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ACTIVITY REPORT

A Review of National Cholera Plansin Guatemala, Honduras, and Ecuador

John Paul Chudy

December 1994

ENVIRONMENTAL HEALTH PROJECT

ACTIVITY REPORTNo. 3

A Review of National Cholera Plansin Guatemala, Honduras, and Ecuador

John Paul Chudy

December 1994

with contributions fromDavid McCarthy, BASICS

Prepared for the Bureau for Latin America and the Caribbean,USAID/Guatemala, USAID/Honduras, USAID/Ecuador

and the Bureau for Global Programs, Field Support and ResearchOffice of Health and Nutrition

U.S. Agency for International Developmentunder the Environmental Health Project, Activity No. 020

» • . , . . . , • • •

\ Environmental Health Project; Contract No. HRN-5994-C-00-3036r00, Project No. 93615994

i$ sponsored by the Bureau for Global Programs, Field Support,-and ResearchOffice of Health and Nutrition :

UN I 1 / / q U . S . Agency for International Development ,: ' • > • < A .601 Washington, DC 20523 „ „ , Í

CONTENTS

ACKNOWLEDGMENTS v

ACRONYMS vu

EXECUTIVE SUMMARY ix

1. INTRODUCTION 1

1.1 Background 1

1.2 Purpose and Methodology 1

1.3 Organization of Report 2

2. CHOLERA IN GUATEMALA 3

2.1 Incidence 3

2.2 Actors in Cholera Control and Prevention 3

2.3 Guatemala's Health Care Delivery System 4

2.4 National Cholera Plan 5

2.4.1 Background 5

2.4.2 Current Plan 6

2.5 Review of 1991 Plan Components 7

2.5.1 Epidemiology 7

2.5.2 Laboratory Diagnosis 7

2.5.3 Water and Sanitation 8

2.5.4 Food Hygiene 9

2.5.5 Social Communication and Training 10

2.5.6 Evaluation 10

2.6 Other Cholera Activities 10

2.7 The Plan and External Assistance 11

2.8 Lessons Learned 11

3. CHOLERA IN HONDURAS 13

3.1 Incidence 13



3.3.1 Background 13

3.3.2 Political Constraints 14

3.4 Review of Plan Components 15

3.4.1 Logistics 15


3.4.3 Food Hygiene 16

3.4.4 Social Communication 16

3.4.5 Epidemiológica! Surveillance and Outbreak Control 17


3.4.7 Improvement of Health Services 17


3.6 Lessons Learned . , 18

4. CHOLERA IN ECUADOR 21

4.1 . Incidence 21



4.4 Review of Components 23

4.4.1 Epidemiológica! Surveillance 23



4.4.4 Case Management 25

4.4.5 Social Communication and Training 25

4.4.6 Logistics 26


4.6 Lessons Learned 26

u

5. CONCLUSIONS 29

5.1 National Cholera Plans 29

5.1.1 Approaches to Implementing Cholera Activities 29

5.1.2 Measuring the Appropriateness of Responses to the Epidemic 29

5.1.3 Effectiveness of Cholera Plan Components 30

5.1.4 Use of Assistance from External Sources 31

5.2 Conclusions, Lessons Learned, and Recommendations 33

5.2.1 Conclusions 33

5.2.2 Lessons Learned from the National Cholera Plans 35

5.2.3 Recommendations 36

REFERENCES 37

APPENDICES

A. Persons Contacted 39

B. External Support for National Cholera Activities 43

ACKNOWLEDGMENTS

The Environmental Health Project wishes to extend special appreciation to four individualswho provided invaluable assistance during the implementation of this activity: Tim Rogers,who conducted research in Washington in pulling together all the documentation on choleraplans and on financial support extended to the study countries; Dr. Fidel Arevalo, whoprovided in-country research and interview support in Guatemala; and Dr. Enrique Gil andDr. Mercedes Torres, who provided research and technical support for the review in Hondurasand Ecuador, respectively.

ACRONYMS

ADDR

AER

AGISA

BASICS

CARE

CDC

CDD

CFR

COPECAS

ECU

EHP

EMPAGUA

ESA

FHIS

FIS

FISE

GOE

GOH

HEALTHCOM

HPN

ICDDRB

IDB

IGSS

INCAP

INFOM

INGUAT

LAC

LUCAM

Applied Diarrheal Diseases Research Project

Association of Radio Broadcasters-Ecuador

Guatemalan Association of Sanitary Engineers

Basic Support for Institutionalizing Child Survival

CARE international private voluntary organization

Centers for Disease Control

Control of Diarrheal Diseases program

case fatality ratio

Coordination Committee for Water and Sanitation-Guatemala

European Currency Units

Environmental Health Project

Water utility-Guatemala City

external support agency

Social Investment Fund-Honduras

Social Investment Fund-Guatemala

Social Investment Fund-Ecuador

Government of Ecuador

Government of Honduras

Communications for Health Project

health, population, nutrition

International Center for Diarrheal Disease Research-Bangladesh

Inter-American Development Bank

Guatemalan Social Security Institute

Nutrition Institute for Central America and Panama

Institute for Municipal Development-Guatemala

Guatemalan Tourist Institute

Latin America and the Caribbean (bureau of USAID)

Unified Laboratory for Food and Medicine-Guatemala

Vll

MOH Ministry of Health

NGO nongovernmental organization

ORS oral rehydration solution

ORT oral rehydration therapy

PAHO Pan American Health Organization

PHN population, health, nutrition

PRITECH Technology for Primary Care Project

PVO private voluntary organization

RSD regional sustainable development

RWSN-CA Regional Water and Sanitation Network for Central America

SANAA Servicio Autónomo Nacional de Acueductos y Alcantarillados (Honduras)

UNICEF United Nations Children's Fund

UPS productive health unit-Honduras

USAID United States Agency for International Development

WASH Water and Sanitation for Health Project

vm

EXECUTIVE SUMMARYBetween June and August 1994, theEnvironmental Health Project (EHP) and theBasic Support for Institutionalizing ChildSurvival (BASICS) Project jointly conducted areview of national cholera plans in 3 of the 20Latin American and Caribbean countries affectedby the 1991 outbreak of the disease. The studyteam in charge of the review looked at the extentto which the plans in Guatemala, Honduras, andEcuador were an appropriate response to theepidemic, how government implemented theplans, which components of the plans were mosteffective, whether or not there was anycorrelation between what was said in the plansand what was done, the effectiveness of assistancefrom collaborating agencies, including theAgency for International Development(USAID), and lessons learned. The team'sfindings are based on a desk review of existingdocuments and field visits to the three countries.

Two Approaches to ImplementingCholera Activities

National plans were written for all threecountries, but only Guatemala and Hondurasused them to implement their cholera activities.Ecuador instead followed a committee approachfor implementation. Both approaches wereequally effective.

In Guatemala, a plan was drafted in 1991 andupdated in 1993, but its implementation wasspotty. After preparing the national plan, theMinistry of Health (MOH) sent it to provincialdirectorates (health areas) that were expected toratify or draft their own plan based on thecentral plan. What actually was done at thehealth area level is unclear, although someimplementation at that level did occurindependently of the central cholera committeeand national plan.

In Honduras, a plan written in 1991 served as aguideline for cholera plans at the national, healtharea, and health center levels. Of the threecountries reviewed, Honduras was the only oneto follow its plan consistently in implementingcholera activities.

In Ecuador, a 1991 plan written by the PanAmerican Health Organization (PAHO) inWashington, D.C., was used only to seekfunding from the international community.Locally, no plan was written, but animplementation strategy was developed by thenational cholera committee that initiallyemphasized three areas of action - socialcommunication, water and sanitation, andepidemiological surveillance. Components wereadded when the committee felt it necessary to doso. This approach was conveyed to theprovinces, where committees were formedaround the same initial three action areas andexpanded as required. The national committeeasked the provincial committees to furthermodify their plans to reflect local needs.

Measuring the Appropriateness ofResponses to the Epidemic

Experience with cholera programs in thehemisphere since 1991 shows that most plans orstrategies contain seven core areas -epidemiological surveillance, laboratorydiagnosis, water and sanitation, food hygiene,case management, social communication andeducation, and logistics. The EHP and BASICSprojects decided, therefore, that the criterion fordetermining the appropriateness of a choleraresponse would be this set of seven key areas. Aplan or strategy that met this criterion would beconsidered an appropriate response.

IX

As noted above, although Guatemala wrote aplan in 1991, it was not well implemented.Epidemiological surveillance and data reportingthere have been highly suspect, and most of theother components in the plan were also found tohave been poorly implemented. A 1993 revisionof Guatemala's national plan addressesweaknesses in the 1991 version while includingall seven of the core areas, but implementationhas yet to take place.

In Honduras, the 1991 plan was consistentwith the seven components and wasimplemented as planned. In Ecuador, the spiritof a plan was apparent in the actions emphasizedby the national cholera committee and provincialcholera committees.

Plan Effectiveness

How the various national governmentsimplemented their cholera plans varied widely.Honduras's approach was the most consistent.

There, the central government developed anational plan that it then shared with regionaland area health officials for ratification and use asa model for their own plans. Conversely,implementation of Guatemala's written planapparently was weakened by the independentactions of some health areas. In Ecuador, thecommittee strategy was implemented first at thecentral level, and then extended to affectedprovinces. Implementation was consistent atboth levels.

In terms of components addressed in thenational approach, Honduras and Ecuadorshared some versions of all seven key plan areas.The Guatemala plan did not formally mentioncase management or logistics, although, inpractice, a large part of the external assistance thecountry received was used to provide casemanagement supplies.

The following table summarizes the seven keyplan components by country and their level ofeffectiveness as reported by program officials.

Effectiveness of Plan Components

Guatemala

Honduras

Ecuador

Epid. Surv.

*

#*

***

Lab.Diagnosis

*

**

*

W&S

*

*

***

CaseMgmt.

nc

•

*

Soc.Comm.

*

**

***

FoodHygiene

***

**

*

Logistics

nc

#

Key: * = weak

** = average

*** = very effective

nc = no component

Having a plan did not ensure effectivecomponent implementation. AlthoughGuatemala and Honduras both have writtenplans, only Honduras has enjoyed some successin carrying out its plan's actions. Ecuador, withno written plan, implemented effectivelyepidemiológica! surveillance and water andsanitation activities, and had some success withsocial communication activities.

Plan Targets and Achievements

In Guatemala, plan targets were not consistentlyfollowed. There, only the food hygienecomponent was effective, apparently because of ahighly motivated person in charge in GuatemalaCity. In the water and sanitation sector, much ofthe work carried out was reported to be outsideof the plan. Other components of the plan werenot followed.

In Honduras, the team observed a good fitbetween what was said and what was done. Thelogistics component achievements wereconsistent with plan targets. Also, food hygienetargets were well addressed under planimplementation, and social communicationtargets were addressed as specified in the plan.The team observed weaknesses only in the waterand sanitation sector and in case management.These last two areas might have benefited fromtechnical assistance to strengthen service deliveryand monitoring capacity.

Achievements in Ecuador reflect the emphasisthe national and provincial committees placed ontarget areas. A noted failure is in casemanagement, which the committees neitheremphasized nor addressed.

Effective Use of Assistance fromExternal Sources

National cholera plans were an effective tool forchanneling external support in the three

countries studied. Most external support camefrom PAHO (specific country support throughPAHO came from Sweden and Holland),USAED, the Inter-American Development Bank(through PAHO), and the EuropeanCommunity. In Guatemala, it was unclearwhether decisions about external support werebased on plan targets, or whether their apparentfit with some plan targets was merelycoincidental. Fifty-six percent of the dollar valueof external resources in Guatemala was used incase management, despite the component'sexclusion from the 1991 written plan.

The use of external resources in Ecuador wasconsistent with the areas the national choleracommittee chose to emphasize. Planimplementors were satisfied with lessons learnedin epidemiology, water and sanitation, and socialcommunication, suggesting a good fit betweenexternal resources and the way the provincialcommittees operated. In Honduras, externalresources were used as specified in the plan, evenin erring on the side of too much material supplyfor case management and too little technicalassistance to put the supplies to optimal use.

General Conclusions andRecommendations

The three countries studied approached thedevelopment and implementation of theircholera actions quite differently. WhileGuatemala and Honduras both had preparedplans, only Honduras followed through from thenational level down to the local level. TheHondurans may have placed too little emphasison the need for technical assistance to improvecase management, as it has had the highest casefatality rate in the region, at more than 2 percent.Admittedly, the country's low incidence ratefrom 1991 to 1993 did not provide healthpersonnel with many direct opportunities toimprove their cholera case management skills,

XI

which in part may explain the high case fatalityratio.

Meanwhile, Ecuador's committee approachproved very effective in mobilizing resources.By giving provincial committees responsibilityfor coordinating activities at their level, thenational committee enabled provincial-levelagencies and nongovernmental organizations(NGOs) to leverage their resources and achievemore than they could have alone. Theexperience has encouraged the MOH to retainthese committees, and to rename them"provincial health committees11 with expandedagendas that include all public health issues, notjust cholera.

The three study countries' plans were anappropriate response to the epidemic. Hondurasand Ecuador addressed all seven core plancomponents, and Guatemala five. This suggeststhat planning helped focus the countries' effortsand, as a result, their programs appeared to beconsistent with one another. Honduras was themost consistent in terms of following its writtenplan, while Guatemala's follow-through seemedcoincidental rather than intentional (for example,plan implementers were active in casemanagement, which was not a formalcomponent of their plan).

Successful components varied by country.Food hygiene was the most effective componentin Guatemala, but as noted above, this was duemore to the motivation of the individual incharge than to plan management. In Honduras,logistics was the most successful component, butepidemiológica! surveillance, laboratorydiagnosis, social communication, and foodhygiene also enjoyed some success. Ecuador'sthree core components of epidemiológica!surveillance, water supply and sanitation, andsocial communication were implementedeffectively.

Lessons Learned about NationalCholera Plans

Good planning: In all three countries, thedevelopment of a national cholera plan served animportant function in getting authorities to focuson the crisis and to think about strategies fordealing with it.

Working without a plan: In Ecuador, where nowritten plan was followed, a successful set ofactions nonetheless flowed from a decentralizedcommittee approach.

Lessons Learned aboutAddressing Cholera

Proper social communication: Interventions mustbe understood by, and be compatible with thecultural characteristics of, the target population.Ecuador's planners acknowledged that in orderto be effective, educational campaigns must firstmotivate and sensitize at the macro level, andlater focus actions and treatment at the microlevel, especially toward at-risk groups. Also, asshown in Ecuador, latrinization programs canbenefit from having the educational componentprecede construction. In Honduras, socialcommunication about cholera is credited with adecline in the incidence of childhood diarrhealdisease.

Decentralization of cholera activities: In Ecuador,the cholera epidemic provided the impetus forthe creation of provincial committees, whichresponded very effectively by coordinatingcholera activities appropriate for theirjurisdictions. In Honduras, local involvement inthe plan was undermined when cholera becamepoliticized and attracted heavy presidential involvement.

xn

Sectoral coordination; In many Latin Americancountries, social investment funds (FIS) programshave been started. These programs have becomeheavily involved in latrinization and waterprojects, but usually are not well coordinatedwith other efforts in the water and sanitationsector, nor with national cholera plans. Keyproblems with these programs are their lack ofhygiene education and the absence of attentionto economic sustainability in the form ofcommunity participation and cost recovery.

