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April 7, 2025
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June 29, 2025
Published
June 30, 2025
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Abstract

Malawi’s health system faces major challenges in managing cholera outbreaks, worsened by climate-induced extreme weather events (EWEs) like tropical cyclone-related floods (TCRFs). These disasters amplify existing vulnerabilities, including poor infrastructure and limited resources. The March 2022 outbreak, the most severe in two decades, impacted all 29 districts, with a case fatality rate three times the anticipated threshold of 1%. This paper examines Malawi’s health system’s resilience using a structured literature review approach guided by the WHO Operational Framework for Building Climate-Resilient Health Systems. Through secondary data analysis, case studies, and comparative assessments, it identifies key structural and operational weaknesses. It also explores the role of intersectoral collaboration and community engagement, highlighting initiatives like the Tipewe Cholera Campaign. Drawing on international best practices, the study presents evidence-based recommendations to strengthen governance, health infrastructure, workforce distribution, financing, early warning systems, and WASH (Water, Sanitation, and Hygiene) infrastructure. These measures aim to build a climate-resilient health system capable of effectively managing future outbreaks.

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Health System Climate-Resilient Climate-Induced Cholera Outbreak Malawi

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Copyright (c) 2025 Lydia Nyimba

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Author Biography

Lydia Nyimba, University of Pretoria, South Africa

Lydia Nyimba is a PhD candidate in Public Health at the School of Health Systems and Public Health, University of Pretoria. She holds a Master’s degree in Public Health from the KIT Royal Tropical Institute, completed in collaboration with Vrije Universiteit Amsterdam, and a Bachelor’s in Public Health (Honours) from Monash University. Her professional background spans a range of public health domains, including sexual and reproductive health rights (SRHR), environmental health, health promotion, and health systems strengthening. Her primary research interests focus on environmental health, air quality, and the intersection between climate change and resilient health systems.

How to Cite
Nyimba, L. (2025). Malawi’s Health System Resilience in Managing Climate- Induced Cholera Outbreaks. Pan-African Journal of Health and Environmental Science, 4(1), 122–142. https://doi.org/10.56893/ajhes2025v04i01.08
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References

  1. Aderinto, N. (2023). Tropical Cyclone Freddy exposes major health risks in the hardest-hit Southern African countries: Lessons for climate change adaptation. International Journal of Surgery, 6, e0152. https://doi.org/10.1016/j.ijsu.2023.01.015
  2. Adriano, L. F., Nazir, A., & Uwishema, O. (2023). The devastating effect of Cyclone Freddy amidst the deadliest cholera outbreak in Malawi: A double burden for an already weak healthcare system—Short communication. Annals of Medicine and Surgery, 10, 97. https://doi.org/10.1016/j.amsu.2023.104764
  3. AFENET. (2024). Field epidemiology training program takes swift action as cholera spreads in Tanzania [Internet]. AFENET. Retrieved July 5, 2024, from https://afenet.net/field-epidemiology-training-program-takes-swift-action-as-cholera-spreads-in-tanzania/
  4. Bagcchi, S. (2022). Malawi takes on cholera outbreak amid cyclone devastation. The Lancet Microbe, 3(7), e480. https://doi.org/10.1016/S2666-5247(22)00163-2
