evaluating the progress in cholera prevention and control in the WHO African region

Cholera continues to represent a major public health concern in Sub-Saharan Africa, driven primarily by limited access to water, sanitation and hygiene (WASH) services^[1]. To control cholera, the GTFCC^[2] launched the strategy Ending Cholera: A Global Roadmap to 2030’ in 2017^[3]. The following year at the WHO Regional Committee for Africa, 47 African countries adopted a regional framework to guide countries in the implementation of the global roadmap^[4]. The framework provides step-by-step guidance to implement the strategy, with 21 milestones grouped according to four targets. The overarching targets include (1) contributing to the goal of eliminating predictable cholera epidemics, (2) achieving a 50% reduction in the magnitude of cholera outbreaks (particularly among vulnerable populations and during humanitarian crises), (3) ensuring regular monitoring, evaluation and adaptation of the regional cholera framework, and (4) ensuring that countries develop their National Cholera Plans (NCPs). 

A recent study by Kapaya et al. has assessed the five-year progress in implementing the framework, identified challenges encountered, and proposed a set of recommendations to meet the 2030 global cholera elimination target^[5]. For this study, 27 of 47 countries in the region participated, including 11 from West Africa^[6], five from central Africa^[7], five from East Africa^[8] and six from southern Africa^[9]. Data was collected from multisectoral teams of experts on cholera from each country via a web-based self-assessment tool. Progress at the country and regional levels were evaluated. 

The overall regional progress was 53 %, ranging from 19 % in Mauritania to 76 % in Ethiopia. Out of the 27 countries, only three - Ethiopia, Kenya and Zambia - had made good progress, while 14 countries had fair progress and 10 countries had insufficient progress. 

Assessing the progress made at the target level revealed that the region is not on track for all four targets. The targets focused on eliminating predictable cholera epidemics and reducing the magnitude of cholera outbreaks were at 59 % and 54 % (fair progress), respectively. Furthermore, the target aiming to ensure regular monitoring and adaptation of the framework was only 39 % (unsatisfactory/insufficient progress). The target addressing the development of NCPs in each country was at 43% (unsatisfactory/insufficient progress).

At the regional level, four milestones were on track, among which cholera hotspot mapping had the highest score (85 %). Seven milestones had fair progress, including development of cholera outbreak preparedness and response plans (61 %), enhanced cross-border surveillance (52 %), established rapid response teams for field investigations (63 %), and strengthened cholera case management capacities (69 %). However, 10 milestones had insufficient progress, including mobilization of resources for cholera (40 %), implementation of multisectoral cholera prevention and control plans in all hotspots (44 %), development of a social mobilization strategy and community-based interventions (43 %), and ensuring water quality interventions in all hotspots (31 %).

Overall, the study revealed progress in some milestones; however, critical investments in WASH remained low and sustainable financing in cholera control programs was insufficient. To curb the current trend of cholera outbreaks in Africa, there is a critical need for solid government commitment and ownership, strengthened health systems and increased investment in long-term cholera control measures.