JPHIA Journal of Public Health in Africa 2038-9922 2038-9930 AOSIS JPHIA-16-1572 10.4102/jphia.v16i4.1572 Original Research A proposed framework for the evaluation of cholera surveillance systems in Africa https://orcid.org/0000-0002-0459-7006 Mercy Kyeng 1 2 https://orcid.org/0000-0002-8711-2579 Pokhariyal Ganesh 3 https://orcid.org/0000-0002-3404-0663 Fongwen Noah Takah 2 https://orcid.org/0000-0002-9498-3428 Ndembi Nicaise 2 https://orcid.org/0000-0002-0958-1580 Kivuti-Bitok Lucy 4 Department of Medical Microbiology, Faculty of Health Sciences, University of Nairobi, Nairobi, Kenya Department of Surveillance and Disease Intelligence, Faculty of Public Health Emergency, Africa Centres for Disease Control and Prevention, Addis Ababa, Ethiopia Department of Mathematics, Faculty of Science, University of Nairobi, Nairobi, Kenya Department of Nursing, Faculty of Health Sciences, University of Nairobi, Nairobi, Kenya Corresponding author: Kyeng Mercy, NjiT@africacdc.org 02122025 2025 16 4 1572 19072025 10102025 © 2025. The Authors 2025 Licensee: AOSIS. This work is licensed under the Creative Commons Attribution 4.0 International (CC BY 4.0) license. Background

Despite the global roadmap to end cholera by 2030, the disease remains a major public health challenge in Africa, compounded by weak surveillance systems, inadequate multisectoral coordination and delayed case detection. A significant impediment is the absence of a comprehensive surveillance evaluation framework for African nations to systematically identify and address these critical capacity deficits.

 Aim

This study builds upon prior research that highlighted the wide variations in existing surveillance evaluation frameworks, aiming to propose a comprehensive conceptual framework for assessing cholera surveillance systems in Africa.

 Setting

This study focused on empirical data and feedback gathered from eight cholera-affected countries: Democratic Republic of Congo, Nigeria, Zambia, Zimbabwe, Mozambique, Somalia, Kenya, and Ethiopia.

 Methods

This was a mixed-method study and leveraged insights from a previous systematic review lasted 7 months (July 2024 to January 2025). The approach involved a detailed assessment of existing frameworks and consultations with eight cholera-affected countries.

 Results

The assessment of 10 existing frameworks revealed consistent gaps, notably the absence of essential components such as cross-border surveillance, digitisation, effective linkages between surveillance and laboratory systems, and sustainable financing mechanisms. Our conceptual framework is structured around three key pillars: resource allocation, system structures and core functions, all underpinned by strong governance and leadership.

 Conclusion

This study recommends the adaptation and integration of our proposed comprehensive framework into broader surveillance strategies and guidelines to significantly improve cholera surveillance across Africa, thereby enhancing early detection and response capabilities.

 Contribution

This study presents a novel comprehensive framework for cholera surveillance system evaluation and recommends its adaptation and integration into broader surveillance strategies and guidelines to significantly improve cholera surveillance in Africa.

 cholera surveillance system evaluation detection Africa public health outbreak framework Funding information This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. Introduction

Despite the World Health Organization’s (WHO) goal to halve cholera cases reported in 2018 by 2022, the past decade has witnessed a global rise in the disease. From January 2013 to February 2024, 1 224 997 cases and 75 784 deaths (case fatality rate [CFR]:6.2%) were recorded across 30 African Union Member States.1,2,3 As of February 2024, six African Union Member States are currently in an ‘acute crisis’ because of cholera: Democratic Republic of the Congo, Ethiopia, Mozambique, Tanzania, Zambia and Zimbabwe.4 Weak surveillance systems resulting in late detection has been reported as one of the critical gaps in the fight against cholera in Africa.5 In addition, cross-border transmission within the region continues to propagate the spread of cholera even in non-endemic countries.6

In response to the increasing global burden of cholera, the Global Task Force on Cholera Control (GTFCC) developed a global roadmap to end cholera by 2030.7 One of the challenges this roadmap highlighted was the issue of weak coordination across sectors and borders and under-reporting. The inadequate availability of trained staff at the peripheral level and limited or poor cross-border surveillance for early detection of cases were also mentioned as major surveillance gaps that should be addressed. While several tools exist to guide the establishment of disease surveillance systems including the Integrated Disease Surveillance and Response (IDSR) strategy, the monitoring and evaluation (M&E) tool for communicable diseases, the Africa Centres for Disease Control and Prevention (CDC) event-based surveillance M&E tool, there is wide variation on recommended core components for surveillance across these tools. There is also limited information on the availability of a cholera surveillance evaluation framework that is comprehensive enough to guide countries on cholera surveillance evaluation.8 This gap has led to several public health practitioners using multiple tools to increase the spectrum of the surveillance capacities evaluated, which may be subjective and not standardised. Our primary goal was to assess critical components across the different existing frameworks and create a comprehensive framework for evaluating cholera surveillance systems in Africa.