  5. Berman, L., Prust, M. L., Maungena Mononga, A., Boko, P., Magombo, M., Teshome, M., Nkhoma, L., Namaganda, G., Msukwa, D., & Gunda, A. (2022). Using modeling and scenario analysis to support evidence-based health workforce strategic planning in Malawi. Human Resources for Health, 20(1), 34. https://doi.org/10.1186/s12960-022-00729-w
  6. Braka, F., Daniel, E. O., Okeibunor, J., Rusibamayila, N. K., Conteh, I. N., Ramadan, O. P., Byakika-Tusiime, J., Yur, C. T., Ochien, E. M., Kagoli, M., & Chauma-Mwale, A. (2024, April 16). Effects of tropical cyclone Freddy on the social determinants of health: The narrative review of the experience in Malawi. BMJ Public Health, 2(1). https://doi.org/10.1136/bmjph-2024-000245
  7. Bulthuis, S., Kok, M., Onvlee, O., O’Byrne, T., Amon, S., Namakula, J., Chikaphupha, K., Gerold, J., Mansour, W., Raven, J., & Broerse, J. E. (2023, January 16). How to scale-up: A comparative case study of scaling up a district health management strengthening intervention in Ghana, Malawi and Uganda. BMC Health Services Research, 23(1), 35. https://doi.org/10.1186/s12913-023-09023-1
  8. Centers for Disease Control and Prevention (CDC). (2024a). Cholera response in Malawi [Internet]. CDC. Retrieved June 30, 2024, from https://www.cdc.gov/global-health/impact/cholera-response-malawi.html
  9. Centers for Disease Control and Prevention (CDC). (2024b). CDC in Malawi [Internet]. CDC. Retrieved June 16, 2024, from https://www.cdc.gov/global-health/countries/malawi.html
  10. Chavula, J. (2023a). Mobile clinics take critical health services to flood-displaced people: Reaching displaced persons with life-saving services [Internet]. UNICEF Malawi. https://www.unicef.org/malawi/stories/mobile-clinics-take-critical-health-services-flood-displaced-people
  11. Chavula, J. (2023b). Cholera in the midst of a floods emergency: Cyclone Freddy stirs cholera resurgence in Blantyre [Internet]. UNICEF. https://www.unicef.org/malawi/stories/cholera-midst-floods-emergency
  12. Chinkaka, E., Chauluka, F., Chinkaka, R., Kachingwe, B., & Latif, E. B. (2024, February 2). Geospatial variability of cholera cases in Malawi based on climatic and socioeconomic influences. Journal of Geographic Information System, 16(1), 1–20. https://doi.org/10.4236/jgis.2024.161001
  13. Government of Malawi. (2019). Harmonised Health Facility Assessment (HHFA): 2018/2019 report [Internet]. Government of Malawi. Retrieved June 27, 2024, from https://documents1.worldbank.org/curated/en/521421611550618689/pdf/Short-Report.pdf
  14. Government of Malawi. (2023a, March). Tropical Cyclone Freddy emergency response plan. https://www.scotland-malawipartnership.org/assets/documents/Tropical-Cyclone-Freddy-Response-Plan_5-04-23_FINAL.pdf
  15. Government of Malawi. (2023b). Malawi 2023 Tropical Cyclone Freddy post-disaster needs assessment. Government of Malawi. https://www.preventionweb.net/media/87994/download?startDownload=20240625
  16. Government of Malawi. (2023c). Report on identification of priority areas for multi-sectoral interventions for cholera. Global Task Force on Cholera Control. https://www.gtfcc.org/wp-content/uploads/2025/04/pami-report-malawi.pdf
  17. Grist, B. B. (2023). As climate change leads to more and wetter storms, cholera cases are on the rise [Internet]. Medical Xpress. Retrieved June 30, 2024, from https://medicalxpress.com/news/2023-08-climate-wetter-storms-cholera-cases.html
  18. International Federation of Red Cross and Red Crescent Societies (IFRC). (2022). Emergency Plan of Action (EPoA) Malawi: Cholera outbreak. IFRC. https://adore.ifrc.org/Download.aspx?FileId=575153