Safe water: The term "safe water" is increasinglyused to describe water that is bacteriologicallysafe. The term opens up opportunities foraddressing water quality monitoring issues, andfor promoting household-level disinfection as thelast line of defense against cholera and diarrhealdisease.

Technical assistance: Ecuador's experiencedemonstrates the effectiveness of technicalassistance. By drawing extensively on externalsupport agency technical assistance in socialcommunication, Ecuador produced a variety ofmessages directed at macro and micro levels thatMOH officials say were responsible for raisingsocial awareness and reducing disease incidence.However, almost no technical assistance wasbrought in to strengthen case management skills,and Ecuador's case fatality ratio remained almostunchanged from 1991 to 1993. This situation wasexacerbated by the national government'sreliance on intravenous solution over oralrehydration therapy (ORT), which increased

program costs. Had some of the domesticresources been directed to ORT and to technicalassistance, the case fatality ratio might have beendifferent.

Follow-up: Unless actions that have beenimplemented are consistently reinforced,achievements made in attacking and preventingcholera are unlikely to be sustained, especiallythose related to behavioral changes among at-riskpopulations.

Recommendations1. US ADD should continue providing assistancewithin the context of national cholera plans.

2. External support agencies should encouragethe channeling of social investment fundresources within the context of national choleraplans.

3. Safe water messages and practices should bepromoted to households that are not serviced bypiped water.

4. Health messages should be based onepidemiológica! investigations and the study ofhigh-risk behaviors, and should be targetedappropriately.

5. Case management should be standardized andimproved through new training and supervisionstrategies.

xui

1INTRODUCTION

1.1 BackgroundBetween 1991 and 1994, the United StatesAgency for International Development(USAID), through its Bureau for Latin Americaand the Caribbean (LAC), made availableapproximately $13 million in material andtechnical support to assist countries affected bythe 1991 outbreak of cholera in Latin America.Shortly after the arrival of the El Tor cholerapandemic in Peru in January 1991, each countryin the region developed, at the initial urging ofthe Pan American Health Organization(PAHO), a national plan for cholera control andprevention that was to serve as a managementtool to help countries channel resources toidentified areas of action. USAID resources, likethose of PAHO and other external supportagencies (ESAs) such as the United NationsChildren's Fund (UNICEF), were provided tohelp mitigate the crisis within the context ofthese organized cholera plans in countriesrequesting assistance. USAID cholera funds werechanneled through several United Statesgovernment agencies and programs, includingthe Centers for Disease Control (CDC) and thePublic Health Service Supply Center, andappropriate USAID projects, including theApplied Diarrheal Diseases Research Project(ADDR), the Communications for HealthProject (HEALTHCOM), the ORSProcurement Project, the Technology forPrimary Care Project (PRITECH), the Waterand Sanitation for Health Project (WASH), andthe Quality Assurance Project.

By 1994, cholera had become endemic in mostof the region, except in Brazil and CentralAmerica, where it continued to increase at

epidemic levels. With these changing trends inthe disease, USAID wanted to know howeffective the national cholera plans had been inmeeting their respective objectives and inmanaging and programming external anddomestic resources.

This evaluation represents an attempt by twoof USAID's cooperating projects, WASH (nowthe Environmental Health Project or EHP) andPRTTECH (now the Basic Support forInstitutionalizing Child Survival, or BASICS,Project), assisted by PAHO, to assess the role ofthe national cholera plans.

1.2 Purpose and MethodologyThe purpose of this review was to assess theprogress to date in implementing the nationalcholera action plans developed by the nationalcholera coordination committees in LatinAmerican countries. The review was carried outin three countries - Guatemala, Honduras, andEcuador - which were chosen because of theirhigh incidence of cholera, easy entry forconsultants, and the excellent cooperationUSAID missions and counterparts historicallyhave extended there. The study team examinedthe plans of the three countries to determinewhether the plans were an appropriate responseto the epidemic, how governments implementedthe plans, which components of the plans weremost effective, whether there was any correlationbetween what was said in the plans and what wasdone, the use of assistance from collaboratingagencies, including USAID, and the generallessons the plan implementation process offers.

The study team collected data in two stages.First, a desk review of existing documentsdeveloped by USAID, PAHO, and other ESAswas carried out in Washington, D.C. This wasfollowed by country visits during which locallyavailable documents were reviewed, andinterviews were held with key personnel of thenational cholera coordination committees andkey individuals from related organizations andagencies, ESAs, nongovernmental organizations(NGOs), private voluntary organizations(PVOs), and the private sector. For a list ofpersons contacted, see Appendix A.

In-country, the approach was first to interviewthe head of the national cholera coordinationcommittee, followed by interviews with keypeople associated with each component outlinedin the respective national plan. Analysis of datawas geared toward determining whether therespective actors understood what was happeningin a real-world context as they wereimplementing the plan, particularly if activitiesvaried from the written plan. Through its dataanalysis, the team also tried to determine whichplan components were emphasized, and whetheremphases changed over time to identify whethera process of rational decision-making wasfollowed. The team did not evaluate thesoundness of the national cholera plans, nordetermine whether input from USAID or otherESAs reduced mortality or morbidity incidence,or reduced or prevented the spread of theepidemic.

The findings and lessons learned from thisactivity are expected to serve as input for the

offices of USAID/LAC/RSD/PHN1 andUSAID/G/PHN2 in the design of futuretechnical assistance strategies for cholera. It isalso expected that the results will be helpful toESA members of the Regional Water andSanitation Network for Central America(RWSN-CA), other countries throughout LatinAmerica, and several African and Asian countriesthat are dealing with endemic cholera.

The Washington desk review and countryvisits took place in June and July of 1994. Theteam visited Guatemala and Honduras fromJune 5 to 25, and Ecuador from July 18 to 22.

1.3 Organization of the Report

Chapters 2, 3, and 4 of this report present thefindings for Guatemala, Honduras, and Ecuador,respectively. Chapter 5 compares and contraststhe approaches followed in the three countries. Italso presents comparative data on externalfinancial support and how these resources wereused. An attempt is made to link these data toplan performance in each country. Finally,Chapter 5 presents some general conclusions andlessons learned from the overall planimplementation experience that may beapplicable to other countries dealing with cholera.

RSD stands for "regional sustainable development";PHN stands for "population, health, nutrition."

2 G stands for "global."

2 CHOLERA IN GUATEMALA

2.1 IncidenceThe first case of the El Tor cholera pandemic inGuatemala was confirmed on July 24, 1991. Thenumber of reported cases remained lowthroughout that year, but late in 1992, and in1993, began to increase slightly while beginningto decrease in South America. From the first casein 1991 to November 1993,46,702 cases werereported in-country, although the real count isprobably higher, given questions anduncertainties that surround the way informationhas been collected. (In comparison, Guatemala'spopulation in 1993 was 9,735,000.) For example, atwo-month Ministry of Health (MOH) strike in1993 suggests that cholera had gone away overthat period. Whatever the true numbers, no onedisputes now that cholera is raging at epidemiclevels in Guatemala, and that too little, or eveninappropriate, action has been taken to arrest itsspread. In 1994, Guatemala's national choleracoordinator anticipates that there will be between50,000 and 60,000 cases, which represents anincrease of between 40 and 50 percent over theprevious year. The country's cholera case rate,that is, the number of cases per 1,000 population,has gone from 0.40 in 1991 to 3.14 in 1993.

2.2 Actors in Cholera Controland PreventionOn February 7,1991, the Pan American HealthOrganization (PAHO) representative inGuatemala informed the MOH that cholera hadbroken out in Peru, and suggested that the alreadyhigh rate of diarrheal disease in the country madeGuatemala susceptible to the disease. In response,the MOH moved to develop a plan to control and

minimize the disease in-country. The MOHassumed a leadership role and moved to engagenational, international, government,nongovernment, and private sector actors in aneffort to confront the disease. Three committeeswere formed: one to coordinate action at thenational level, one to define areas of internationalemphasis, and one to make policy.

The National Committee for the Surveillanceand Control of Cholera, formed to coordinateaction at the national level, comprisedrepresentatives of the following groups:

• the MOH as coordinator,

• the ministries of external relations, government,education, and agriculture,

• INGUAT, the Guatemala Tourist Institute,

• IGSS, the Guatemalan Social Security Institute,

• military sanitation,

• the University of San Carlos,

• the municipality of Guatemala City,

• INFOM, the Institute for MunicipalDevelopment,

• P A H O .

The Inter-Agency Committee was formed tocoordinate and define areas of internationalassistance, and was originally made up mainly ofinternational financial and technical assistanceagencies operating in the country. These includedUNICEF, the World Food Program, the RotaryClub, USAID, PAHO, and the MOH.

Today, the World Food Program and theRotary Club have been replaced as members bythe Nutrition Institute for Central America and

Panama (INCAP), Clapp & Mayne (USAID'sbilateral contractor in health), and CooperaciónItaliana.

Finally, the Technical Committee wasdesignated as the coordination and policy-makingbody. This committee originally consisted ofmembers of the following organizations:

• MOH's Division of Disease Surveillance andControl;

• the divisions of environmental sanitation,human resources, food hygiene, school healthprograms, and the Unified Laboratory for Foodand Medicine (LUCAM);

• the permanent Coordination Committee forWater and Sanitation (COPECAS);

• the Guatemala City water utility (EMPAGUA);

• science faculties at the University of San Carlos;

• municipal sanitation department;

• INCAP;

• municipal fire department;

•USAID;

• UNICEF; and

• P A H O .

Currently, the Technical Committee managescholera prevention and control in Guatemala, andis now made up exclusively of MOH technicaldivisions. The committee is chaired by a generalcoordinator, a position that was created in 1993when the 1991 cholera plan was reformulated (seeSection 2.3). Divisions of the MOH that formthe Technical Committee include the following:

• human resources,

• environmental sanitation,

• food hygiene,

• epidemiológica! surveillance,

• logistics, and

• investigation.

The MOH has been the biggest player in thecountry, and accounts for major actions takendomestically. This appears to explain theTechnical Committee's shift toward choleracontrol.

2.3 Guatemala's Health CareDelivery System

The MOH is one of Guatemala's largestministries, with approximately 22,000 employees.Services are organized by health areas, with onehealth area corresponding to each of the country's24 departments (states). Theoretically, the healthcare referral system for patients begins at thehealth post, the first level of care, which is staffedby health auxiliaries. Health centers are thesecond level of care, and provide higher-qualityout-patient services than do the health posts; somealso provide in-patient services. Finally, at thethird level are hospitals.

In Guatemala, 785 health posts are located incounty seats (municipios) or larger villages in thedepartments, 28 percent of which lack theminimum equipment to function properly. Ofthe 220 health centers, 188 do not provide in-patient service. Sixty-seven percent of the centerslack adequate equipment. Of the 35 hospitals(serving a total of 10 million people) located at thedistria or regional level, 70 percent are reportedto be deteriorating.

Apart from poor facilities, the limits of theMOH's service provision are underscored bynational coverage figures: the ministry reachesonly 25 percent of the population. Another 15percent of the population are served by IGSS.The private sector reaches another 14 percent,most of whom have adequate economic resourcesto pay for the services. Finally, some 350nongovernmental organizations (NGOs) providesome type of support to Guatemala's health caresystem.

A large portion of the population serviced by-Guatemala's health care system live in isolatedareas, or in areas where the MOH's health postsare not always attended by staff. Yet, like othersectors of the society and the economy, healthcare is heavily concentrated in the formal urbanareas. While only 20 percent of the country's 9.7million people live in the capital, 45 percent ofhospital beds and 80 percent of doctors arelocated there. Moreover, poor coordination existsamong the various providers, and no standardreferral system operates to help make the mostefficient use of existing services. In addition,health spending accounts for only 1.3 percent ofthe gross national product.

In short, Guatemala's health care deliverysystem is plagued by excessive bureaucracy,duplication of effort, inefficient use of resources,and poor administration. Moreover, preventionefforts, according to the MOH, have been passedover in recent years in favor of curative services,which have accounted for the majority of healthsector spending.

It is within this environment that the designersof Guatemala's national cholera plan had to try tomake an impact on the prevention and control ofthe disease. The national plan provided healtharea directors, in consultation with their healthcenter and health post personnel, a model bywhich to fashion actions at the local level as wellas to define how to use existing resources.However, the team found no evidence that thecomponents of the plan were implementeduniformly across the country's 24 health areas. Infart, some interviewees reported that there wasconflict between the central government andregions at the health area level.

In terms of USAID cholera assistance, of a totalof $1,500,014 provided to date, 54 percent hasbeen used to purchase intravenous solution,laboratory supplies, and oral rehydration supplies.The balance has been programmed for varioustechnical assistance packages to strengthen aspectsof either epidemiological surveillance, case

management, or preventive measures. PAHO,whose support came from the governments ofSweden and Holland, provided materials and/ortechnical assistance in excess of $890,000.Although activities carried out in Guatemalabetween 1991 and 1993 and financed by externalsupport agencies (ESAs) fit into one or more ofthe components of the 1991 plan, the team wasunable to determine whether this had happenedbecause of the plan or merely by coincidence.What is certain is that the greater degree ofspending on curative measures—mainly casemanagement—than on preventive strategies hasbeen consistent with recent health sector history.

How Guatemala's national cholera plan evolvedfrom 1991 to the present provides some furtherunderstanding of how effective it has been as amanagement tool.

2.4 National Cholera Plan

2.4.1 Background

At the suggestion of PAHO, the Ministers ofHealth of Central American countries met inPanama on April 24, 1991, to examine and discussthe threat cholera posed in the region, and issueda resolution laying the basis for formulating asubregional plan to control and prevent cholera.The ministers met again from May 15-17, in SanJose, Costa Rica, and devised a plan to bepresented to the international community tosolicit funding and support for cholera controland prevention programs. The group decidedthat national plans would be the basis ofimplementing the subregional plan. Cholera wasviewed as the result of acute shortages of water(78 percent of urban areas suffered fromshortages, as did 50 percent of rural areas), poorenvironmental sanitation, and inadequate foodcontrol and housing, among other factors. Theplan of action the group decided on contained astandard set of five project components:epidemiological surveillance, laboratory diagnosis,water and sanitation, promotion and education,

and case management. PAHO would coordinatecooperation.

In October 1991, Guatemala's MOH releasedits national plan laying out a series of priorityprojects that included the same ones presented bythe ministerial group. The national plan was inturn sent to the regional health areas for theirreview and for the development of regional plansbased on local needs. (The assessment team wasunable to determine whether regional plans wereactually developed. This was due in part to thetravel restrictions USAID placed on theconsultants, and also in part to the fact that thenational-level interviewees were unable toproduce an example of a regional plan.)

The assessment team was unable to determinehow effective the 1991 plan was in channelingresources. Comments from various intervieweessuggest that it was followed fairly closely at thecentral level, and that it had served as an effectivetool to attract resources from the internationalcommunity. However, as shown in Section 2.5,many institutions, especially private sector groupsand NGOs implemented activities independent ofthe plan. Moreover, area and district chiefs at thehealth area level reached accords amongthemselves on actions in the plan as well as onother actions that sometimes were in conflict withthe central government. Within the MOHstructure, the central plan served as a model forGuatemala's public health care delivery system,but the system's weaknesses nonetheless affectedthe delivery of cholera services.