 Research methods and design

This study was a mixed-methods study that built up on a previous systematic review that assessed M&E frameworks that have been deployed in Africa for the assessment of cholera surveillance systems.8 It followed a three-step approach that lasted 6 months (July 2024 – January 2025) including: framework assessments (strengths and weaknesses), consultation with countries for the mapping of critical variables for the proposed framework and the validation of the new framework with country surveillance focal persons (Figure 1). The strengths and weaknesses of existing frameworks were assessed based on a consolidated list of parameters proposed by Mercy et al.8 Critical parameters included in the proposed framework were identified through a consultative process with surveillance focal points from eight African Union Member States (Democratic Republic of Congo, Nigeria, Zambia, Zimbabwe, Mozambique, Somalia, Kenya and Ethiopia) reporting cholera cases in February 2024. During the development of the conceptual framework, four assumptions were made. The first assumption was that a country’s national policies and capacities are homogenous nationwide, and there is a central coordination mechanism in charge of developing and enforcing surveillance policies. The second is that the public health surveillance pillar is not a stand-alone ministry but embedded within the national public health institute, the ministry of health or equivalent structures. The third is that all African countries are signatories to the Abuja declaration and committed to achieving its target. Lastly, surveillance systems are agile and flexible to adapt to new recommendations and changes.

Framework development steps.

 Study setting

The study setting for this research is Africa, specifically focusing on the evaluation of cholera surveillance systems across the continent. The core setting for gathering empirical data and feedback involved eight cholera-affected African countries: Democratic Republic of Congo, Nigeria, Zambia, Zimbabwe, Mozambique, Somalia, Kenya and Ethiopia.

 Data collection

Data on key parameters available in existing surveillance framework were obtained from a previous systematic review conducted by Mercy et al.8 Disease surveillance experts reviewed and proposed other evaluation tools missing in the systematic review. Information on the title, the targeted threat (or disease under study), objective of the framework and the strength and weaknesses of the framework was entered into an Excel tool.

 Data analysis

We consolidated and summarised results in a tabular form to facilitate the visualisation of the availability of key elements evaluated: type of framework, objective of the framework, and strength and weaknesses. The strengths and weaknesses were assessed based on the literature review of articles that deployed them as well as expert opinions.

 Ethical considerations

Ethical approval to conduct this study was obtained from Kenyatta National Hospital (KNH), University of Nairobi (UoN) Ethical Review Committee (Ref: No. No. KNH/ERC/R/71).

 Results

A total of 10 frameworks or guidelines were assessed (Table 1). Five from the systematic review study and the other five from other sources. Three were tailored specifically for cholera, while seven had a broader scope of hazards and risks of which cholera was included.

Surveillance evaluation frameworks assessed.

