Engaging in the development of an NCP means that cholera is recognized as a national priority by the country. Demonstrating political will and engagement in the Global Roadmap is considered a prerequisite for the development of an NCP. It will mark the beginning of the NCP preparatory phase that includes the identification of the priority areas for intervention (also called cholera hotspots), and identification of mechanisms and stakeholders that can be leveraged to ensure strong coordination of the NCP development, implementation and monitoring .The situational analysis will facilitate the formulation of the national goal regarding cholera control or elimination, and the establishment of a coordination mechanism that will guide the NCP implementation.

A. Country commitment

Countries formally express their political, technical and financial engagement to control or eliminate cholera through a multisectoral approach . Countries should commit to the following guiding principles:

  • An alignment with the approach described in the Global Roadmap.
  • The NCP should be multisectoral and comprehensive . Relevant ministries, government agencies and institutions at all levels (national, regional, municipal levels) -as well as the private sector - should be involved in the process (relevant sectors include health, water, construction, finance, education, food production, etc.).
  • The NCP should be linked with existing health and WASH systems and relevant emergency and development frameworks and plans.
  • The NCP should be multi-year and should include plans for monitoring and evaluation of the country's progress over time .
  • The NCP states the country's goal regarding cholera control or elimination.

Examples of activities to be considered:

Expressions of commitment will vary depending on the country. Examples include:

  • Establishment of a national cholera programme.
  • Development of specific legislation on cholera control.
  • Organization of a high-level workshop with key stakeholders.
  • Written or public commitments to achieve the Global Roadmap goals.
B. Identification of cholera hotspots

Following the expression of commitment, the country should conduct a situational analysis. This analysis should first include the identification of the priority areas for intervention, often referred to as cholera hotspots. ⁽⁴⁾ Cholera hotspots are geographically limited areas where cultural, environmental and socioeconomic conditions facilitate the transmission of disease and where cholera persists or reappears regularly.

It is important to note that as part of the monitoring and evaluation of the plan, the list of cholera hotspots should be reviewed and updated annually.

Suggested tools:

Hotspot definition: A geographically limited area (such as a city, administrative level 2 or health district catchment area or lower) where environmental, cultural and/or socioeconomic conditions facilitate the transmission of the disease, and where cholera persists or reappears regularly

  • The first step in hotspot identification is an analysis of data from within the last 5 years. Mandatory information to be reviewed include mean annual incidence and persistence. The GTFCC has developed a tool to facilitate this process: https://www.gtfcc.org/wp-content/uploads/2023/04/2023-gtfcc-pami-cholera-control-excel-tool.xlsx
  • Once an initial analysis is done, cultural, geographical, environmental and socioeconomic factors (e.g., WASH conditions, presence of vulnerable groups, etc.) shall be considered.
  • When the hotspots are identified, it will be important to convene stakeholders from different sectors and administrative levels to undertake a critical review of the findings of the analysis.

Examples of activities to be considered:

  • Collect and compile all data on historical cholera burden. At a minimum, the past five years should be reviewed.
  • Develop relevant graphs and maps to illustrate epidemiological information.
  • Based on the analysis of data, identify the hotspots in the country and their priority ranking for cholera risk.
  • Review the social, cultural, political and linguistic context that could impact the implementation of the NCPs, as well as community strengths and resources.
C. Situational analysis

1. Capacity assessment

Countries are encouraged to undertake a review of their own capacities across the five technical pillars of the NCP, including the identification of existing services, funding and capabilities .The capacity assessment should also provide a description of main constraints, challenges and bottlenecks (e.g., lack of funding or technical resources, lack of political leadership or institutional coordination, etc.) . In addition, any lessons learned from historical and ongoing work should be highlighted in each pillar. Whenever possible, a comprehensive approach across pillars should be considered.

Countries may use the results of assessments and exercises (simulation exercises, after action reviews, etc.) that have already been conducted and that are relevant for cholera (e.g., evaluation of surveillance system, laboratory assessment, etc.).

Suggested tools:

  • Countries may consider utilizing strengths, weaknesses, opportunities and threats (SWOT) matrices to conduct this capacity assessment. (See Appendix 3.)

Examples of activities to be considered:

For each of the pillars, conduct geographic mapping of relevant infrastructures and resources available in cholera hotspots (e.g., health care facilities, cholera treatment centres, laboratories, cold chain capacity, community health workers and key community stakeholders, etc.) and assess their functionality

  • Describe the existing WASH services, programmes at household, community and institutional levels (including schools and health care facilities, markets, factories, etc.).
  • Identify specific sites (e.g., religious sites, construction, mining, etc.) and vulnerable1 populations (e.g., refugees, internally displaced populations, nomads, ethnic minorities, professions at risk, etc.) in cholera hotspots.
  • Complete a summary table of all relevant information on implemented oral cholera vaccine campaigns conducted in-country, including post-campaign reports and assessments.

