The health system during the period 2008–2009 was far from being resilient

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. Th

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