  19. International Federation of Red Cross and Red Crescent Societies (IFRC). (2023). Emergency appeal: Malawi cholera response [Internet]. IFRC. Retrieved July 3, 2024, from https://reliefweb.int/report/malawi/malawi-cholera-response-emergency-appeal-ndeg-mdrmw017
  20. Joshua, M. D., Stathers, T., Chirwa, R. K., Ngongondo, C., Lamboll, R., Monjerezi, M., Mwathunga, E., Kasei, R., Chipungu, F. P., & Liwenga, E. T. (2021). A comparative study of the impacts of flooding on food security of urban and rural households in Blantyre City and Chikwawa, Malawi. In Cyclones in Southern Africa: Volume 3: Implications for the Sustainable Development Goals (pp. 35–58). Springer. https://doi.org/10.1007/978-3-030-79778-0_4
  21. Karamagi, H. C., Titi-Ofei, R., Kipruto, H. K., Seydi, A. B., Droti, B., Talisuna, A., Tsofa, B., Saikat, S., Schmets, G., Barasa, E., & Tumusiime, P. (2022). On the resilience of health systems: A methodological exploration across countries in the WHO African Region. PLOS One, 17(2), e0261904. https://doi.org/10.1371/journal.pone.0261904
  22. Masefield, S. C., Msosa, A., & Grugel, J. (2020). Challenges to effective governance in a low-income healthcare system: A qualitative study of stakeholder perceptions in Malawi. BMC Health Services Research, 20, 1–6. https://doi.org/10.1186/s12913-020-05810-x
  23. Miggo, M., Harawa, G., Kangwerema, A., Knovicks, S., Mfune, C., Safari, J., Kaunda, J. T., Kalua, J., Sefu, G., Phiri, E., & Patel, P. (2023). Fight against cholera outbreak, efforts and challenges in Malawi. Health Science Reports, 6(10), e1594. https://doi.org/10.1002/hsr2.1594
  24. Ministry of Health. (2023). Malawi emergency preparedness and response roadmap 2023-2025. World Health Organization, Malawi Country Office. https://www.afro.who.int/sites/default/files/2024-05/EPR%20ROADMAP%202023%20TO%202025.pdf
  25. Muula, A. S. (2023). The paradox of Malawi’s health workforce shortage: Pragmatic and unpopular decisions are needed. Malawi Medical Journal, 35(1), 1–2. https://doi.org/10.4314/mmj.v35i1.1
  26. Niederberger, E., Karam, S., & Tanner, L. (2022, December). Social, behavioural and community dynamics related to the cholera outbreak in Malawi. Social Science in Humanitarian Action Platform. https://rcce-collective.net/wp-content/uploads/2023/01/Cholera-synthesis_Malawi_Collective-Service.pdf
  27. OCHA. (2023c). Malawi cholera & tropical cyclone Freddy response dashboard [Internet]. OCHA. Retrieved June 28, 2024, from file:///C:/Users/lydia/Downloads/ROSEA_20230824_Malawi_Cholera_&_TC_Freddy_Response_Dashboard_June-2023_final.pdf
  28. Olu, O. O., Usman, A., Ameda, I. M., Ejiofor, N., Mantchombe, F., Chamla, D., & Nabyonga-Orem, J. (2023). The chronic cholera situation in Africa: Why are African countries unable to tame the well-known lion? Health Services Insights, 16, 11786329231211964. https://doi.org/10.1177/11786329231211964
  29. Oliveira, R., Santinha, G., & Sá Marques, T. (2024). The impacts of health decentralization on equity, efficiency, and effectiveness: A scoping review. Sustainability, 16(1), 386. https://doi.org/10.3390/su16010386
  30. Pangapanga-Phiri, I., Mungatana, E. D., Pangapanga, L., & Nkoka, F. S. (2022). Understanding the impact of sustainable landscape management practices on farm productivity under intensifying tropical cyclones: Evidence from Southern Malawi. Tropical Cyclone Research and Review, 11(4), 265–276. https://doi.org/10.1016/j.tcrr.2022.12.003
  31. Pensulo, C. (2024). How a major health campaign sprang Malawi out of its cholera emergency. GAVI. https://www.gavi.org/vaccineswork/how-major-health-campaign-sprang-malawi-out-its-cholera-emergency