Document title Target threat Objective Strength Weaknesses
Global Taskforce for Cholera Control: Public health surveillance for cholera: Interim guidance Cholera To provide interim recommendations for strengthening public health surveillance for cholera Tailored specifically for cholera. It highlights the need for multisectoral information exchange and recommends this component in the proposed information flow. Did not include indicators for the evaluation of the effectiveness of established cholera surveillance.Doesn’t highlight cross-border surveillance for cholera. Also, focuses only on case-based surveillance. The integration of environmental surveillance for cholera is also absent.
An overview of the WHO framework for monitoring and evaluating surveillance and response systems for communicable diseases All communicable diseases To strengthen surveillance and response activities and build on experiences gained by Member States in monitoring and evaluating their surveillance and response systems Has well-outlined indicators and parameters to be considered for evaluation. Includes all core functions and supportive functions. Outline steps for monitoring and evaluating systems. This tool was deployed successfully by Ngwa et al. Did not include cross-border collaboration, a parameter to be considered. Digitalisation and linkage of surveillance to lab capacity was also not included.
International Association of Public Health Institutes: Conceptual framework in the integrated disease surveillance summary report All diseases of interest (both communicable and non-communicable) To identify key barriers, enablers, and opportunities revealed by responses to the COVID-19 pandemic Includes indicators for core functions and supportive functions (system requirements) of surveillance systems. It also includes enablers such as multisectoral coordination, partnership, digitalisation and IT.In addition, prediction and forecasting were listed as one of the capabilities of the surveillance institutes. Did not consider cross-border collaboration as a parameter to be evaluated. Even though laboratory networks were mentioned, it was not clear if linkage of surveillance system to lab capacity was considered. Environmental surveillance was not mentioned.
Integrated Disease Surveillance and Response M&E Forty priority diseases, including cholera, are listed under immediate reporting. To implement comprehensive public health surveillance and response systems for priority diseases, conditions and events at all levels of health systems The M&E tool includes all the core functions in alignment with the IHR (detection, reporting, analysis, and interpretation, prepare, respond, feedback and supportive supervision) and provides a comprehensive list of all system attributes. Although the IDSR strategy highlights all core functions in the IHR, there is need to include prediction as an additional function. The M&E tool focuses only on the core functions and attributes. Thus, countries may not be able to evaluate critical supportive capacities such as coordination, cross-border, digitalisation etc.Also, the system does not perform adequately during conflicts or emergencies.
IDSR Integrated surveillance and response framework and scorecard All acute public health events including cholera-related events To guide stakeholders interested in implementing EBS using a multisectoral, One Health approach Includes all indicators for core functions and supportive functions in the context of event-based surveillance. Also includes enablers such as digitalisation, governance and legislation. Underscores multi-sectoral coordination and information exchange in the proposed information exchange architecture. The focus was only on event-based surveillance. Countries may not be able to apply some of the indicators in the context of indicator-based surveillance.
US CDC Updated Guidelines for Evaluating Public Health Surveillance Systems All diseases and acute events To organise the evaluation of a public health surveillance system Provided a comprehensive picture of the indicators for system attributes to be evaluated and other tools have adopted and integrated this list into their M&E matrix. It also provides a step-wise process to stakeholders on how to evaluate a surveillance system. Majority of the core and supportive functions were not included and thus evaluations done using this tool may provide limited information to stakeholders on areas such as the ability of the system to verify events, availability of guidelines and SOPs, multisectoral coordination, digitalisation etc.
Outbreak surveillance and response in humanitarian emergencies: WHO guidelines for EWARN implementation. All diseases To provide a standard framework and best current practice for implementation of an EWARN and its operation in the field, following humanitarian emergencies Very efficient in humanitarian or crises settings. It has been tested and proven efficient by Somalia and South Sudan.Leverages digitalisation for reporting. In general, no M&E indicators for core functions. All attributes were extracted from IDSR.It is mainly a supportive surveillance approach that complements a national surveillance system/strategy during emergencies.
Ethiopia National guideline for cholera surveillance and outbreak response-3rd edition Cholera To provide national guidance in achieving global targets of 90% cholera death reduction by 2030 This guideline is focused on cholera and outlines a generic M&E framework (similar to IDSR). The M&E included coordination across sectors and legislation, which are often missed.Digitalisation was not captured as a key enabler to be monitored. Even though the guideline laid emphasis on the establishment of cross-border surveillance, the M&E had no indicators on this piece. In addition, digitalisation was not emphasised as a key component or enabler of the system. The framework was focused on case-based surveillance with no strategy of the use of environmental surveillance data for early warning.
Early warning alert and response in emergencies: An operational guide Cholera and other outbreak prone diseases and events To guide decision making on when and how to implement and strengthen EWAR in preparation for and response to emergencies Detailed guidance on the implementation of indicator and event-Based surveillance listed. The M&E tool provides details on the monitoring attributes adopted from the IDSR framework. Not tailored for cholera and thus multisectoral coordination not included in indicators. No indicator on cross-border surveillance, digitalisation and system structuring.
Framework for the development and monitoring of a multi-sectoral National Cholera Plan Cholera To assist national governments in all relevant sectors, technical partners and any other stakeholders involved in planning cholera prevention and control activities Provides comprehensive indicators for the monitoring of the implementation of national cholera plans inclusive of cholera surveillance indicators. Emphasises the establishment of multisectoral coordination mechanisms for surveillance. Identified environmental surveillance as a gap.Cross-border surveillance was also recommended. Indicators not available on public domain. The use of other surveillance data (metrological data, environmental data) for risk mapping and early warning was not emphasised.Digitalisation under the surveillance pillar was not mentioned.Prediction and forecasting capabilities were not mentioned.There is no visualisation on how the different components in surveillance connect with each other.

EBS, event-based surveillance; EWARN, Early Warning and Response Network; IDSR, Integrated Disease Surveillance and Response; EWAR, Early Warning Alert and Response; GTFCC, Global Task Force on Cholera Control; M&E, monitoring and evaluation; US, United States; CDC, Centres for Disease Control and Prevention; WHO, World Health Organization; IHR, International Health Regulations; SOPs, standard operating procedures; IT, information technology.