In 1993, a sudden change of government andthe steadily increasing number of reported casesprompted the MOH to step back and take a lookat cholera control and prevention measuresprovided in the 1991 plan. An interagencycommission headed by the MOH was formed toassess the plan. The commission found the plan tobe inadequate in meeting the challenges of thecontinuing and growing epidemic, especially withrespect to prevention.

In the 1991 plan, as little as 10 percent ofavailable resources were used for preventivemeasures such as water and sanitation and hygieneeducation. Instead, most of the actions taken fromthe time the disease first broke out in the countryhad been directed at case management - thoughthis was not formally written into the plan - andother curative measures. The interagencycommission criticized the performance of pastactivities and in November 1993 drafted a revisedplan that emphasized preventive over curativemeasures, with almost 97 percent of resources tobe allocated for water and sanitationinfrastructure and hygiene education.

2.4.2 Current PlanThe MOH interagency commission formed in1993 to look at Guatemala's cholera problem inlight of the increasing case rate observed thatthere had been some successes in laboratorydiagnosis, in case management (despite there beingno formal component for case management in the1991 plan), and in the improvement of basicsanitation in some communities. The commissionalso noted that significant shortcomings existedwith respect to an information system on diarrheaand cholera, decision-making, emphasis onprevention versus curative assistance, follow-upand evaluation on actions taken, effective policies,and attention to water and sanitation. As a result,the commission's new plan identified nine areasof attention and required a total budget of487,508,000 quetzals (Q), or US$86 million. Thenine areas are as follows:

1. Policy decisions (intended to seek politicaland financial support for the plan), includingestablishing a national coordination position,which was done on December 1, 1993.

2. Human resources (capacity building andcoordination at all levels).

3. Epidemiological surveillance.

4. Logistics.

5. Management capacity (strengthening ofmanagement at the local level).

6. Case management.

7. Inter- and intrasectoral coordination.

8. Promotion and education.

9. Environmental sanitation (to improve waterquality and basic sanitation services).

The reformulated plan had just been distributedto the 24 health areas in the country for commentand use in the development of their respectiveregional plans at the time of this assessment.Shortly after the interagency commissioncompleted its report in 1993, the MOH went onstrike and much of the momentum obtained inreviewing the 1991 plan was lost and has yet to beregained. The following discussion, therefore,addresses the components of the 1991 plan.

2.5 Review of 1991 Pian Components

The 1991 plan addressed six components:epidemiológica! surveillance, laboratory diagnosis,water and sanitation, food protection, socialcommunication, and evaluation. It had a budgetexceeding US$10 million.

2.5.1 Epidemiology

The assessment team had limited success infinding out much about this component.Available documentation suggests that PAHOprovided training and technical support to localefforts in epidemiológica! surveillance andreporting. In addition, apparently USAIDprovided case management supplies, includingoral rehydration solution (ORS) packets andintravenous solution, as part of this componentbecause of the plan's lack of a formal casemanagement component. How effective theseinputs were is perhaps best captured in the 1993MOH interagency commission report, which led

to the revised national cholera plan. Thecommission cited the following shortcomings:

• Late detection of outbreaks,

• Information restricted to health services,

• Very little community participation,

• Underestimation of the magnitude of theepidemic,

• Weak epidemiological surveillance,

• Reactive epidemiological surveillance,

• An incomplete norms manual,

• Poor information system,

• No utilization of existing database,

• No utilization of proven and developedinstruments,

• No utilization of risk criteria to definepreventive actions for at-risk groups,

• Little information available to groups that donot have access to health services, and

• Lack of information-sharing within and amongprivate sector and other organizations.

2.5.2 Laboratory Diagnosis

This component of the 1991 plan emphasized thestrengthening of laboratory facilities throughoutGuatemala over a four-year period. The planproposed a budget of approximately $1 millionfor this component, of which more than 80percent was to come from external sources, toestablish seven regional laboratories and tostrengthen the national reference laboratory ofthe MOH, which is called LUCAM.Strengthened facilities were to lend greater qualitycontrol over water, food (both restaurant andindustrial), and ice. PAHO provided somesupport to this component in terms of equipmentand training (see Appendix B for more detail).The team was unable to determine how effective

PAHO's support was, or how much was achievedthrough the component generally.

2.5.3 Water and Sanitation

PAHO reports that the bigger cholera outbreaksin Guatemala are attributable to poor waterquality, and that the smaller outbreaks areattributable to inadequate food hygiene. A thirdproblem in cholera transmission, in PAHO'sview, is attitudes regarding personal behavior. Interms of ranking, water quality is clearly the mostsignificant of these.

The 1991 plan's guidelines for this componentwere not followed. The plan had outlined sixwater and sanitation action areas: latrinemanufacture and distribution in Region M, repairand improvement of water systems in high-riskareas, chlorination of water in small ruralsystems in high-risk areas, installation of 400manual pumps and improvement of artesian wellsin high-risk areas, latrinization in ruralcommunities m Region VI, and basic sanitation inperi-urban areas of Guatemala City. The 1993interagency commission cited almost 20 majordeficiencies in the implementation of the plan. Inaddition to resources, which are always lacking,coordination, organization, and policy guidancewere probably the elements most in need.

Fifty percent of the resources required to meetGuatemala's water and sanitation needs are said toexist in the country, but the appropriatemanagement and coordination critical to theefficient use of the resources have yet to beachieved. Management and coordinationproblems take two forms. First, there are a largenumber of agencies and groups involved inbuilding infrastructure with no coordinationbetween them. This has led to duplication ofeffort and, more seriously, to an inconsistentapproach in terms of policy guidance andstandards for the infrastructure that is put inplace. Second, many of the financial resourcesavailable in-country are either used inefficiently

or underutilized because government agencies feelcompelled to design and build the systems as wellas to train the communities to run them, ratherthan to contract the private sector for as much ofthis work as possible. The outcome of thisapproach is inefficiency and gross underutilizationof existing financial resources.

In an attempt to improve the 1991 nationalcholera plan, the Guatemalan Association ofSanitary Engineers (AGISA), convened a two-dayseminar in June 1991 to develop a specific plan forwater and sanitation that presented a series ofactions for short-, medium-, and long-termimplementation. This plan too was neverimplemented.

Under the AGISA plan, short- and medium-term actions were developed to address immediatechallenges presented by the cholera epidemic interms of water quality and basic sanitation inhigher-risk areas, and a set of long-term actions (7to 10 years out) were intended to address moreglobally the problem of water coverage andquality, and sanitation coverage. With a budgetof approximately $45 million, it was a veryambitious plan. However, it did offer amechanism to address the issue of coordinationand management. The plan had proposed thecreation of five commissions to coordinate actionsin the water and sanitation sector. Onecommission each would be devoted to rural waterand sanitation, urban water and sanitation, solidwaste, food hygiene, and hospital waste.Organized under COPECAS (the permanentcommittee for the coordination of water andsanitation), which is an integral member of thenational cholera Technical Committee, thecommissions would have brought some order tothe chaos that characterizes the 30 or so agenciesinvolved in water and sanitation in Guatemala.Instead, most of the activities implemented in thesector have been independent of the nationalcholera plan.

Two activities stand out as important eventhough they are being implemented independent

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of the national cholera plan. The first began in1991, when USAID initiated a $10 million projectin support of water and sanitation in theGuatemalan highlands. The five-year projectobjective is to improve the health status of thehighlands rural poor through the reduction ofdiarrheal disease. Through the project, twohundred potable water systems and 24,000 latrineswill be constructed in 300 communities in sixdepartments of the western highlands.

The second noteworthy activity beingconducted outside the national cholera plan is aprogram run by the international privatevoluntary organization (PVO) CARE. CARE hasbeen programming resources for water,sanitation, and hygiene education in Guatemalafor a number of years. In 1992 and 1993, theagency accessed cholera funds from the LACBureau through the WASH Project. CARE usedthe funds to develop a behavior-based monitoringsystem for one of its larger projects. However,CARE has been implementing its activitiesindependent of the national cholera plan.

Meanwhile, PAHO has developed a $100,000program to chlorinate water supplies in 20communities identified as being at high risk forcholera.. PAHO has funded $30,000 of theprogram and is presently searching for donors tocover the balance. The spirit of this activity isconsistent with the revised, 1993 national plan.

The study team also found that a large numberof NGOs have been active in water and basicsanitation, but have operated totally independentof the cholera plan. Complicating the picturefurther has been the entrance of the SocialInvestment Fund (FIS), which has startedconstructing water and sanitation facilitiesthroughout Guatemala. Because the objective ofthe FIS program is employment generation, itdoes not lend itself easily to the parameters of ahealth program like a national cholera plan. Yetthe FIS is a sizable player with considerable

resources. Moreover, because the FIS is anemployment generator, it pays for many of theinputs—such as local labor and materials—thattraditionally have been borne by communitymembers under NGO or national developmentprojects financed by bilateral donors. An effortshould be made to channel FIS resources that goto water and sanitation infrastructure within thecontext of the national cholera plan.

In summary, Guatemala's water and sanitationobjectives under the 1991 cholera plan were notcarried out. Any accomplishments were probablycoincidental.

2.5.4 Food Hygiene

The 1991 plan laid out four-year objectives fordeveloping and implementing improvedsurveillance of hygiene conditions in foodprocessing plants, street-vendor carts, and foodmarkets, as well as for improved data collectionand monitoring. To some extent, plan objectiveshave been met. In Guatemala City, theDepartment of Food Hygiene late in 1992instituted a program for the licensing andmonitoring of water tanker trucks. Theconfidence level in this program is high in thatabout 80 percent of the tankers are thought to becomplying with it. Training programs for foodvendors, especially street vendors, with supportfrom PAHO, have been instituted in urban areas,and the perception among officials is that theprogram has been effective. Similarly, majormarkets in the higher-risk areas in the countrywhere cholera cases have been reported werevisited by health officials, and improved hygienepractices have been impressed upon sellers inthese markets. Extension visits to markets alsoaddressed improved waste disposal practices. Theplan had budgeted about $2 million for thiscomponent, of which about $900,000 was tocome from external sources.

2.5.5 Social Communication andTraining

This component focused mainly on food sellersand handlers. Training and promotion was to bedirected at health sector workers who, in turn,would monitor and train food handlers. Inaddition, promotion would be directed at thegeneral public to raise awareness about foodhygiene and the care consumers should take whenbuying prepared or raw food in markets. In 1993,the MOH interagency commission found thiseffort lacking in several respects. First,promotion and education were neither systematicnor sustained. Second, promotion and educationwere not directed at prevention, but more atalerting consumers to be aware during the crisisperiod. Finally, the commission observed thateducational messages often reflected very little ofthe local reality, tending instead to be more of astandard message, such as, "Do not buy food fromstreet vendors," rather than being based onepidemiological data or investigations.

2.5.6 Evaluation

The intent of this component was to evaluate theimplementation of cholera control andprevention activities in Guatemala at least threetimes a year. Evaluation reports would then beprovided to participating institutions so thatservice delivery and impact could be improved.Apart from the assessment that the MOHcommission conducted in 1993, the study teamfound no evidence that any evaluations werecarried out, much less three times a year. TheMOH commission noted among the generalproblem areas the deficiency of coordinationamong and between sectors in terms of planning,implementation, and evaluation.

Although the 1991 Guatemala plan failed toaddress case management as one of itscomponents, the plan did account for it. Whycase management was left out of the 1991 plan isdifficult to understand, given that more than half

of the dollar value of external assistance wasdirected toward provision of case managementsupplies. The introductory sections of the planaddress the national health situation and the needfor training, but none of the subsequentcomponent sections is directed toward casemanagement, nor do any sections mention casemanagement training specifically. As was citedabove, most training appeared to be directed atfood hygiene. Perhaps the MOH pian preparentook for granted case management, givenGuatemala's hospital infrastructure. Followingthis logic, it would be unnecessary to plan forsomething that would get preferential treatment.Another explanation would be that none of themain ESAs-such as PAHO, UNICEF, andUSAID—was involved in the plan's finalpreparation.

2.6 Other Cholera Activities

As described above, together the MOH, the IGSS,and the private sector, provide health services toabout 54 percent of Guatemala's population. Thisformal health care delivery system was the mainmechanism for implementing actions under the1991 national cholera plan. In addition to thisformal sector, NGOs provide some input. Oneof these, Fundazucar, operates on a relativelylarge scale providing service to communities infive health areas.

Fundazucar is the Guatemalan sugar industry'ssocial arm. The sugar industry, both at theplantation and refinery level, is concentrated infive departments of southeast Guatemala:Guatemala, Santa Rosa, Escumda, Suchitepéquez,and Retalhuleu. When the cholera epidemicbroke out in July 1991, Fundazucar decided toextend assistance to control and prevent thespread of the disease. It has provided andcontinues to provide the following services:

• In 1991, organized a forum to publicize itsintentions of extending assistance to control andprevent the spread of cholera.

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• Printed and distributed 30,000 educationalposters among municipalities in the fivedepartments.

• Purchased and distributed 10 tons of chlorine tomunicipalities in the five departments.

• Distributed more than 350,000 ORS packets tohealth posts, health centers, and MOH hospitals,and to units of the IGSS and to municipalities.

• Trained and equipped 150 rural healthpromoters.

• Equipped and provided a mobile unit for use inthe cholera campaign in the five departments.

• Trained 100 nurses in its Technical VocationalInstitute who now work in hospitals in Escuintlaand Mazatenango.

• Through sugar refineries, mounted acontingency plan to address cholera among theirworkers, families, and communities.

• Provides training for IGSS health promoterswho work in the five departments (IGSS isconcentrated in these departments more than arethe MOH services).

• Strengthens services to sugar workers to includeeducational videos, ORS salts, and waterchlorination, as well as other needs as they arise.

• Coordinates monthly meetings with medicalpersonnel in the region to discuss the epidemic'sprogress.

• Provides medical equipment, materials, andother inputs to the hospitals of Coatepeque,Mazatenango, and Escuintla, as well as to healthcenters in San Antonio, Suchitepéquez, SantaLucia Cotzumalguapa, and Patulul.

• Collaborates with the MOH in the transport of5,000 latrines to communities in the southerncoastal area.

• Is developing and implementing 116 potablewater projects in communities of the southerncoastal area. To date, more than 40 percent havebeen completed.

These actions have been or are being carried outwith the knowledge of the MOH and IGSS.However, how closely each of them isimplemented within the framework provided byeither the 1991 or the 1993 plan is unclear. Itappears that Fundazucar is workingindependently of the plan, but in collaborationwith the MOH in some instances. The manner inwhich Fundazucar has worked, and the impact ithas had, probably were responsible for the 1993commission's observation that coordinationbetween the public and the private sector must beimproved.

2.7 The Plan and External AssistanceThe Guatemalan government's budget for the1991 national cholera plan was US$329,000.USAID contributed US$1.5 million and PAHO,US$891,024. (A summary of financial resourcesprovided to Guatemala by external supportagencies is provided in Appendix B.)