  32. Qu, M. H., Suphachalasai, S., Thube, S. D., & Walker, M. S. (2023, June 26). South Africa carbon pricing and climate mitigation policy. International Monetary Fund. https://doi.org/10.5089/9798400247620.018
  33. Rossi, B., Formenti, B., Cerini, C., Tique, N., da Celma Cossa, R., Boniotti, F., Comini, B., Tomasoni, L. R., & Castelli, F. (2024, February 14). Addressing health care disruption in rural Mozambique due to extreme climate events: Mobile units tackling cyclones, vaccine-preventable diseases, and beyond. Frontiers in Tropical Diseases, 5, 1328926. https://doi.org/10.3389/ftd.2024.1328926
  34. Shariff, S., Kantawala, B., Siddiq, A., Oseili, T., Nazir, A., & Uwishema, O. (2024, May 1). Cholera outbreak in Malawi: Empirical assessment and lessons learnt. International Journal of Surgery: Global Health, 7(3), e0262. https://doi.org/10.1016/j.ijsgh.2024.03.002
  35. The World Bank Group. (2022). Malawi country climate and development report. World Bank. https://documents1.worldbank.org/curated/en/099545010272237260/pdf/P1772201ced75ce9182e7142761bde013662bca4fe42.pdf
  36. The World Bank. (2023). Building climate resilient and environmentally sustainable health systems in Africa: A summary of findings and recommendations from Climate and Health Vulnerability Assessments (CHVAs) funded by AFRI-RES across four countries. Washington, DC: The World Bank. https://www.preventionweb.net/media/89881/download
  37. UN Volunteers. (2023). Helping WHO navigate the cholera outbreak in Malawi [Internet]. UNV. Retrieved June 30, 2024, from https://www.unv.org/Success-stories/helping-who-navigate-cholera-outbreak-malawi
  38. UNICEF Malawi. (2022). Action against cholera [Internet]. UNICEF. Retrieved June 25, 2024, from https://www.unicef.org/malawi/media/8666/file/Action%20against%20cholera%20-%20UNICEF%20Malawi%20Response%20Plan.pdf
  39. UNICEF Malawi. (2023a). Health budget brief 2023/24: Building a resilient and sustainably financed health system in Malawi [Internet]. UNICEF. https://www.unicef.org/malawi/media/10111/file/Health%20Budget%20Brief%2020230-24.pdf
  40. UNICEF Malawi. (2023b). Cholera flash update – February 2023. UNICEF. https://www.unicef.org/malawi/media/8576/file/Malawi%20Cholera%20Response%20Flash%20Update%20-%2016%20to%2022%20January%202023.pdf
  41. UNICEF. (2024). As cholera remains a concern in the region, UNICEF and partners are working to support vulnerable children and families [Internet]. UNICEF. Retrieved June 27, 2024, from https://reliefweb.int/report/malawi/cholera-remains-concern-region-unicef-and-partners-are-working-support-vulnerable-children-and-families
  42. United Nations Central Emergency Response Fund. (2023a). Malawi Rapid Response Cholera 2022 [Internet]. United Nations CERF. Retrieved June 20, 2024, from https://cerf.un.org/what-we-do/allocation/2022/summary/22-RR-MWI-55260
  43. United Nations Central Emergency Response Fund. (2023b). CERF allocation Malawi: Cholera, 17 March 2023 [Internet]. United Nations. Retrieved July 12, 2024, from https://cerf.un.org/what-we-do/allocation/2024/summary/23-RR-MWI-57751
  44. United Nations Office for the Coordination of Humanitarian Affairs (OCHA). (2023a, March 31). Malawi: Tropical Cyclone Freddy flash update No. 11. ReliefWeb. https://reliefweb.int/report/malawi/malawi-tropical-cyclone-freddy-flash-update-no-11-31-march-2023
  45. United Nations Office for the Coordination of Humanitarian Affairs (OCHA). (2023b). Malawi cholera & floods flash appeal 2023 (revised in March following Cyclone Freddy) (February - June 2023) [Internet]. United Nations Office for the Coordination of Humanitarian Affairs. Retrieved June 4, 2024, from https://www.unocha.org/publications/report/malawi/malawi-cholera-floods-flash-appeal-2023-revised-march-following-cyclone-freddy-february-june-2023