 Proposed framework for cholera surveillance

This framework composed of three key pillars (see Figures 2 and 3): resource allocation, system structures and core functions, is anchored on good governance and leadership. To ensure that the system constantly remains relevant and is meeting its set objectives, it is continuously monitored for the system attributes (see Figure 1).

Interaction of different core components of the proposed cholera framework.

A proposed framework for the evuluation of cholera surveillance.

 Key parameters often missed across frameworks assessed Digital system and interoperability

This was 2 out of 10 (20%) framework but was found very critical by 100% of the surveillance focal points for inclusion in the proposed framework:

‘Linkage between surveillance and lab systems is crucial for timely confirmation and monitoring of cholera strains. Improved coordination can enhance data completeness, timeliness of response, and analysis by ensuring a seamless flow of information between surveillance and laboratory teams.’ (Nigeria surveillance focal point, ID-002, Male)

As countries continue to embrace digitalisation with the on-boarding of new technologies, the interoperability of such systems with existing ones should be assessed.

 Cross-border surveillance coordination mechanisms

Cross-border was missing in 100% of all the frameworks assessed but surveillance focal points indicated that this was one of the major surveillance gaps leading to cross-border spread of cholera both in the horn of Africa and in Southern Africa:

‘Gaps currently exist in strengthening screening at cross-border points [especially ground-crossing points] especially for porous borders. We also need more cross-border collaboration meetings and creating forums for sharing data across countries.’ (Uganda event-based surveillance focal point, 1D-004, Male)

Cross-border surveillance is thus a key mechanism for information sharing and coordinating response and hence should be considered when evaluating the effectiveness of a surveillance system.

 Laboratory and surveillance networks

While laboratory confirmation capacity is one of the core functions of a surveillance system listed by several frameworks, laboratory and surveillance networks that are key mechanisms towards achieving optimal laboratory performance (such as whole genome sequencing) were often not included in the frameworks assessed.8,9 All the surveillance experts agreed that laboratory networks could play a critical role in improving the weak testing capacity as well as validation of testing at lower levels:

‘While there is an elaborate laboratory network within the country, most of them are poorly resourced in terms of technical capacities, supplies, equipment, and infrastructure that weaken the capacity to support surveillance. Weak links exist in validated POS screening field RDTs, sample management [collection, packaging, storage, and shipment facilities], Confirmation capacities at the lowest level possible, surveillance and laboratory information linkages and Genomic surveillance.’ (Kenya event-based surveillance focal point, 1D-001, Male)

 Prediction and forecasting

While all (100%) the frameworks included data analyses and interpretation as a core function, this analysis is mainly limited to trend lines, case distribution maps and other basic epidemiological analysis.10 This currently represents a gap that Zimbabwe focal point attested to. Given that the current outbreaks in the southern Africa region is driven by climate change, improving predictive analysis using weather and other relevant surveillance data would improve country planning and preparedness efforts:

‘Prediction analytics would greatly help us to prepare for the seasonal occurrence of cholera outbreaks. This would also be added onto the national and sub-national seasonal calendars.’ (Zambia event-based surveillance focal point, ID-003, Male)

 Governance and legislation

The main legislative reference made by several frameworks was compliance with IHR,11,12 which urged countries to build core capacities to prevent, detect, notify and respond to health threats. It also urged countries to establish data sharing frameworks to improve information exchange across the borders for improved coordinated response to health threats. Kenya focal point expressed concerns about the lack of data sharing frameworks as one of the gaps that needs to be addressed to improve cross border surveillance for cholera and other infectious diseases and recommended the inclusion of this parameter in the proposed framework:

‘Lack of data sharing frameworks and regulations remains a critical gap that needs to be addressed to facilitate information sharing across countries’ (Kenya event-based surveillance focal point, 1D-001, Male).

Compliance with government financial investments in healthcare such as the ‘Abuja declaration’ was also not included by any of the frameworks.

 Discussion

There is a wide diversity in the parameters included in the different frameworks assessed. Within the resource pillar, human resources remained one of the vital components of the performance of any surveillance system highlighted by the existing frameworks as well as expert opinions. Other studies have demonstrated the critical role human resource coordination plays in the control of cholera outbreaks.9 This ranges from community health workers at the lowest level of the health system to modellers, mentors/supervisors and decision-makers at all levels. However, it is important to ensure that these workforces acquire the necessary skills to enable them to optimally perform. Guidelines and standard operating procedures, including standard case definitions, signals (data and/or information considered by the Early Warning and Response System as representing potential acute health risk, such as an outbreak, namely, cluster of cases presenting with similar signs and symptoms, change in watercolour, taste and smell), definitions and reporting timelines should be available at all levels. Laboratory capacity is also one of the critical resources that would determine timely confirmation of cholera cases. However, it is recommended that such capacities must be decentralised to achieve the desired results.14 To ensure that the system can meet up with the timeline matrix, functional and sustainable digital infrastructure should be established.