Guatemala's use of assistance from all externalsources appears to be consistent with the nationalcholera plan. Approximately 54 percent ofUSAID assistance was used for the purchase ofintravenous solution, ORS, and related casemanagement supplies. The remaining 46 percentwas provided in the form of technical assistance.This support was consistent with the plan. Mostofficial actions in the plan were directed at casemanagement, and therefore resources receivedfrom external as well as internal sources were usedaccordingly. Some of the technical assistance, suchas the support to CARE for the development of abehavior-based monitoring system, while relevantto cholera control and prevention, was notexplicit in the plan.

2.8 Lessons LearnedGuatemala's national cholera plan and itsimplementation offer the following lessons.

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Management Function: Although the 1991 planwas not implemented as described, it did fulfill aplanning and management function by providinga reference point for measuring progress. In 1993,when the MOH saw the number of cholera casessurpass 30,000, it realized it was putting most ofits effort into case management at the hospitallevel, while expending little effort on casemanagement at the community level. The MOHalso acknowledged it was paying even lessattention to prevention.

In evaluating what the 1991 plan proposed todo, the 1993 interagency commission found somesuccesses, including laboratory diagnosiscapability in identifying cholera, utilization ofresources to obtain inputs, reduction in mortality,formation and training of some local committees,and the improvement of water and sanitation insome communities. In this regard, the plan servedas a framework for external support agencies,especially PAHO and USAID, who were thelargest donors. Material assistance intended to beused for case management, namely ORS packetsand intravenous solution, was programmedaccording to the plan. Similarly, training andequipment for the purpose of improvingepidemiological surveillance were performed andused according to the plan's broad outlines.

However, the commission also noted many ofthe 1991 plan's shortcomings, including poormanagement of information on diarrhea andcholera, centralized decision-making, absence ofrisk and equity criteria in defining actions, a focusthat was almost exclusively curative, a shortage ofresources, the lack of coordination within andbetween agencies, and deficient managementoverall. As a result, many available resources werepoorly utilized.

Uncoordinated Activities: Guatemala's SocialInvestment Fund (FIS) has established itself as asignificant player in the water and sanitationsector, but well outside the context of the choleraplan. Such a lack of coordination weakens thepotential for FIS programs to improve health andto make a positive contribution to development.Better coordination of FIS programs would notonly help improve preventive efforts to controlcholera, but would also strengthen recentattempts in the sector to provide infrastructurethat is economically sustainable, and therefore ismore beneficial to public health over a longperiod of time.

A Second Chance: The 1993 revised plan gives theMOH a second chance to improve itsperformance. However, the Ministry's strike thatyear disrupted this effort, and the momentumthat was gained with the interagencycommission's review has yet to be recaptured.Political leadership has been absent. The electionsof August 1994 will affect the current choleracampaign, and may reinvigorate the 1993 effort.

Social Communication: Information sent topeople through the private sector and throughofficial channels has conveyed the messages that"cholera kills" (and that therefore treatment inhospitals is required), and that services inhospitals and health centers are better than thoseat home. As a result, the MOH found its facilitiesand staff overrun and unable to addressprevention issues. Messages must be crafted toaddress the risks for contracting cholera, and musteducate people about what they can do first toprevent the disease and, second, to treatthemselves. Messages that instill fear should beavoided.

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CHOLERA IN HONDURAS

3.1 Incidence

Although cholera arrived in Honduras in October1991, when compared with its neighbors, thecountry's disease incidence remained low untilonly very recently. (In comparison, the incidencerate in Guatemala in 1993 was more than sixtimes higher.) As of June 10,1994, the cumulativenumber of cholera cases since 1991 totaled only5,283, but more than 4,000 of these occurred inthe previous 12 months. (For comparisonpurposes, Honduras's population in 1993 was5,240,000.)

During 1992 and 1993, while the epidemic wasincreasing at a faster rate in both Guatemala andEl Salvador, the low incidence in Hondurasattracted the attention of neighboringgovernment officials who wanted to know whatHonduras was doing right. This elevated theimportance of prevention and control actions tothe level of the presidency, but in so doing,produced a downside effect of centralizing bothdecision-making and plan implementation.

The sudden increase in cases Hondurasexperienced in 1993-1994 stemmed from thefloods of September and October 1993. Theprevention efforts that had been credited withholding down the number of cases, such asgeneric health messages, were not as effectivewhen the flooding accelerated diseasetransmission. Up to that time, specific actions inthe country's cholera plan—especially socialcommunications and the high political visibilitygiven the crisis—were thought to have helpedhold down the incidence of disease. However,although incidence increased only recently(starting at 0.002 per 1,000 population in 1991,and rising to 0.51 per 1,000 in 1993), the case

fatality rate has been high throughout theepidemic, at greater than 2 percent, while the ratehas been about 1 percent in most other LatinAmerican countries.

3.2 Actors in Cholera Controland Prevention

The main player in cholera activities in Hondurassince the 1991 outbreak has been the Ministry ofHealth (MOH) and its various divisions,including epidemiológica! surveillance,laboratory, environmental sanitation, healthservices, education and social communication,logistics, and communications. In 1991, each ofthe divisions formed a subcommission to fightcholera. Other entities that lent, and are lending,assistance include the Ministry of Government,the Presidency of the Republic, PAHO,UNICEF, USAID, SANAA (Servicio AutónomoNacional de Acueductos y Alcantarillados), andlocal municipalities.


3.3.1 Background

The Honduras Plan for the Prevention andControl of Cholera, released in February 1991,was an effort to mobilize resources on anemergency basis that would be implementedthrough the MOH's national health care deliverysystem. Essentially the plan provided guidance forregions, areas, and health care units (healthcenters and hospitals) to design and implementemergency measures at their respective levels. Theplan presented approaches for seven components:

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logistics, water and sanitation, food hygiene,social communication, epidemiologicalsurveillance and outbreak control, laboratorydiagnosis, and improvement of health services. Inaddition, PAHO made available to internationalagencies a plan drafted by local ministers of healthin San Jose, Costa Rica, in May 1991. The CostaRican plan addressed the same components as theHonduras plan, and therefore was used to solicitadditional technical and financial support fromthe international community to complementnational cholera efforts. This plan was thereinmore a funding document than an action plan.

In April 1994, the MOH presented a new draftplan emphasizing the continuation of the sameseven components presented in the 1991 plan, butthis time integrating them into its Control ofDiarrheal Diseases (CDD) program as one moreelement of diarrheal disease management. Thisdecision was made for two reasons, one beingpolitical—the Liberal Party that assumed power inMarch 1994 following national elections wantedto redefine the CDD program to fit its platformof modernization and decentralization (calledmunicipalización)—and the other reason beingadministrative. Having observed that theemergency cholera measures implemented underthe 1991 plan had reduced the incidence ofdiarrheal disease in children, the MOH now feltthat integration of cholera control and preventionefforts with the CDD program would have aneven greater impact on diarrheal disease reductionoverall.

3.3.2 Political Constraints

When the assessment team began its review inTegucigalpa on June 13,1994, there soon aroseconfusion about the existence of one single plan.Several documents, in addition to the PAHOCosta Rican document, were identified, includingthe February 1991 plan, an April 1991 strategydocument, and an undated cholera strategydocument that appears to be a hard copy of

overhead slides. Part of the confusion stemmedfrom the electoral change of government at thenational level in March 1994, when the LiberalParty took office. The new political appointeesnow occupying key positions in the MOH andelsewhere in the government suggested to theassessment team that no uniform plan had existedfrom 1991 to 1994. In addition, someinternational agency observers suggested that nocoherent plan existed prior to the April 1994integrated draft plan. However, as interviewsproceeded, especially with career healthprofessionals at the subcommission level and atthe regional and area levels, a pattern ofsubcommission, regional, and local plansconsistent with the February 1991 plan was soonestablished.

The February 1991 plan was an outline thatprovided guidance to MOH units at all levels onhow to proceed in an emergency. Althoughinitially a decentralized plan, its implementationturned out to be centralized and fairly vertical.According to the former national choleracommittee coordinator, following thedevelopment of the 1991 plan at the central level,officials from the various divisions of the MOHtraveled around the country to provide oralinstruction to regional health officials about howthe plan should be adapted and implemented atthe regional, area, and local levels. Regionalhealth officials were instructed to organize rapidresponse teams to respond to outbreaks in theirregion.

After Honduras's low reported case rateattracted regional political attention, thepresidency became involved both to take creditfor and to try to ensure a continued low incidencerate. One consequence was that rapid responseteams were fielded from the national levelwhenever outbreaks occurred, underminingregional and local efforts. These brief visits alsomasked the seriousness of the disease byconveying a message that the disease was undercontrol once the national response teamsdeparted. This experience led to the observation

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that to be sustainable, plan implementationshould not only be decentralized initially butshould be maintained that way, as well.

3.4 Review of Plan ComponentsThe following reviews the essential elements ofeach of the national cholera plan's sevencomponents.

cholera patients, putting the system under furtherstress.

An additional logistical burden stems from theway commodities were distributed under theearly emergency phase of the cholera plan. Evenhealth centers at which no cholera cases werereported received supplies. In these areas, unusedstocks have now become outdated. Distributionbased on diarrheal disease rates or actual choleraincidence might have put the stocks to better use.

3.4.1 Logistics

This component was fully implemented.Commodities received were efficiently deliveredand inventoried, and continue to be for the mostpart. The plan specifies maintaining a minimumstock of intravenous solution and accessories, oralrehydration solution (ORS) packets, antibiotics,chlorine, and laboratory materials sufficient totreat 10 patients at each productive health unit(UPS). When an outbreak occurs at the UPSlevel, additional stocks from the regionalwarehouse are sent in where needed. A fairlyefficient system of fax machines and radiosconnect the regional warehouse with UPSs inhealth areas, as well as with the capital.

Through 1992 and 1993, Honduras's logisticssystem worked well. The problem facing theMOH now is the resupply of intravenoussolution and accessories, chlorine, antibiotics, andreagents for water quality testing kits. Most of theinventory handled has been provided by US ADD.The most recent shipment received from USAIDwas on December 12, 1993, and will probably bethe last the Government of Honduras (GOH)will receive from the agency. The challenge nowis to determine how to maintain inventories basedon the national budget. Normal health caresupplies are financed from the national budget,while cholera preparedness during the last twoyears has been supported with funds outside thebudget. Normal UPS supplies intended for otherhealth care probably will have to be extended to


The 1991 plan outlined the following action areasunder this component:

• household disinfection,

• chlorination of water systems,

• water quality monitoring,

• repair of installed systems in high-riskestablishments (for example, markets andhospitals),

• disinfection of rural wells,

• organization and training of water committees,

• control of water tankers,

• construction of public standpipes anddisinfection of water, along with training inbarrios of difficult access, and

• organization of municipal chlorine banks.MOH efforts at the regional and communitylevels were well intended, but limited in coverageand sustainability.

Water service coverage, water qualitymonitoring, and basic sanitation coverage arethree areas in which very little was achieved dueto a lack of both resources and capacity. Forexample, monitoring the quality of water sold bytanker trucks serving peri-urban areas ofTegucigalpa was initiated but was not sustainedfor very long because of the lack of know-how,

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lack of a policy on water quality, and lack ofresources. Also, municipalities failed to follow upon their responsibility to treat water and monitorwater quality. The latest cases of cholera haveoccurred in municipalities that have failed tomaintain water quality (for example, El Paraíso),due to the absence of a monitoring routine andeither a lack of resources or a lack of motivationto obtain resources through water-use tariffs.

Data on basic sanitation coverage and usage areunreliable, but it is estimated that 63 percent ofurban and rural Hondurans have access to basicsanitation. The Honduran Social InvestmentFund (FHIS) is implementing a large latrineconstruction program under whichapproximately 22,000 units have been completedso far. Although it is meeting some degree ofneed, the program poses challenges in terms ofhealth and general development, as its mainobjective is employment generation rather thanhealth care, and customary approaches tocommunity participation are not being followed.Additionally, although labor and local materialsare fully paid for, there is no cost recovery. Interms of health impact, latrines built early in theprogram (1992) were not complemented byhygiene education and, as a result, are little used.(The program now contains an education andpromotion component that is currently beingevaluated.)

FHIS promotes only a simple ventilatedimproved pit model latrine, which may alsoexplain the low usage rates under its Honduranprogram. While other groups are also promotingthis model, other options might be appropriateunder certain conditions. Differing opinionsprevail about the appropriateness of the latrinetechnologies being used.

3.4.3 Food Hygiene

The 1991 plan urged education, promotion, andquality control in six action areas: education andtraining for all food sellers; improvement of thehygiene practices of street vendors; improvementand monitoring of, on a permanent basis, thehygiene of food markets; improvement andmonitoring of the food hygiene conditions inrestaurants and hotels; monitoring of the hygienepractices of food processing installations; anddevelopment of safe alternatives for theproduction of green and leafy vegetables. As anemergency plan, these actions were broadly andwell implemented through 1992 and 1993. Thedifficulty now is sustainability. Under the newnational government's decentralization program,the MOH will try to transfer the responsibility tomunicipalities.

3.4.4 Social Communication

The early mass media effort in this componentwas grand in scope and largely financed by theprivate sector, but messages were based on knownrisks, (for example, those in Peru), not on localexperience. When disease hit, messages remainedunchanged. Additionally, PAHO and MOHpersonnel reported that the majority of outbreakswere associated with water, yet messagescontinued to stress food hygiene.

The national plan defined five areas forbehavior modification through educationalefforts, including mass media. These were handwashing, treatment of water with chlorine at thehousehold level, food handling in the home andfrom street vendors, proper use of a latrine, anduse of ORS salts. The areas were not based onepidemiológica! data, however, but rather were astandard set of behaviors that, while relevant, are

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not directly related to how people contractcholera. The problem was exacerbated by theprivate sector, which, though generous with itsresources, advertised its products with choleramessages attached to them. Many of thesemessages generated unwarranted fear on the partof consumers by suggesting that cholera could killthem, and that the use of a particular maker'sproduct might save their lives.

3.4.5 Epidemiológica! Surveillanceand Outbreak Control

Until the end of 1993, Honduras only reportedlaboratory-confirmed cases of cholera, which ledto suspected underreporting. Now, the casedefinition no longer requires laboratoryconfirmation of all cases. After the firstconfirmed case in an area, cases of severe diarrheain persons older than five years of age are countedas cholera cases. A central-level unit has beenestablished at which suspected cholera cases arereported on a daily basis. The unit in turnprovides weekly reports to the relevant MOHunits. Upon notification of a suspected case,central- and regional-level personnel mount anintensive series of interventions at the communitylevel designed to control the outbreak. Thisproved successful until the flooding in Septemberand October of 1993, when widespread outbreaksoccurred.


All regional laboratories in Honduras are capableof culturing and identifying the cholera vibrio;however, the central laboratory has no setprocedures for sampling isolates for the purposesof tracking the epidemic and monitoring drugresistance.

3.4.7 Improvement of HealthServices

In 1991, all MOH health service providers andsupervisors were trained in cholera casemanagement. However, the low incidence ratelimited the "real-world" opportunity for thesetechnicians to apply their new skills and improvethem hands-on. Health personnel in othercountries, such as Peru, have benefited from alearning curve made steep by a higher incidencerate. When Honduras's cholera rate edged upsharply in 1993, the unused skills acquired twoyears before did not hold health personnel ingood stead. Moreover, there had been no follow-up to the 1991 training. Other factors influencedskill levels as well. For example, norms manualswere not completely accurate in describing casemanagement techniques. The cumulative effect ofthese factors is that Honduras is reported to haveone of the highest cholera case fatality rates in thewestern hemisphere, at 2.6 percent. (There existslittle difference between the hospital case fatalityrate and the nonhospital case fatality rate, 2.4percent versus 2.7 percent.) In June 1994,retraining at the hospital level was initiated.

