The research team, led by Chanda Mwamba and Tikulirekuti Banda of the Centre for Infectious Disease Research in Zambia, together with collaborators from the Zambia National Public Health Institute, the Ministry of Health, Unity Health Toronto and the World Health Organization’s Alliance for Health Policy and Systems Research, evaluated the implementation of Zambia’s Multisectoral Cholera Elimination Plan, or MCEP. The plan, running from 2019 to 2025, aims to reduce cholera-related mortality by ninety percent, in line with the global roadmap. To understand how the plan moved from paper to practice, the researchers applied six phases of the Knowledge-to-Action framework, a widely used implementation science model that tracks how evidence is adapted to local contexts, how barriers are assessed, how interventions are put in place, and how knowledge use is monitored, evaluated and sustained over time.

The study combined several qualitative methods to build a layered picture of implementation. The researchers independently reviewed the MCEP document itself, examining how global guidance had been contextualized for Zambian conditions. They then triangulated this documentary evidence with 24 key informant interviews involving policy-makers and implementers at national, provincial, district and facility levels, 12 in-depth interviews with cholera survivors, and four focus group discussions with 28 members of community-based neighbourhood health committees. Fieldwork took place between April 2020 and May 2021 in two contrasting cholera hotspots: Mpulungu District, a swampy lakeside setting, and Lusaka District, a densely populated periurban environment. Thematic analysis, guided by the Knowledge-to-Action domains, was used to organize and interpret the data, and findings were cross-checked across sources to strengthen credibility.

Zambia’s vulnerability to cholera is well documented. Between 1977 and 2018, the country endured 29 cholera emergencies, with recorded cases ranging from 14 to 13,500 and case fatality rates between 0.5 and 9.3 percent. These outbreaks occurred chiefly in periurban areas and fishing camps that share waters with the Democratic Republic of Congo, Mozambique, Tanzania and Zimbabwe, and are characterized by poor sanitation, inadequate water supply, deficient drainage and weak solid waste management. Rapid urbanization intensifies these pressures, while high cross-border movement with cholera-prone neighbours complicates control efforts. The 2017 to 2018 outbreak that preceded the study period affected seven of Zambia’s ten provinces, producing 5,905 suspected cases and 98 deaths, an experience that sharpened political attention on the elimination agenda.

The document review revealed that the MCEP strategically targets twelve identified cholera hotspots for oral cholera vaccine campaigns, aiming for quick, visible results and public confidence before embarking on larger infrastructure and behaviour-change projects. These hotspots were identified through epidemiological, geographical and contextual analyses, encompassing areas with recurrent outbreaks, poor water, sanitation and hygiene services, transit points, slums, flooding, fishing camps and refugee influxes. The plan rests on a decentralized multisectoral governance structure anchored in national frameworks such as Vision 2030 and the Seventh National Development Plan, and it operationalizes its strategy through technical working groups covering water, sanitation and hygiene, case management, surveillance and laboratory capacity, community engagement and vaccination. Local adaptations emerged as well: in Mpulungu, revitalized community-led total sanitation projects target open defecation around lakeshores, while in Lusaka, interventions included installing pipes and drainage systems, burying shallow boreholes, and creating designated rubbish collection points after outbreaks.

Despite this thoughtful design, the study uncovered formidable barriers that have produced fragmented implementation. Perhaps the most consequential is the absence of a dedicated budget line for the MCEP, which left financing dependent on ministries with different priorities and vulnerable to redirection, particularly during the COVID-19 pandemic. Participants described how funds arrived late and flowed toward temporary emergency measures, such as water tanks during outbreaks, rather than durable infrastructure. ‘Cholera is seen as health rather than a development issue,’ one non-governmental organization actor explained, noting that funding only materializes during outbreaks, which is expensive and diverts resources from developmental activities. Underfunding of water, sanitation and hygiene infrastructure shaped how communities received cholera guidance, since hygiene recommendations are difficult to follow where piped water, sewerage and drainage simply do not exist. Community health volunteers, meanwhile, reported demotivation stemming from a lack of allowances, protective equipment and transport.

Knowledge translation emerged as another critical weak point. National and provincial health leaders demonstrated solid understanding of the MCEP’s strategic direction, but facility-level implementers and non-governmental actors, particularly in Mpulungu, knew far less about the plan itself, with one participant admitting they were ‘learning of that document today’ despite being familiar with district and provincial cholera taskforces. Stakeholders even disagreed about whether implementation was fundamentally bottom-up or top-down, revealing inconsistent internal communication. Coordination also faltered because the response was perceived to be driven predominantly by the Ministry of Health, leaving other sectors with variable responsibility and resources. Participants consistently argued that stronger accountability, commitment and shared ownership across ministries were essential, and some pointed to the COVID-19 response, with its rapid policy-making and enforcement, as a model for how cholera guidelines might be more effectively communicated and upheld.

Nevertheless, the study documents meaningful progress. The appointment of a national cholera elimination coordinator and the formation of multisectoral technical working groups improved coordination and strengthened the case for investment in laboratory capacity, vaccines and infrastructure. Zambia became one of the first four countries to receive Global Task Force on Cholera Control funds in recognition of its elimination efforts, and the leadership team continues to lobby parliamentarians for inclusion of the MCEP in the national budget. Each level of the health system now maintains emergency preparedness plans, and a monitoring framework with strategic and programmatic indicators tracks case fatality, early detection, coordination, financing and vaccine coverage. Encouragingly, Zambia has recorded no cholera outbreak since 2019, which national informants attribute to high vaccine uptake in hotspot areas during and after the 2017-2018 outbreak, intensified environmental cleaning, and increased community knowledge about chlorine use and preventive measures.

The sustainability of these gains, however, is not assured. The researchers found gaps in evidence synthesis for knowledge users, limited monitoring and evaluation capacity, and no earmarked funds for locally determined operational research. The National Health Research Authority, which is responsible for knowledge synthesis, was integrated into technical working groups only after the MCEP was developed and is still building its systems. Drawing comparisons with Zimbabwe and Ethiopia, where multisectoral cholera elimination plans similarly face large funding gaps, the authors caution that global attention and resources diverted to COVID-19 may further threaten resource mobilization. The authors conclude that a multisectoral approach can generate the momentum and efficiencies needed to eliminate cholera in Zambia, but only if stakeholders are fully committed and funding is secured. They call for comprehensive advocacy, national and international budget commitments, robust monitoring and evaluation, and an adaptive collaborative strategy embedded within national guidelines that genuinely includes target communities in local translation and adaptation of the elimination agenda.

Subject of Research: Translating global cholera elimination guidelines into national multisectoral policy and local implementation in Zambia

Article Title: Raising the bar: translating global guidelines to achieve local policy on cholera elimination in Zambia—a qualitative case study

Article References: Mwamba, C., Banda, T., Mazaba, M., Mukonka, V., Malama, K., Hamweemba, E., Syulikwa, M., Chilengi, R., Sharma, A., Fahim, C., Marten, R., Yangchen, S., Straus, S., & The RAISE Project (2026). Raising the bar: translating global guidelines to achieve local policy on cholera elimination in Zambia—a qualitative case study. Health Research Policy and Systems, 24(S1), Article 71. https://doi.org/10.1186/s12961-026-01464-7

Image Credits: AI Generated

DOI: 10.1186/s12961-026-01464-7

Keywords: cholera elimination, Zambia, multisectoral approach, Knowledge-to-Action framework, Global Task Force on Cholera Control, oral cholera vaccine, water sanitation and hygiene, health policy implementation, knowledge translation, qualitative case study, sub-Saharan Africa, community engagement