  46. United Nations. (2023). The United Nations and humanitarian partners call for $45.3 million to provide life-saving aid to people devastated by the cholera outbreak in Malawi [Internet]. United Nations. Retrieved June 20, 2024, from https://malawi.un.org/en/220033-united-nations-and-humanitarian-partners-call-453-million-provide-life-saving-aid-people
  47. United Nations. (2024). Sustainable Development Cooperation Framework for Malawi 2024-2028. United Nations. https://malawi.un.org/sites/default/files/2024-05/United%20Nations%20Sustainable%20Development%20Cooperation%20Framework%20for%20Mala%C5%B5i.pdf
  48. World Health Organization. (2023a). Disease outbreak news: Cholera - Malawi [Internet]. World Health Organization. Retrieved June 6, 2024, from https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON435
  49. World Health Organization. (2023b). Malawi takes bold steps to combat cholera through multisectoral strategy [Internet]. World Health Organization. Retrieved June 20, 2024, from https://www.afro.who.int/countries/malawi/news/malawi-takes-bold-steps-combat-cholera-through-multisectoral-strategy
  50. World Health Organization. (2023c). Vaccines help battle cholera outbreak in Malawi [Internet]. World Health Organization. Retrieved June 20, 2024, from https://www.afro.who.int/countries/malawi/news/vaccines-help-battle-cholera-outbreak-malawi
  51. World Health Organization. (2023d). WHO African Region Health Expenditure Atlas 2023. World Health Organization. Retrieved from https://www.afro.who.int/publications/who-african-region-health-expenditure-atlas-2023-0
  52. World Health Organization. (2023e). World Health Organization deploys Emergency Medical Teams to support cholera outbreak response in Malawi [Internet]. World Health Organization. https://www.afro.who.int/countries/malawi/news/world-health-organization-deploys-emergency-medical-teams-support-cholera-outbreak-response-malawi
  53. World Health Organization. (2023f). Malawi launches Tipewe Cholera/COVID-19 campaign as part of National Community Health Day commemorations. World Health Organization Regional Office for Africa. https://www.afro.who.int/countries/malawi/news/malawi-launches-tipewe-cholera-covid-19-campaign-part-national-community-health-day-commemorations
  54. World Health Organization. (2024a). Multi-country outbreak of cholera: External situation report n. 11. https://www.who.int/publications/m/item/multi-country-outbreak-of-cholera--external-situation-report--11---12-february-2024
  55. World Health Organization. (2024b). Cholera in the WHO African Region: Weekly regional cholera bulletin. World Health Organization Regional Office for Africa. https://www.afro.who.int/publications/cholera-who-african-region-weekly-regional-cholera-bulletin-12-june-2023
  56. World Health Organization. (2024c). WHO supports cholera-vulnerable districts to implement RCCE activities for cholera prevention and preparedness [Internet]. World Health Organization. https://www.afro.who.int/countries/malawi/news/who-supports-cholera-vulnerable-districts-implement-rcce-activities-cholera-prevention-and
  57. World Health Organization. (2024d). Multi-country outbreak of cholera: External Situation Report n. 15 [Internet]. World Health Organization. https://www.who.int/docs/default-source/coronaviruse/situation-reports/20240619_multi-country_outbreak-of-cholera_sitrep_15.pdf?sfvrsn=80f3d7af_3&download=true
  58. World Health Organization. (2024e). Malawi curbs cholera through enhanced outbreak control [Internet]. https://www.afro.who.int/countries/malawi/news/malawi-curbs-cholera-through-enhanced-outbreak-control