3.5 The Plan and External AssistanceThe GOH's budget for the 1991 national choleraplan was approximately US$1 million. USAIDcontributed US$1.117 million, PAHOUS$561,444, and FHIS US$8.75 million throughan InterAmerican Development Bank loan. (Amore detailed breakdown of financial resourcesprovided to Honduras by external supportagencies is provided in Appendix B.)

Honduras's use of external assistance, fromUSAID and other sources, was generallyconsistent with the national cholera plan in oneor more of its components. The plan itself was

17

appropriately focused, yet little coordinationexisted among components. For example, somestocks of intravenous solution expired before theycould be used, suggesting an oversupply. Thus,questions remain about the criteria used fordistributing intravenous solution and relatedequipment. The logistics unit decided on aminimum stock for 10 patients at each healthcenter, rather than basing distribution ondiarrheal disease incidence or trends in choleraincidence. As a result, health centers in areas thatto date have never reported cholera cases haveoutdated supplies, while centers with a highnumber of cases are in short supply.3

Meanwhile, the assessment team learned thatpoor lab procedures could have been improvedhad some short-term technical assistance beenbrought in to complement the materials supply.The impact of the technical assistance providedfor the development of case management normsappears to have missed its intended goal. Severalfeatures of the norms were not consistent withWHO recommendations. Specific examplesinclude the excessive stress placed on renal failurewith the use of bicarbonate in acidosis and addedpotassium. The resulting case management is thusexcessively complex and requires several othermedications (KCL, NaHCO3, diuretics) as part ofthe cholera medications. Yet, in reality it appearsthat these other drugs are not being used, andgenerally the WHO guidelines are followed. It isconfusing to have the norms differ from practice.

Technical assistance on water quality initiativesmight have helped advance a monitoring systemthat could have averted the later outbreaks incommunities where treatment systems neithermonitor water quality nor treat water. Yet given

According to USAID officials, the estimation of needswas based on an expected number of cases, corresponding tothe experience of other countries in the region. To date thesecases have not materialized. However, the expiration is alsorelated to the fact that these supplies arrived only 6-8 monthsbefore their expiration dates.

that there are over 100 urban and over 2,000 ruralsystems in Honduras, water quality monitoringand treatment programs take time to implementregardless of technical inputs. Greatimprovements have been made over the last fiveyears in this area, but there is still a long way to

3.6 Lessons Learned

Honduras's national cholera plan and itsimplementation offer the following lessons:

Continuity: Obviously, an emergency plancannot be sustained over a long period of time.However, the emergency phase of a plan can helpcreate an enabling environment that protectspublic health in a sustainable way. An emergencycreates opportunities for linkages between goodepidemiological data, health information systems,and communication with the public. Anemergency also creates opportunities for, andoften forces, government and private agencies towork together to make a plan work. InHonduras, different divisions of the MOHdiscovered that they could work togetherharmoniously.

Decentralization: Although Honduras's originalnational cholera plan was designed to beimplemented at the local level, politics rapidlyovertook the rational planning methodology andhurt the plan. The involvement of centralgovernment figures in local outbreaksundermined the impact of plan activities bysending the public the wrong signal when thenational figures returned to the capital, giving theimpression that the danger had passed.

Decentralization not only leads to betterimplementation because it engages localauthorities, it also maintains credibility in aprogram over time. A role exists for strongcentral involvement, but it should be to supportlocal efforts with the latest technologies andapproaches necessary for preventing and

18

controlling the spread of disease. The "doing"should be left to local authorities.

Interagency Coordination: Coordination amongthe national cholera committee, local groups, andinternational agencies was weak. Following initialcontacts in 1991, there was little-to-no formaleffort made to coordinate activities or shareinformation among the agencies. While a faircriticism to level at the national choleracommittee, circumstances, including the lowincidence rate, and the decentralized approachcontributed to this situation. As a consequence,when cholera accelerated in 1993 and 1994, theselinkages were not in place to help deal with theproblem of providing services and attention toactual and potential cholera victims.

Sectoral Coordination: As in Guatemala, theHonduran Social Investment Fund (FHIS) hasbecome a big player in providing sanitationservices (almost exclusively latrines) in peri-urbanand rural areas. Yet FHIS has stressedemployment generation without dueconsideration of national health care objectives.Coordination with the national cholera plan isessential to ensure that not only employment isincreased, but that health objectives are alsoaddressed. Similarly, coordination withnongovernmental organizations working in thesector is essential to ensure that coverage in high-risk areas is addressed. Coordination also shouldconsider the longer-term issue of economicsustainability of infrastructure, one aspect of theFHIS program that is glaringly weak. As anemployment generation program, FHIS is notconcerned with the challenges of cost recovery,and thus its presence undermines the efforts byother agencies or groups that work in the same orcontiguous areas.

Technical Assistance: Case management practicesunder the national plan's implementation, which

are faulted for the high case fatality rate inHonduras, were weak in part because externalresources brought in were mostly material.Technical assistance for case management,especially for training and training reinforcement,might have helped reduce mortality rates.Similarly, technical assistance for water qualitycontrol and monitoring might have helped avertsome of the municipal system outbreaks ofcholera. In summary, technical assistance shouldbe considered an important part of resourcesbrought in through a national cholera plan.

Social Communication: Under its national choleraplan, Honduras experienced a remarkable declinein childhood diarrhea. This has been attributed toincreased publicity surrounding cholera. Theimpact of generally broad cholera messages isobvious in terms of morbidity rates; however,more targeted messages may be more effective inlowering mortality.

Integrating Cholera into CDD Programs: As withmany countries in the region, Honduras isintegrating CDD programs as part of governmentpolicy. However, there is a concern that CDDprograms traditionally have not attracted theattention that cholera programs have. InHonduras, cholera management has been separatefrom the MOH and usually managed at the levelof the presidency, which has helped maintain thedisease's high level of public visibility. Integratingcholera programs into CDD programs, however,runs the risk of lowering cholera's profile to thetraditional level of diarrheal disease control,rather than raising the visibility of all diarrhealdiseases to the level cholera sustained during theinitial emergency. Efforts therefore should bemade to ensure that integration elevates bothcholera and other diarrheal diseases to the level ofpublic visibility that cholera received during theemergency stage of the epidemic.

19

4 CHOLERA IN ECUADOR

4.1 Incidence

Cholera entered Ecuador in March 1991, twomonths after its South American debut in Peru.Ecuadorian health officials, in anticipation of itsarrival, intensified epidemiológica! surveillancealong its border with Peru, only to see the diseasetake an end-run approach entering near Máchala,along the coast some distance from the border.Although the estimation about where choleramight enter was off the mark, the ferocity of itsarrival was not underestimated. By the end of theyear, Ecuador had experienced more than 46,000cases, with 692 resulting in death. Almost 32,000cases with 208 deaths were reported in 1992, butin 1993, the disease began to decline dramatically,with less than 7,000 cases and 72 deaths occurring.Through the first six months of 1994, Ecuadorreported just slightly more than 1,000 cases with14 deaths. (For comparison purposes, thecountry's population in 1993 was 11,252,000.)

Through the course of the first three years ofthe epidemic, data show that 20 cantons—areaswhere access to safe water and adequate sanitationis limited—generated more than 80 percent of thecases. Although the disease greatly declined inmost areas of the country in 1993,epidemiológica! data now show a pattern ofpersistence in some regions of the sierra and thecoast. Communities in three provinces,Chimborazo, Esmeraldas, and Imbabura,characterized by appreciable densities ofindigenous or peri-urban populations withoutwater and adequate sanitation, have beenassociated with persistent, though small,outbreaks of cholera. Apart from these pockets ofresistance, however, the disease seems to havecome under control in most of the country.

4.2 Actors in Cholera Controland PreventionThe main player in cholera control activities inEcuador has been the Ministry of Health (MOH),which is a member of the national choleracommittee formed in April 1991. In addition tothe MOH, national committee membersoriginally comprised representatives of theMinistry of Defense, Ministry of Education, somelocal NGOs, PAHO, and UNICEF. USAIDjoined in early 1992.

In the early months of 1991, the committeeleadership was provided by the National Secretaryfor Information, not the MOH. The selection ofleadership was intentional, and was directed atinforming the public as quickly and as extensivelyas possible about the dangers of cholera and howpeople should protect themselves. Only in 1992,when the government changed followingelections, did the MOH assume the leadershipposition. By that time, however, the incidence ofdisease had started its decline.

At the outset, PAHO was the most activeinternational member of the national choleracommittee, providing guidance and support forepidemiológica! surveillance, especially in theearly warning effort mounted along the Ecuador-Peru border, and in material support forlatrinization and safe water. PAHO was alsoinstrumental in assisting in the development ofhealth messages, with UNICEF covering thebroadcast costs. After joining the committee in1992, USAID provided a variety of support,including technical assistance in socialcommunication, water quality issues, casemanagement, research, and material support in

21

the form of oral rehydration solution (ORS)packets.


The only national cholera plan available to theassessment team was the one obtained inWashington, D.C., from PAHO. This plan,developed in December 1991, presumably byPAHO, laid out a series of actions that includedepidemiological surveillance, laboratory diagnosis,water and sanitation, food hygiene, medicalservices and case management, socialcommunication, and training. The plan had anestimated budget of US$18.95 million, of whichmore than 80 percent was proposed forimproving water and sanitation infrastructure.Both government officials and PAHOrepresentatives interviewed as part of thisassessment were unaware of the existence of thePAHO/Washington plan. The apparent role ofthis plan was to seek funding from theinternational community.

The assessment team was unable to locate anational cholera plan in-country. Nonetheless, theprinciples of the December 1991 plan drafted inWashington are reflected in cholera actionscarried out in Ecuador, beginning with threecomponents—social communication, water andsanitation, and epidemiological surveillance—thatthe committee selected for initial emphasis. Thesecomponents were maintained as prioritiesthroughout 1991, 1992, and 1993, though othercomponents were added later. The nationalcholera committee's decision to focus on thesethree areas indicates a rational decision-makingprocess and one that also retains the spirit of theWashington plan.

Perhaps the reason the team could find no planin-country was because the national committeedecided to use a committee approach instead offollowing a written plan. At the national level,the committee wrestled with issues as they arose,trying usually to take the fullest advantage of

available resources, both domestic andinternational. As the committee progressivelygained knowledge over the first three years of theepidemic, its actions increasingly reflected itsawareness of what needed to be done, with theexception of case management, in which costlyand inappropriate actions continue to beimplemented routinely.

As the epidemic unfolded in 1991, reportedcases began to be concentrated in some coastaland sierra provinces. As a result, the nationalcommittee decided the best way to deal with thecrisis was to form committees in these provinces.Over time, the creation of provincial choleracommittees was to prove an effective approachfor implementing cholera activities. Thedecentralization of responsibility allowedprovincial committees to respond to local needs asrequired. This not only increased efficiency, italso laid the groundwork for sustaining improvedhealth service delivery beyond cholera.

Thriving under chaos best describes howactivities have been carried out in Ecuador'sefforts to attack cholera, leading to somesuccesses, especially the creation of provincialcholera committees. Unlike Guatemala andHonduras, where the experiences of the firstcouple of years of the epidemic gave way to thedevelopment of revised plans and newapproaches, Ecuador's decentralized approach hasbeen followed consistently. In 1994, with thereported case rate down to around 145 cases amonth, the approach is not one of recasting thecholera plan, but of reassessing priorities. This isbeing done informally within each plancomponent by the respective MOH divisions,government agencies, provincial healthdirectorates, and NGOs involved. The nationalcholera committee has stopped meeting on aregular basis, and is unlikely to meet again untiland unless there are renewed outbreaks thatsuggest the epidemic intensity of 1991 and 1992.At the current incidence rate (about 0.60 per1,000 population), the MOH feels it is notnecessary to treat the disease apart from other

22

aspects of public health.

In this context, Ecuador's cholera epidemicappears to have driven home the lesson ofprotecting public health. Government officialsnow realize that social communication involvesmore than just the transmission of messages. Thisunderstanding stems from epidemiological datathat show that during the epidemic, the widedistribution of basic hygiene messages such ashand washing led to a better informedpopulation, but not necessarily to a bettereducated one that changes its behavior as a resultof receiving the information. To bring aboutbehavioral change, many in the MOH nowbelieve social communication must be based onwhy people practice bad behaviors and onunderstanding what in their environment compelsthem to do so. Global messages complemented byspecific ones targeted to areas of high risk are nowseen as essential elements of socialcommunication, and of any effort to protectpublic health. Consequently, any futureapproaches to communication will draw uponimproved use of epidemiological information thatwill include cholera as one component of abroader health education effort. A concernremains, however, that follow-up and supervision,historically weak, need to be improved andsustained. To better understand this change andothers that have evolved through Ecuador'scholera epidemic experience, a review of each ofthe plan components is helpful.

4.4 Review of Plan Components

4.4.1 Epidemiological Surveillance

This has been the most successful component. Atthe outset, however, the MOH was unprepared toconduct adequate epidemiological work. Beforethe vibrio reached Ecuador, PAHO workedclosely with MOH epidemiology personnel tostrengthen surveillance along the Peru border andcoastal provinces. Alas, the disease entered at a

point other than where they were preparing tointercept it, but nonetheless, surveillancemechanisms were being improved.

The cholera crisis led to the development of animproved health information system in Ecuador.In addition to a monthly report that wasproduced before the cholera outbreak, the systemnow produces a weekly report that providesupdates on cholera and 11 other diseases. Datareporting and analysis skills have likewiseimproved. Initially, the epidemiological approachwas unfocused and global, but with experience, ittargeted peri-urban and rural areas that wereexhibiting higher and more persistent incidencerates.

One outcome of better data and improvedreporting has been the establishment of arelationship between small outbreaks andtraditional or folkloric festivals, although thenature of the relationship remains unclear.Analyses have identified 10 high-risk cantons,divided between the sierra and coastal peri-urbanareas, where cholera is persistent.

Epidemiological training has been, andcontinues to be, provided through an agreementwith France and the European Community (EC).This project, called the French-EcuadorianProject for the Control of Diarrheal Diseases andCholera, which will last three more years, seeksto improve epidemiological surveillance ofdiarrheal diseases and cholera and, over the longterm, other infectious diseases. This project isimportant because technical capacity in Ecuadorremains weak, especially outside of Quito, wherelittle data analysis capability exists. The keyelement here is supervision of staff at lower levels,as effective supervision at provincial and healtharea levels is still absent. The French-Ecuadorproject is directed at improving both technicalskills and supervisory skills so that Ecuador'sepidemiological system works effectively andefficiently.

23


The reference laboratory in Quito is fullyoperational and is able to carry out diagnosiswork on diarrheal diseases and cholera; the lab inGuayaquil, through assistance from the French-Ecuador project, will soon have the same range ofcapability. As noted above, little capacity existedat the epidemic's outset to test for the choleravibrio. A technician from Guayaquil hadrecently received training in Japan when cholerabroke out in 1991; however, the appropriatereagents were unavailable. PAHO provided these,and stocked other labs as well. Additionally,PAHO and CDC provided training to labtechnicians around the country.