2. Mapping of stakeholders and existing initiatives

The third part of the situational analysis is a mapping of stakeholders and existing initiatives . The objectives are to: 1) identify, assess and prioritize the roles and responsibilities of active stakeholders in cholera prevention and control in the country (within and outside the government and at all levels), and 2) proceed with a detailed mapping of all existing initiatives and programmes - and associated funding - (e.g., health security, safe water and sanitation projects, diarrheal diseases programmes, etc ) that contribute — directly or indirectly — to the goal of controlling cholera .This will also include the identification of existing coordination mechanisms that may be used to organize and oversee the implementation and monitoring of the NCP.

The stakeholders and initiatives/plans to be considered should not only include those within the public health sector. To effectively address cholera in a multisectoral manner, stakeholders from the WASH, education, finance, construction and food production sectors should also be included . Local governments and municipalities are also critical actors and will be responsible for implementing several components of the plan .The private sector should also be part of the mapping process and should be consulted during the planning process.

Suggested tools:

  • Countries may consider using a stakeholder analysis tool to identify stakeholders and define their level of engagement in the NCP (see Appendix 4).

Examples of activities to be considered:

  • Identify and map the roles and responsibilities of the government, national/ international partners and institutions and donors regarding cholera prevention and control across all pillars, including identification of areas for collaboration and coordination.
  • Map all actors (state and non-state) and their roles/capacities in the elimination/ control of cholera, both present and in the future.
  • Identify existing initiatives and programmes in relevant sectors (e.g., health security, safe water and sanitation projects, diarrheal diseases programmes, etc.) that contribute to cholera control/elimination and map all relevant activities (with associated funding).
  • Conduct a mapping of existing funding streams available in cholera hotspots across the Global Roadmap pillars.
D. Multisectoral leadership and coordination mechanism

The situational analysis will help to assess whether a new coordination mechanism should be created or if cholera control could be included in the mandate of an existing high-level multisectoral coordination body. The national coordination mechanism should:

  • Be inclusive of all relevant ministries, stakeholders and partners (see stakeholder mapping) .
  • Clearly assign roles and responsibilities among all actors and identify an in-country programme manager that focuses on bringing all the pieces together and ensures accountability to the country stakeholders, donors and beneficiaries.
  • Be accountable to the highest level of government (e.g., Prime Minister, President) .
  • Establish national reporting lines across different sectors and platforms to share alerts and epidemiological information.

From the inception to the implementation and monitoring of the plan, the high-level multisectoral coordination body should be mandated to:

  • Maintain multisectoral political commitment at all levels toward the Global Roadmap goals .
  • Guide and direct the planning process and ensure that the NCP is endorsed and approved across all relevant sectors .
  • Build and maintain systematic and effective coordination for all cholera prevention and control activities .
  • Monitor and report progress both to high-level national authorities and the GTFCC on implementation of cholera interventions and impact.

Examples of activities to be considered:

Identify existing coordination bodies and mechanisms involved in cholera (e.g., National Cholera Task Force, Emergency Operation Center, clusters [Health, WASH]), technical working groups (e.g., Community Engagement, regional platforms), and identify their terms of reference, ongoing activities and funding.

  • If appropriate, select one of these bodies and adapt the terms of reference. If none of the existing coordination mechanisms are appropriate, develop new terms of reference and have them endorsed at the highest level of government.
E. Formulation of a national goal

Based on the information gathered in the situational analysis, the country should formulate the overarching goal for the national cholera programme .This goal must be aligned with those of the Global Roadmap, including the reduction of cholera deaths by 90% by 2030 . The national goal should also define whether the country chooses elimination or control, and by what year (e.g., "Achieve cholera elimination by 2025") . The goal of "control" should also be defined by desired outcome indicators (i.e., national or district disease burden below a specific annual incidence). The goals should have a set of annual milestones to continuously monitor and report progress to GTFCC, donors and key stakeholders .An example of potential milestones toward the overarching goal might be:

 Formulation of a national goal

¹ Vulnerability is the degree to which a population, individual or organization is unable to anticipate, cope with, resist and recover from the impacts of disasters. Environmental health in emergencies and disasters: a practical guide. (WHO, 2002).