The establishment of coordination mechanisms including architecture of reporting and flow of information across different levels and relevant sectors (e.g., ministries of human, environment, water and town planning) has been shown to be vital for ensuring better collaboration on strengthening preventive, preparedness and response measures.15,16,17 The absence of these mechanisms in frameworks has hindered the ability for countries to evaluate these systems as an integral component of a functional surveillance system making it difficult for the identification of gaps for improvements. Within the International Health Regulation (IHR), coordination and legislation are a recommended core capacity, however, all countries but Ethiopia, South Africa and Mauritius had limited or no capacity in both areas during the last joint external evaluation.18 The establishment of solutions, systems and networks that allow the use of data across multiple sectors is also key to advancing collaboration and coordination. Expert forums which is one of the recommended mechanisms in this framework has shown to support the analyses and interpretation of complex data sets for early detection, prediction and risk mapping.19 Laboratory and surveillance networks have also been instrumental in improving quality control on procedures and peer to peer support on data interpretation.20 Cross-border committees have been established in the Eastern Africa for diseases such as Tuberculosis.21 However, the integration of this parameter in the proposed framework would provide an opportunity for the evaluation of the actual functionality of these cross-border committees.

Some limitations of this study such as a focus on English frameworks and only on the surveillance component in the entire detection and response spectrum may limit the generalisability of the study. Despite the weaknesses, our study is the first to synthesise the evidence on the evaluation frameworks for cholera surveillance in Africa and the framework proposed is the first of its kind to be developed, drawing from the caveats of other frameworks. Furthermore, the feedback obtained from countries provided a representative country feedback that enhanced the robustness and potential relevance of the proposed framework in the field.

The proposed framework provides guidance to public health practitioners on critical parameters to consider during the evaluation of cholera surveillance systems in Africa. To better understand the feasibility in implementing the proposed parameters in this conceptual framework, future research should focus on piloting this framework in selected African countries. In addition, the response component should be incorporated to complete the surveillance and response spectrum.

 Conclusion

Several guidelines exist for cholera, some of which include guidance for cholera surveillance as well as a monitoring framework for national cholera plans that could be adapted for the evaluation of cholera surveillance systems. However, the current surveillance frameworks are missing critical indicators of core functions and mechanisms that are critical to the optimal functioning of a good cholera surveillance system such as digital infrastructure and system interoperability, cross-border surveillance, predictive and forecasting capabilities, laboratory and surveillance networks, system financing. This study assumes that if these components are considered and integrated within the framework of surveillance system evaluations for cholera and other communicable diseases, countries would be better placed to understand where the surveillance gaps are and work towards addressing them. The IDSR strategy implemented by the WHO Africa region and the integrated disease surveillance strategy implemented by the WHO EMRO (Eastern Mediterranean) region could be a good way to start.

 Acknowledgements

The authors would like to thank Moses Otieno for facilitating some of the focus group discussions in Nairobi and all the focal points from the different facilities who took part in the study. They would also like to acknowledge the insights provided by Dr Philip Ngere (National event-based surveillance focal point) for his valuable contributions. We also acknowledge the contributions of all key informants as well as participants of the focus group discussions.

Competing interests

The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.

 Authors’ contributions

K.M. developed the original idea for this study including the study design and methodology. K.M., N.T.F. and L.K.B. analysed the data. K.M., G.P., N.N. and L.K.B. reviewed and improved the article. All authors provided feedback and approved the content of the final article.

 Data availability

All data analysed and discussed are included in this article.

 Disclaimer

The views and opinions expressed in this article are those of the authors and are the product of professional research. The article does not necessarily reflect the official policy or position of any affiliated institution, funder, agency, or that of the publisher. The authors are responsible for this article’s results, findings and content.

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How to cite this article: Mercy K, Pokhariyal G, Fongwen NT, Ndembi N, Kivuti-Bitok L. A proposed framework for the evaluation of cholera surveillance systems in Africa. J Public Health Africa. 2025;16(4), a1572. https://doi.org/10.4102/jphia.v16i4.1572

Note: The manuscript is a contribution to the themed collection titled ‘Strengthening Scientific Publication Capacity of African Researchers’, under the expert guidance of guest editor Prof. Peter Nyasulu.