Despite the lack of specific national goals for thiscomponent (although there are specifiedobjectives in the Washington plan), it achievedconsiderable success. Two significantachievements stand out: sanitary education andsafe water. Latrinization was a central feature forwhich PAHO and USAID provided significantfinancial support (more than US$1.5 millioncombined). The approach adopted was to putsanitary education ahead of construction, an ideathat originated with the Minister of Health andthat was put into practice by CARE. The resultswere impressive. Basic sanitary educationcomplemented by a latrine was well received inrural communities and led to a usage rate inprovinces such as Chimborazo of 80 percent.CARE's contributions to basic sanitationcoverage were, in 1991, 1,584 latrines constructedin 11 communities in 2 provinces; in 1992, 18,345units in 304 communities in 8 provinces; and in1993, 24,168 units in 410 communities in 12provinces. Other agencies also built latrines inrural and peri-urban areas, but the assessmentteam was unable to locate a total numberconstructed. In 1990, rural sanitation coverage inEcuador was about 42 percent; urban coverage

was better at 82 percent. These cholera effortsprobably improved the coverage levels slightly,but figures to support this assumption wereunavailable to the team.

Early efforts to step up latrine construction didlead to some duplication of effort. (Cases havebeen reported where up to three latrines havebeen built for one home compound, with none ofthem being used.) The problem was that littlecoordination of effort existed at the outset,especially among NGOs that often work in anarea independent of government influence orconcurrence. The cholera experience, however,has necessitated that the MOH step in andprovide some coordination.

In 1992, the MOH created the Office ofInternational Relations, which coordinates theactivities of international agencies or groups inthe health sector. Any external group wishing towork in Ecuador's health sector is expected toobtain the MOH's approval before it can beginwork. The arrangement breaks down when anagency perceives its primary work to be in someother sector, say education, but also is active inthe health sector. However, there has beenimprovement in coordination since this office wasformed. Improvement has also come about as aresult of better coordination at the provincialcommittee level.

Rural areas receive assistance for latrineconstruction from Ecuador's Social InvestmentFund (FISE), largely supported by theInterAmerican Development Bank (IDB) and theWorld Bank. As in other countries, however,there has been little coordination between thelatrine construction work FISE is involved in andnational cholera plans or strategies.

Safe water is a term that is coming intocommon usage by MOH personnel to meanwater of quality that protects health, whilepotable water is increasingly interpreted to meanwater that is piped to a more convenient location,for example, inside or near the home. As part of

24

its safe water campaign, the MOH is trying tostress the use of chlorine as the last Une of defensein high-risk peri-urban and rural areas whereinstitutionally provided water (that is, watersystems that can be treated and managed bytrained people) is unavailable. The private sectoris playing a role. Colgate-Palmolive, for example,is providing chlorine for distribution in remoteand peri-urban areas, and provides somepromotional materials as well.

The private sector's contributionsnotwithstanding, the MOH lacks the resourcesand technical know-how required to make safewater a reality in high-risk areas. For example,MOH officials say that among indigenous groupsin the sierra, soap and chlorine bleach are notcommonly used for laundry, nor is soap, in manyinstances, used for personal hygiene. Therefore,these products are not available in local markets.Also, the introduction of safe water is challengedby local customs and behaviors. These factorsmust be well understood before an interventioncan be designed that proposes the use of liquidchlorine, such as bleach. Outside resources wouldbe necessary for the study of behaviors and thedesign of appropriate promotional efforts andinterventions.

Absent from the water and sanitationcomponent have been actions regarding foodhygiene and solid waste management issues.Neither of these areas has been addressed in anycholera control and prevention measuresimplemented in Ecuador since 1991.

4.4.4 Case Management

This component has been the least successfulbecause neither the motivation nor the capacityfor good case management existed among medicalpersonnel in Ecuador during the cholera crisis. Atthe outset, no one had training in dealing withcholera. Moreover, because cases occurredoverwhelmingly in adults, the use of intravenousfluid became the treatment of choice and,

unfortunately, remains so. ORS was deemedunacceptable for cholera treatment when theepidemic first broke out, and only after trainingand some experience with it were gained did ORScome into use. Nonetheless, confidence in ORSremains low within Ecuador's medicalcommunity.

Reliance on intravenous fluid during the crisisincreased the cost of case managementsignificantly; for intravenous solution alone, theMOH had to foot a bill in excess of US$500,000.However, some high points are noteworthy. Twovisits by technicians from Bangladeshrepresentatives of the International Center forDiarrheal Disease Research, arranged throughUSAID, were well received and are credited withproviding some immediate and very helpfulguidance to clinical staff. Also, improvement hasbeen made in the prescription of antibiotics.Overprescription had become a problem andresistance to antibiotics was being recordedbecause of the abuse. Now, both kind and dosageare better understood and are properly prescribed.Abuse continues, however, in the overuse ofintravenous solution and the prescription ofsodium electrolytes to treat cramps. Overall,more training and capacity building are needed atthe health unit level.

4.4.5 Social Communicationand Training

Success in this component was reflected in thehigh level of cooperation among PAHO,UNICEF, the MOH, the Ecuadorian Associationof Radio Broadcasters (AER), and USAID In1991 and 1992, PAHO provided funding (througha regional IDB grant) for development of radioand television spots, as well as print materials.UNICEF disseminated these materials, and AERprovided air time for the spots. Other choleratraining was provided by PAHO, and by USAIDthrough WASH Project. The MOH claims it hasa budget to continue some of these efforts.Follow-up is widely recognized as the weak link

25

in sustaining these actions.

In 1993, HEALTHCOM (the Communicationsfor Health Project) developed a new strategy formass media campaigns that moved the MOHaway from behavioral instruction to motivation.HEALTHCOM research found that the cholerapathogen frightened people more than any otherdisease, including AIDS. HEALTHCOM's workimpressed upon MOH personnel the importanceof developing social communication messagesbased on data about at-risk population behaviorsand beliefs, and the interpretation of that data.When messages are based on how affected groupsview the world, the messages stand a greaterchance of changing behavior.

An evaluation of HEALTHCOM's work hadnot been completed by the time of thisassessment, and no hard evidence exists yet thatthere is an association between any reduction inincidence and HEALTHCOM's communicationsapproach. Nonetheless, the methodology hasstruck a cord. Like the CARE sanitary educationthat preceded latrine construction, focused socialcommunications are now accepted as the mosteffective way to implement health services.

4.4.6 Logistics

The assessment team found that no rational basiswas used to distribute medical supplies to specificEcuadorian provinces during the choleraepidemic. Instead, initial distributions wereapproximations. Later efforts, however, didreflect disease incidence levels. Management wasperformed ad hoc at the national level; only theprovincial cholera committees used logisticscomponents in their approach to attackingcholera.

4.5 The Plan and External Assistance

A summary of national expenditures on directcholera costs in Ecuador was not available to the

assessment team. The only domestic cost thatwas revealed was the MOH's expenditure ofUS$500,000 for locally purchased intravenoussolution. That and other resources used to attackcholera are summarized below (see Appendix Bfor a more specific breakdown of assistanceprovided by international donors).

• GOE/MOH US$500,000 (for intravenoussolution),

• PAHO US$792,013,

• AID US$2,457,024, and

• EC US$2,400,000 (2 million ECUs).

All assistance received, including that fromUSAID, appears to have been well utilized for themost part. With the exception of ORS packets,which were underutilized, and intravenoussolution, which was overutilized, material andtechnical assistance was well programmed andconsistent with the spirit of a national plancomponent by component.

4.6 Lessons Learned

Although the PAHO/Washington nationalcholera plan was not implemented in Ecuador, itdid serve to establish the core principles for thenational cholera committee's strategy. The utilityof the PAHO plan was obvious in that itprovided a general direction for cholera activities.Its usefulness was further apparent in the actionsthat were implemented. The provincial choleracontrol committees, which were formed at theurging of the national cholera committee,developed components based on the Manual ofNorms and Procedures, first published by theMOH in March 1992. The manual provides basicguidance in epidemiológica! surveillance,laboratory diagnosis, water and sanitation, andsocial communication—all the elements of asound plan. Direction in other areas had to behandled verbally from the MOH in Quito, or

26

were developed locally by the provincialcommittees based on need.

Actions were carried out in an increasinglyrational fashion as experience was gained both atthe national and provincial levels. In the veryearly stages of the disease, the national choleracommittee emphasized epidemiológica!surveillance, social communications, and waterand sanitation. As time went by, more actionswere added, eventually giving rise to theappearance that a plan with multiple componentswas being carried out.

Specific lessons the Ecuadorian experience withcholera reveals are addressed below.

Decentralization of Cholera Activities: One of themost important lessons learned in Ecuador camefrom the formation of provincial choleracommittees. The cholera epidemic provided theimpetus for the creation of these bodies, and theyresponded very effectively to the responsibilitygiven them. Provincial health directors werequick to realize the potential the committees hadfor bringing together complementary resourcesand forces. Groups that alone were limitedpooled their resources with other groups toaccomplish much more than they couldindependently. These committees have now beenrenamed as provincial health committees with anagenda that spans all public health issues, not justcholera. If continuing support can be extended tothese committees, they have a good chance ofbeing sustained and of contributing to the largerpublic health well into the future.

Social Communication: The experience in Ecuadorshows that interventions must be understood by,

and be compatible with the cultural characteristicsof, the targeted population. In Ecuador, there wasan acknowledgment that in order to be effective,educational campaigns first had to motivate andsensitize people at the macro level, and later focusactions and treatment at the micro level,especially among at-risk groups.

Safe Water: Strategists in Ecuador recognized theimportance of safe water and the opportunity itcreates for establishing household disinfection asthe last line of defense against waterbornediarrheal diseases.

Hygiene Education and Infrastructure: Thelatrinization program demonstrated the value ofhaving the educational component precede theconstruction component.

Follow-up: Unfortunately, Ecuador's achievementsare unlikely to be sustained, especially thoserelated to behavioral changes in at-riskpopulations, unless actions already implementedare followed up. Follow-up is essential to supportactions such as the following:

• The use of ORS, which was poor throughoutthe epidemic;

• Chlorine use at the household level, which hasyet to take hold; and

• Hygiene behavioral changes observed with theuse of latrines.

The MOH should support follow-up activitiesas part of its ongoing public health policy.Carrying out these kinds of activities should be acore responsibility of the MOH in normal timesas well as during times of emergency.

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5 CONCLUSIONS

5.1 National Cholera Plans

This report highlights the national choleraprograms in 3 of the 20 countries in the regionaffected by the disease—Guatemala, Honduras, andEcuador. Certainly, no generalizations can bedrawn from a sample of three. Nonetheless, thisreview presents some idea of how useful nationalcholera plans were in guiding and focusing actionsin the region. The findings are indicative of whathas gone right and what remains wrong with theapproaches to cholera prevention and control inthese three countries.

5.1.1 Approaches to ImplementingCholera Activities

How governments implemented the plans variedwidely. Honduras's approach was the mostconsistent and, of the three, was the only writtenplan actively put into practice. The centralgovernment developed a national plan that wasthen passed on to regional and area health officials,who in turn drafted local plans. The approach wasoriginally intended to be decentralized. Onceregional and health areas were organized with then-own plans, decision-making and implementationwould occur independently of the centralgovernment. Only health information andrequests for backup logistics support woulddirectly involve central authorities. However,once the low incidence rate in Honduras attractedpolitical attention, the approach became morecentralized as the presidency weighed in both totake credit for the low rate and to try to ensurethat it would remain low.

In Guatemala, a written plan exists, drafted in1991 and updated in 1993, but the assessment teamwas unable to determine whether the plan hadbeen implemented at any level of the healthservices system. After preparing a national plan,Guatemala's Ministry of Health (MOH) sent it toprovincial directorates (health areas), which wereexpected to ratify or draft their own plan based onthe central plan. What the directorates actuallydid remains unclear.

In Ecuador, a written plan drafted in 1991 inWashington, D.C., by PAHO, was used to seekfunding from the international community.Locally, no written plan was followed. Instead,the national cholera committee adopted a strategythat emphasized three areas of action: socialcommunication, water and sanitation, andepidemiológica! surveillance. This approach wascarried to affected provinces, where committeeswere formed to address these three areas.

5.1.2 Measuring the Appropriatenessof Responses to the Epidemic

Experience with cholera programs in thehemisphere since 1991 shows that most plans orstrategies contain seven coreareas—epidemiológica! surveillance, laboratorydiagnosis, water and sanitation, food hygiene, casemanagement, social communication andeducation, and logistics. The EnvironmentalHealth Project (EHP) and Basic Support forInstitutionalizing Child Survival (BASICS) Projectdecided, therefore, that the criterion fordetermining the appropriateness of a choleraresponse would be this set of seven key areas. A

29

plan or strategy that met this criterion would beconsidered an appropriate response.

Although Guatemala developed a plan in 1991that addressed most of the core areas, it was notimplemented. Epidemiológica! surveillance anddata reporting there have been highly suspect, andmost of the other components in the plan werealso found to have been poorly implemented. A1993 revision of Guatemala's national planaddresses weaknesses in the 1991 version, but eventhis improved plan has not been implemented todate. The ambiguity surrounding planimplementation in the country is underscored bythe fact that case management, which was notformally included in Guatemala's written plan,accounted for a large share of the dollar value ofexternal assistance, an inconsistency that suggeststhat some independent decision-making was takingplace somewhere.

In Honduras, the 1991 plan was consistent withthe seven core areas and was implemented in aconsistent fashion.

In Ecuador, a written plan was used only forfunding, but the reviewers think the plan helpedestablish the spirit of a decentralized nationalcholera committee strategy that embraced threeimportant core areas at the outset of the crisis, andthat expanded to include others as deemednecessary at the provincial level.

5.1.3 Effectiveness of CholeraPlan Components

The national cholera plans worked well wherethey were written and followed. In Honduras, thedevelopment and implementation of a planenhanced the government's credibility to combatthe disease. In Ecuador, one of the largestrecipients of combined external assistance at morethan US$5 million, the absence of a plan did nothamper the implementation of a coherent strategy.Guatemala, despite having a plan, has not faredwell in its struggle to confront the disease.

In terms of the seven key plan componentsnoted above, Honduras and Ecuador shared someversions of all seven. The Guatemala plan failed toinclude formally case management or logisticsamong its components, which is mystifying, giventhat most of the external assistance the countryreceived was used to provide case managementsupplies. One thought for this omission is that casemanagement was actually taken for granted by theMOH plan preparers, given the hospitalinfrastructure that exists in Guatemala. Followingthis logic, it would be unnecessary to plan forsomething that would receive preferentialtreatment anyway. Another explanation would bethat none of the principal external supportagencies (ESAs), such as PAHO, UNICEF, andUSAID, were involved in the plan's finalpreparation, because any one of them would havenoted the omission.

Table 1 summarizes the plan components bycountry and their level of effectiveness as reportedby program officials.

30

Table 1

Effectiveness of Plan Components

Guatemala

Honduras

Ecuador

Epid. Surv.

4

* * *

Lab.Diagnosis

*

**

*

W&S

*

*

***

CaseMgmt.

nc

*

*

Soc.Comm.

*

**

***

FoodHygiene

***

**

*

Logistics

nc

***

*

Key:

NC

= weak= average= very effective= no component

The score of component effectiveness is asubjective measure based on the degree ofemphasis the national cholera committees placedon the components, or on how well thecomponents were managed in the opinion ofprogram officials whom the team interviewed.

Having a plan did not ensure more effectivecomponent implementation. In Honduras, wherea written plan was followed, water and sanitationand case management were weak. In the former,water service coverage, water quality monitoring,and basic sanitation coverage fell short, while incase management, efforts suffered from a lack offollow-up. Regarding the other components,however, the assessment team observed a fairlytight fit between what was said and what wasdone. Honduras's accomplishments in the otherfive components were either average—meaningthey were somewhat effective in theiroutcome—or were very effective. Logisticscomponent achievements were consistent withplan targets and food hygiene targets were welladdressed under plan implementation. Socialcommunication targets were also addressed asspecified in the plan, although these efforts werenot based on epidemiológica! data as they should

have been. Ecuador, which had no written plan,was effective in three areas it targeted:epidemiológica! surveillance, water and sanitation,and social communication. A noted failure,however, occurred in case management, which wasneither emphasized nor addressed by the country'snational and provincial committees.

In Guatemala, plan targets were not kept infocus as the plan was being implemented. Forexample, much of the work carried out in thewater and sanitation sector occurred outside of theplan. Only the food hygiene component wasimplemented effectively, and then only because ofa highly motivated person in charge in GuatemalaCity.

5.1.4 Use of Assistance from ExternalSources

Table 2 details the total assistance the majorexternal agencies provided to Guatemala,Honduras, and Ecuador in the countries' attemptsto fight the epidemic. The table also offers abreakdown of how the funds were used in-countryby project component.

31

Table 2

Use of External Assistance

Country

Guatemala

Honduras

Ecuador

US$ Amount

$2,391,038'

$1,677,9542

$5,649,0373

Epid.Suiv.

9%

8%

46%

Lab.Diatg.

10%

5%

1%

W&S

10%

21%

30%

CaseMgmt.

56%

51%

6%

Soc.Comm.

6%

6%

18%

FoodHygiene

4%

6%

1%

Logistics

4%

3%

0%

Total

100%

100%

100%

1 PAHO= US$891,024; USAID= US$1,500,0142 PAHO= US$561,444; USAID* US$1,116,5103 PAHO= US$792,013; EC= US$2,400,000; USAID= US$2,457,024

Note: Figures are rounded and therefore may not equal 100%.

The assessment team made some subjectivedecisions in preparing Table 2. The informationavailable from the ESAs was not neatly packagedby component. To come up with such abreakdown, the team used the summary data foreach country presented in Appendix B. Forexample, in the case of Guatemala, support fromSweden through PAHO provided $413,240 forvarious actions in support of epidemiológica!surveillance, lab diagnosis, case management, andwater protection. The team decided to divide thistotal amount into thirds, assigning a third each($137,746) to epidemiological surveillance and tolab diagnosis; because the team found out littleabout case management and water protection, thefinal third was divided between these twocomponents at $68,873 each. The same kind ofapproach was applied to each country in whichonly total figures were available.

In the case of Ecuador, the French-Ecuadorproject posed a somewhat different problem. Thisproject is being financed with US$2.4 million fromthe European Community. The French teamimplementing the project takes a position thatthese funds should not be considered choleraassistance funds because the project purpose goes

way beyond cholera to include virtually allinfectious diseases in the country. However, theteam decided to include the total here because, forpurposes of this paper, the French-Ecuador projectis a response to the cholera epidemic. It is doubtfulthis amount or kind of assistance would have beenprovided by the European Community hadcholera not revealed how weak epidemiology skillswere in Ecuador.

While far from perfect, this approach topresenting ESA assistance data provides someindication of the spending trends being followed ineach country. In Ecuador, for example,interviewees talked about achievements, especiallythe lessons learned, in water and sanitation, socialcommunication, and in improved epidemiologicalsurveillance. These achievements track closelywith what was emphasized in the strategyEcuador's national committee followed, and withhow much was spent on them. The team foundthat while little of the ESA support given toEcuador was used for case management, almost allthe domestic support was, which remains an issue.

Most external support in the three countries todate has come from PAHO (specific country

32

support through PAHO from Sweden andHolland), USAID, the InterAmericanDevelopment Bank (through PAHO), and theEuropean Community.3 Use of the assistance hasbeen consistent with the components of the plansin Guatemala and Honduras, and consistent withtargeted actions in Ecuador. It was unclearwhether decisions about external support werebased on plan targets, or whether their apparent fitwith plan targets was merely coincidental.

In Guatemala, the manner in which ESAassistance was used reflects the poorimplementation of the 1991 plan. Fifty-six percentof ESA support went to case management, which,as noted earlier, was not formally included in theplan. Other components included in Guatemala'splan, such as epidemiological surveillance andsocial communication, were given little emphasis.Guatemala's 1991 plan had an estimated budget ofUS$10,363,000 of which 23 percent was forepidemiological surveillance, 11 percent forlaboratory diagnosis, 35 percent for water andsanitation, 19 percent for food hygiene, and 12percent for training and evaluation. The resultspresented in Table 2 suggest that the plan wasneither followed nor emphasized. The lack of anynotable cholera activities is the result of a planningprocess that was not followed through. Thecountry's steady increase in reported cholera cases,even after four years of experience, may also stem

from Guatemala's failure to follow its nationalplan.

While the distribution of ESA support inHonduras resembles that in Guatemala, thedifference lies in the purposefulness ofimplementation in the former. Honduras'sexpenditures were consistent with its plan.Likewise, its spending weaknesses were alsoconsistent with the plan (for example, casemanagement in the form of heavy investment inoral rehydration solution and intravenousmaterials, while social communication and othertechnical assistance were lacking).

An accounting of domestic expenditures bycomponent was not available from any of thecountries.

5.2 Conclusions, Lessons Learned, andRecommendations

5.2.1 Conclusions

The following table presents the population ofeach of the three countries studied from 1991 to1993, along with reported cholera cases, incidencerate per 1,000 population, and case fatality ratio(CFR).4

USAID missions requesting assistance from the regionalcholera program were required to indicate whether assistancefit within the national committee plans and whether it wascoordinated with other donors.

The number of cases is reported using clinical diagnoses,not lab diagnoses, so CFRs must be interpreted with caution.However, consistent use across countries makes CFRs areasonable basis for comparison.

33

Table 3

Population, Number of Reported Cases, and Cholera Incidence, 1991-1993

Country/Rates

GuatemalaPopulation

No. of casesRate/1,000CFR%

HondurasPopulation


EcuadorPopulation


1991

9,266,0003,674

0.401.40

4,949,00011

0.0020

10,752,00046,320

4.31.5

1992

9,498,00015,395

1.621.30

5,093,0003840.084.40

10,999,00031,870

2.90.65

1993

9,735,00030,604

3.141.00

5,240,0002,690

0.512.57

11,252,0006,833

0.601.05

Source: PAHO

Guatemala clearly has had the worstperformance of the three countries. It may onlybe coincidence that Guatemala's incidence rateseems to reflect the -weakness of its cholerastrategy, just as much as Honduras's seems toreflect the strength of its plan. Admittedly, it isinviting to speculate that the more consistentapproaches observed in Ecuador and Hondurasmight have played some role in the trends thosecountries have experienced.

The three countries approached thedevelopment and implementation of choleraactions quite differently. While Guatemala andHonduras both had prepared plans, onlyHonduras followed through from the nationallevel down to the local level. It is interesting tonote that in Honduras the incidence of disease waslow, which may have been related to having andimplementing a good plan. On the other hand,while morbidity was kept low, the case fatalityrate of greater than 2 percent in 1992 and 1993 wasamong the highest in the region. Meanwhile,Ecuador's committee approach proved very

effective in mobilizing resources. The provincialcommittees were asked to implement localstrategies patterned after the national strategy.Especially effective was the water and sanitationcomponent, one of the largest in the nationalstrategy. By giving provincial committeesresponsibility for coordinating activities at theirlevel, the national committee allowed provincial-level agencies and nongovernmental organizations(NGOs) to leverage their resources and achievemore than they could have alone. The experiencehas encouraged Ecuador's MOH to retain theprovincial committees and to rename them"provincial health committees" with expandedagendas that include all public health issues.

Ecuador's weakness in implementing its nationalcholera strategy, as Table 3 implies, was casemanagement. In 1991, Ecuador had a CFR of 1.5.It dipped to 0.65 in 1992, but rose again in 1993 to1.05, despite a declining incidence rate over thesame period. While the decline in incidence mayhave been influenced by national and provincialcommittee efforts in social communication and

34

water and sanitation, the CFR was very likely theresult of poor case management. Only 6 percentof ESA support went for case management inEcuador. It is arguable that had more technicalassistance been provided—of the type contributedby the International Center for Diarrheal DiseaseResearch-Bangladesh (ICDDRB)technicians—Ecuador's CFR trend would haveparalleled its decline in incidence.

5.2.2 Lessons Learned from theNational Cholera Plans

Good Planning: In all three countries studied, thedevelopment of a national cholera plan served theimportant function of getting authorities to focuson the crisis and to think about strategies fordealing with it. Even in Ecuador, where a writtenplan was used only for funding purposes, theprinciples and spirit of a plan were incorporated inthe decentralized committee approach that wasfollowed. In Guatemala, a poorly implementedplan drafted in 1991 provided a starting point for a1993 government commission that evaluatedcholera activities and that produced a revised plan.In Honduras, a fully implemented plan wasupdated in 1994 to conform to the agenda of a newnational government, and to integration into theControl of Diarrheal Diseases (CDD) program.

Working without a Plan: A successful countrycholera program does not depend on a plan. InEcuador, where no written plan was followed, asuccessful set of actions flowed from adecentralized committee approach.

Proper Social Communication: Interventions mustbe understood by, and be compatible with thecultural characteristics of, the target population. InEcuador, officials acknowledged that in order to beeffective, educational campaigns first had tomotivate and sensitize people at the macro level,and later focus actions and treatment at the microlevel, especially toward at-risk groups. Also, asshown in Ecuador, latrinization programs canbenefit from having the educational component

precede construction. In Honduras, socialcommunication about cholera is credited with adecline in the incidence of childhood diarrhealdisease.

Decentralization of Cholera Activities: In Ecuador,the cholera epidemic provided the impetus for thecreation of provincial committees, whichresponded very effectively by coordinating choleraactivities appropriate for their jurisdictions. Bypooling resources, groups were able to accomplishmuch more than they could have independently.In Honduras, local involvement in the plan wasundermined when cholera became politicized andattracted heavy presidential involvement.

Sectoral Coordination: In many Latin Americancountries, social investment fund (FIS) programshave been started. These programs have becomeheavily involved in latrinization and waterprojects, but usually are not well coordinated withother efforts in the water and sanitation sector,nor with national cholera plans. Key problemswith these programs are their lack of hygieneeducation and the absence of attention toeconomic sustainability in the form of communityparticipation and cost recovery.

Safe Water: The term "safe water" is increasinglybeing used to describe water that isbacteriologically safe. The term opens upopportunities for addressing water qualitymonitoring issues, and for promoting household-level disinfection as the last Une of defense againstcholera and diarrheal disease.

Technical Assistance: Ecuador's experiencedemonstrates the effectiveness of technicalassistance. By drawing extensively on ESA-supported technical assistance in socialcommunication, Ecuador produced a variety ofmessages directed at the macro and micro levelsthat many MOH officials say were responsible forraising social awareness and reducing diseaseincidence. However, almost no technicalassistance was brought in to strengthen casemanagement skills, and Ecuador's CFR remained

35

almost unchanged from 1991 to 1993.

Follow-up: Unless actions that have beenimplemented are consistently reinforced,achievements made in attacking and preventingcholera are unlikely to be sustained, especiallythose related to behavioral changes among at-riskpopulations.

5.2.3 Recommendations

Based on the experiences in Guatemala, Honduras,and Ecuador, the team makes the followinggeneral recommendations regarding planning andimplementing cholera programs.

1. USAID should continue providing assistancewithin the context of national cholera plans.

2. The channeling of FIS resources should beencouraged within the context of national choleraplans.

3. Safe water messages and practices should bepromoted to households that are unserviced bypiped water.

4. Health messages should be based onepidemiological investigations and high-riskbehaviors, and should be targeted appropriately.

5. Case management should be standardized andimproved through new training and supervisionstrategies.

36

REFERENCES

Comisión Ministerial, Ministerio de Salud Publica y Asistencia Social de la Republica de Guatemala.November 1993. Plan de Atención al Colera en Guatemala. Guatemala City, Guatemala.

Ministerio de Salud Publica. April 1994. Pfcn ISacion^ 4ç Prevención y Control de EnfermedadesDiarreicas y Colera 1994-1995. Tegucigalpa, Honduras.

Ministerio de Salud Publica. February 1991. Plan de Prevención y Control del Colera. Tegucigalpa,Honduras.

Ministerio de Salud Publica y Asistencia Social de la Republica de Guatemala. October 1993. Plan deprevención y Control para la Epidemia del Colera. Guatemala City, Guatemala.

Pan American Health Organization. June 1994. Cholera Situation in the Americas. Update Number 10.Expanded Program for the Control of Diarrheal Diseases. Washington, D.C.: PAHO.

Pan American Health Organization. 1991-1993. Cholera Situation in the Americas. Reported cases bycountry and year. Update Number 9. Sanitary Bureau Regional Office. Washington, D.C.: PAHO.

Pan American Health Organization. 1992. PAHO at Work Todav: The Case of Cholera. Washington,D.C.: PAHO. 26(4) : 293-300.

37

Appendix A

Persons Contacted

Guatemala

Dr. Enrique Duarte, Vice-Minister, Ministry of Health (MOH)

Dr. Fransisco Ardón, General Coordinator, National Cholera Committee

Ing. Guillermo Garcia Ovalle, Chief, Environmental Sanitation Division, MOH

Dr. Dannys Cifuentes, Chief, Department of Registry and Food Control, MOH

Dr. Jacabo Finkelman, PAHO Country Representative

Dr. Carlos Andrate, UNICEF Health Advisor

Mr. Gary Cook, USAID, Health and Education Office Director

Dr. Jorge Chang, USAID Clapp & Mayne Project Officer

Dr. Victor Lara, Clapp & Mayne, Inc. - Guatemala

Ing. Ana Lucia Obiols, CARE

Ing. Mauricio Pardon, PAHO Environmental Health Advisor

Dr. Miguel Machuca, PAHO Country Epidemiologist

Dr. Paul Chinchilla, Social Security Institute (IGSS) Epidemiologist

Mr. Steve Maber, Coordinator, Regional Water and Sanitation Network

Ing. Ricardo Rojas, Program Specialist, Regional Water and Sanitation Network

Mr. Juan Diego Bonilla, General Manager, Chlorine "Magia Blanca"

Dr. Junio Robles, Chief, Technology Transfer Division, INCAP

Honduras

Dr. Enrique Zelaya, Director General, At-Risk Populations, Ministry of Health (MOH),and Coordinatorof the National Cholera Committee

Dr. Alejandro Melara, Director General, Environmental Health Division, MOH

Dr. Alirio Cruz, Former National Cholera Committee Coordinator

Dr. Godofredo Andino, Director, Disaster Unit, MOH

Ing. Mario Ruiz Funez, Coordinator, Environmental Health and Water Quality, MOH

Ing. Marta Elena Raudales, Department of Design Studies, MOH

39

Sra. Margarita Calix, Health Region Seven Director

Sra. Tanya Olivara, Health Region Seven Chief for Environmental Health

Sra. Mirta Escobar, Health Region Seven Supervisor for Food Control

Sra. Eda Safia Calix, Health Region Seven Epidemiologist

Lie. Roberto Montes, Health Region Seven Microbiologist

Dr. Marvin Andrés Maldonado, Campamento Health Unit Chief Officer

Sr. Leonel Torres, Campamento Health Unit Health Promoter

Dr. Luis Roberto Escoto, UNICEF Project Officer for Health and Nutrition

Dr. César Hermida B-, PAHO Country Representative

Dr. Sylvia Robles, PAHO Country Epidemiologist

Dr. Jose Ochoa, PAHO National Maternal and Child Health Advisor

Ms. Elena Brineman, USAID Deputy Director

Dr. David Losk, USAID Office of Health Director

Dr. Stan Terrel, USAID Child Survival Advisor

Mr. Herb Caudill, USAID TAACS Advisor

Ing. Amoldo Caraccioli, Director, Honduran Social Investment Fund (FHtS)

Ing. Roberto Rivera, FHIS Chief of Education

Ing. César Salgado, FHIS Chief of Water Projects

Ecuador

Leo Roozendaal, CARE

Dr. Silvie Briand, French-Ecuador Project

Dr. Efran Pacheco, Director General, Ministry of Health (MOH)

Dr. Alberto Narvaez, Chief of Epidemiology, MOH

Leda. Lídia Garcia, Department of Epidemiology, MOH

Leda. Ynes Yepez, Department of Health Communications, MOH

Lie. Victor Ortega, Department of Social Communication, MOH

Lie. Eduardo Salazar, Department of Social Communication, MOH

Dr. Rodrigo Paredes, Director, Province of Cotopoxi, MOH

Dr. Fabian Enriquez, Director, Province of Chimborazo, MOH

Dr. Ana Burgos, Director, Osvedo Hospital

Dr. Mario Valcarcel, PAHO, Quito

Dr. Carmen Laspina, Department of Public Promotion and Protection, MOH

40

Dr. Adela Vimos, Chief of Epidemiology, Chimborazo, MOH

Lie. Luis Sangoquiza, Health Educator, Chimborazo

Sra. Mercedes Molina, Promoter, CARE/Chimborazo

Ing. Ivan Palacios, Coordinator, CARE/Chimborazo

41

Appendix B

External Support for National Cholera Activities

1992-1994

43

GUATEMALA: External Support tor National Cholera Activities, 1992 -1994

PAHO Support for national cholera activities, 1992-94

Sweden (SIDA) Technical Cooperation, training, field research,supplies and equipment to supportepidemiological surveillance, lab diagnosis,case management and protection of water

Netherlands Information/Education/Communications(Local level social communication; with MOH)

GUT-CDD-020 GUT-CDD-020- Misc. expenses: staff contracts, travel related to TA

OPEC Support for Emergency Phase, including:18,000 -Update cholera emergency plans, publish guide*S4.000 -Follow-up training to food-handlers in 8 high-risk districts

SI8,000 -EpkJemiologkal surveinanca of high-risk groups (migration)-24 HIS courses for health personnel

Total budgeted

Inter-American Development Bank (IDB)S66.200 Strengthening EpidemUogical SurveMance$45.765 Laboratory Strengthening$94,584 Environmental Health & Food Protection

Total Authorized Funds

Director's Emergency Cholera Fund: for Environmental Health

Total through PAHO

$413,240 in prog.

$102,152 In prog.

$29.083 completed

in prog.

$90.000

$206,549

$50,000 approved

$891.024

12-31-94(compiouon oatej

9-30-94(completion date)


1-1-94

USAIO support for national cholera acUvtUM, 1992-94

ORS Supply$217,386 ORS Packets: 1.417,500$229.040 ORS Packets: 1,600,000

Public Health Supplies

PRITECH

$80,000 IV Solutions$79,624 Cholera Supply

$7.404 Technical Assistance to CARE$7.054 Evaluation of CARE Emergency Project

$66.650 CHW Training and ORS Logistic*

Quality Assurance $66.367 QA Project Country Plan

WASH

ADDR

CDC

HealthCom

Mission

$38.500 Technical; sta$0 Technical/

> to CAREi on Sewerage

$21.500 Follow-up TA to CARE

$1,000 Chotera Surveillance in Shigella Study

r FDA: TA to Govt of Guatemalar Epidemiologist TA

$0 TA in Health Communication*

Total $446,426

Total

Total

Total

Total

Total

Total

$155,000 Procurement One mlDon ORS packets$24,000 Education on Cholera prevention at the community level$30,000 OR intervention in cholera - local health personnel$38,000 Procurement ORS and pamphlets

$141,783 Strengthen Nati. Cholera Plan Capacity$114.865 Assistance to LAPROMED$114,741 Diarrhea! Disease Interventions

-Central Funds"

Regional W&S Network

Procurement 500,000 posters

Technical Support for water supply and sanitation

Summary:

Completed 6-15-92Completed 5-18-93

Total $159,624

Completed 2-20-92In prog. 2-20-92

$81.108

CompletedIn prog.In prog.

9-18-924-21-927-13-93

$66,367Completed 3-3-92

$60,000

CompletedOn holdCompleted

$1.000Inpreg.

$o

CompletedPlanning

On hold$0

11-19-922-14-92&4-93

2-18-92

1-19-931-4-93

8-10-92

Ml

Total

stance

PAHOUSAID

Total

$618.389

$11,500

$55.600

$1,500.014

$891,024S1.500.014$2.391,038

In prog.In prog.In prog.In prog.Inpreg.In prog.Inpreg.

in prog.

3-16-923-16-923-16-323-16-924-16-934-16-934-16-93

3-16-92

HONDURAS: External Support for National Cholera Activities. 1992 -1994

PAHO Support for national cholera activities, 1992-94

Sweden (SIDA)

Netherlands

OPEC

Various activities to supportbasic hygiene, case management laboratorydiagnosis, and epidemiological surveillant»

Information/Education/Communications

$273,980 in prog. 12-31-94(completion date)

$67,800 completed 9-30-93

Support for Emergency Phase, including: $45.000 in prog.$16,000 -Purchase and install water disinfection means in 18 high-risk communities$4,000 -Four regional workshops training health workers in

case management and epidemiological surveillance

Director's Emergency Cholera Funds: Mosquita Region $126,000- Health education- Environmental Hearth- Institutional Strengthening

Inter-American Development Bank (IDB)$43,532 Strengthening Epidemiological Surveillance

$0 Laboratory Strengthening$5.132 Environmental Health & Food Protection

Total Authorized Funds $48.664

Total through PAHO $561,444


1994

USAID support for national cholera activities, 1992-94

Public Health Supplies

ORS Supply

CDC

WASH

Mission

$275.178 PHS Supplies I$59,700 Chlorine. Test Kits. Reagents$11,100 Reagents tor Chlorine Tests$13,480 Laboratory Supplies

$246.043 Supplies for North Coast Flood$55.322 Antibiotics for North Coast Flood

$53.740 375,000 packets$96,732 675.000 packets

$6.462 TA in Epidemiology0 TA in Epidemiology II

(indirect) TA / Laboratory Assessment

$0 Translation of Torrents Report

$160,000 Water Seal Toilets for Emergency Latrinization$15,000 Creation of Mobilization Fund for Choi.

$5,000 Training Video for Hospitals$500 RTAC produced posters

$60.653 Diarrhea! Disease Control and Cholera

Total $660,823

In prog.In prog.In prog.In prog.In prog.In prog.

Total $150.472

In prog.In prog.

2-20-921-4-937-6-926-4-9312-3-9312-6-93

7-8-9210-13-93

Total

Total

$8.462

Completed 2-24-92On hold 6-4-92Completed 1-19-93

"PH" 7-7-92$0

Total $241.153

In prog.In prog.In prog.In prog.In prog.

3-16-923-16-923-16-923-16-924-16-93

Regional W&S Network Technical Support for water supply and sanitation $55,600

Total AID Assistance $1,116,510

Summary: PAHO $561,444USAID 81 116.510

Total $1,677.954

#

ECUADOR: Extamal Support for National Cholera Activities. 1992 - 1994

PAHO Support for national chotera activities, 1992-94

Sweden (SIDA) Latrinization and Safe Water

Netherlands Sanitary Education through CAAPfor indigenous groups in Sierra

$529,000 in progress 6-30-94(completion date)

$67,600 completed 8-31-93

IH e.v. & Wetthüfe (Belgium) Prevention & Control of Cholera & other D.D.s $60,000 in progress 1992(arranged by WHO) (In 1992. $20,000 remained for -environmental health interventions at the local lever)

Inter-American Development Sank (IDB)$64,368 Strengthening Epidemiological Surveillance$39,882 Laboratory Strengthening$30,963 Environmental Health & Food Protection

Total Authorized Funds $135,213

Total through PAHO $792,013

European Community (EC) Support for national cholera activities, 1992-94

EC Support to French Ecuador Project $2,400.000

Total through EC $2.400,000

USAID support for national cholera activities, 1992-94

HeehhCom

ORS Supply

WASH

$3,082 TA in Communiation Strategy$17.807 Communication Ran Workshop

$9,887 Communications Strategy Development$440,468 Communications Campaign

$8,694 Máchala TA w/WASH

$163,136 ORS Packets: 1,000.000$163,117 ORS Packets: 1.000.000

TOTAL $479.936

TOTAL $326.253

ADDR

$0 Technical Assistance Request$55,472 TA for water systems assessment - chlorine$17.500 Máchala: Prep/Strategy Seminar & Wrap-upS30.380 Máchala Latrine Design Workshop$35,510 Máchala TA in Financial Management$29.200 Máchala Pre-feas. Water Management Plan Study$37.500 Máchala Control and Prevention Workshop$13,660 Paute River Rapid Env. Assessment

TOTAL

$10,680 TA from ICDDRB in case management$70.000 Research Proposal #1$28,704 Research Proposal #2

tbd IV Lat Am. Congress of Tropical Medicine

$219,222

CompletedCompletedCompletedIn progCompleted

CompletedAssignment

PHCompletedIn progCompletedIn progCompletedCompletedCompleted

CompletedPlanningPlanningSOW

2-18-929-23-921-4-932-12-937-13-93

6-15-923-4-92

6-2-926-4-936-4-936-4-936-4-936-4-937-26-936-4-93

6-29-921-27-931-27-932-12-93

TOTAL $109,384

Quality Assurance $75,342 Hermida Technical AssistanceTOTAL $75,342

In prog 8-20-93

PRITECH

CDC

Mission

"X" Assessing Drug Use in Treatment of CholeraTOTAL

Report Writin 2-13-92

V T A from Mintz and WebberTOTAL $0

Completed 1-19-93

$100,000 Prep & Dissem of educational materials on cholera$200.000 Hygiene Education$20,000 Cholera Prevention Communication

$620,000 Cholera response in affected rural areas - CARE$306.887 CARE Cholera Response

TOTAL $1,246.887

In prog.In prog.In prog.In prog.In prog.

3-16-923-16-923-16-923-16-924-16-93

Total AID Assistance $2,457,024

Summary: PAHO $792.013EC $2,400.000

USAID $2,457,024Total $5,649,037

PAHO: Cholera Support from Inter-American Development Bank (IDB)Approved Funds for Ecuador, Guatemala and Honduras

1992 -June. 1994

pA£tivitH«''Fun(léd:'3f^'|¡^^

I. Strengthening Epidemiológica! SurveillanceTraining and Development

National SeminarsSub-regional SeminarsRegional Seminars

Monitoring Epidemiológica! InformationNational ConsultantsInternational ConsultantsPublications

RegionalNationalEquipment

Dissemination of Information to CommunityAudio-Visual, Educ. itemsPrinted Materials

I. TOTAL

II. Laboratory StrengtheningDiagnosis of Diarrheal Diseases - Lab. Training

National ConsultantsNational Courses/SeminarsLaboratory Supplies

Environmental Health LaboratoriesNational Courses/SeminarsSupplies

Sanitary / Food Protection LaboratoriesNational Courses/SeminarsSupplies

$12.988$0$0

$2,659$4,058

$6,000$7,819

$12,000

$15,000$3,844

$64,368

$5,744$3.928$2,000

$5,462$4,710

$7,956$10,032

$10,947$11,388

$0

$15,416$1,247

$927$6,147$8,000

$0$11,930

$66,002

$2,000$8,431$6.916

$2,778$7,932

$6,000$11,708

$25,191$0

$3,600

$7,800$1,340

$0$1,500

$0

$4,100

so$43,531

$0$0$0

$0$0

$0$0

II. TOTAL $39,882 $45,765

III. Environmental Health and Food ProtectionTechnical Collaboration in Controlling Contamination Levels

National ConsultantsInternational Consultants

Technical Collaboration in Food ProtectionNational ConsultantsInternational Consultants

Training and DevelopmentNational Courses/SeminarsDissemination of Information to the Community

Audio-Visual, Educ. items $0Printed Materials $4.000

$6,950$3,236

$4.400$0

$19,556$0

$3,000$0

$12,377 $44,480

$16,731$10.817

$0

$5,132$0

$0$0

$0

$0$0

III. TOTAL $30,963 $94,584 $5,132

Ecuador Guatemala HondurasTotal Funds from IDB: $135,213 $206,351 $48,663

GuatemalaESAJS2,391,038

HondurasESA_$1,677,954

EcuadorESA_$5,649,037

EPI137,74618,00066,200

1,000

222,9469%

EPI68,49525,00043,532

0000000

137,0278%

EPI64,368

2,400,000109,384

0000000

2,573,75246%

LAB137,74660,00045,765

243,51110%

LAB68,49513,4808,462

0000000

90,4375%

LAB39,882

000000000

39,8821%

WS&S14,45860,00055,60068,87350,000

248,93110%

WS&S16,00042,00059,70011,100

160,00055,600

0000

344,40021%

WS&S529,000219,222620,000306,887

000000

1,675,10930%

CASE68,873

446,426159,62466,650

155,00030,00038,000

141,783114,865114,741

1,335,96256%

CASE68,4954,000

42,000275,178246,04355,322

150,47220,219

00

861,72951%

CASE326,253

000000000

326,2536%

COMM102,15224,00011,500

137,6526%

COMM67,8005,000

50020,217

000000

93,5176%

COMM67,80060,000

479,93675,342

100,000200,00020,000

000

1,003,07818%

FOOD HY4,000

94,584

98,5844%

FOOD_HY68,4955,132

20,2170000000

93,8446%

FOOD HY30,963

000000000

30,9631%

LOGIST29,0838,000

66,367

103,4504%

LOGIST42,00015,000

00000000

57,0003%

LOGIST00000000000

0%

TOTAL

2,391,036100%

TOTAL0000000000

1,677,954100%

TOTAL0000000000

5,649,037100%

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