The recurrent cholera outbreaks in Zambia should provoke reflection on the root causes. Together with a strategic focus on improving water and sanitation infrastructure it will be necessary to complement new investments with reforms to address the problem of weak institutions to achieve a lasting solution to the problem.

Since October last year, Zambia has been battling a severe cholera epidemic that led to more than 81 deaths country-wide and thousands of hospitalisations. The military was deployed in Lusaka to enforce measures aimed at curbing cholera transmission which included bans on street vending and public gatherings, closure of marketplaces, schools, universities and colleges, and curfews in the worst affected parts of the city.

In addition to the human toll of the outbreak, the impact of cholera can also be measured in direct and indirect economic costs and impact on already strained government finances. Depending on the severity and length of time such epidemics persist, studies suggest total costs could run as high as 2% of GDP. Much of this cost is borne by the poor whose economic activities are curbed and disrupted. Adverse publicity related to the outbreak can also discourage foreign investment in Zambia. With the current crisis seemingly under control, the question that remains is whether this outbreak will prompt policy makers to implement measures to prevent future outbreaks and what actions would be needed to achieve a lasting solution. To answer this, it is important to first understand the root causes.

Understanding underlying causes: Lack of access to quality infrastructure
Cholera epidemics are not new to Zambia. As figure 1 shows, outbreaks have been frequent since 1990, with a cumulative number of 4731 reported deaths.

Cholera epidemics are associated with poor water and sanitation infrastructure that help spread the bacterium, Vibrio cholerae. Approximately 68% of households in Zambia have access to improved water supply, but only 40% have improved sanitation. The figures for Lusaka are 96% and 78%. The inequality of access to water relative to sanitation reflects the fact that sanitation improvements tend to lag behind water supply as the required infrastructure tends to be costlier. Access is generally worse in the peri-urban areas where water-spread disease outbreaks tend to be most prevalent.

Improved water access does not necessarily mean access to safe water. For instance, water from boreholes typically considered safe has tested positive for cholera during the current outbreak in Lusaka. Furthermore, many households are dependent on unreliable municipal water supply or public taps and may at times be forced to turn to less safe alternatives. Moreover, in Lusaka, on-site sanitation systems are compromised by ineffective faecal sludge management and lack of drainage networks which contribute to flooding and contamination of water sources. Recent surveys by researchers at the International Food Policy Research Institute (IFPRI) in collaboration with the International Growth Centre (IGC) reveal that most vendors in Lusaka lack access to safe water and to sanitary toilets. In addition, political considerations have led to lax enforcement of regulations on vendors, a rapidly growing and therefore politically salient population. It is therefore not surprising that Lusaka faces such frequent outbreaks of cholera.

Is a lack of investment in water and sanitation infrastructure the cause?
It is important to acknowledge that Zambia is urbanising rapidly and cities like Lusaka are subject to high population growth, particularly in peri-urban areas that lack water and sanitation facilities. Urbanisation increases the need for upgrading water and sanitation infrastructure in cities and towns.
Government of Zambia’s spending on water and sanitation has been declining in the last few years, from US$147 million in 2013 to just US$27 million in 2016. For comparison, a World Bank analysis from 2016 estimates that Zambia would need to invest US$385 million per year in order to meet the 2030 sustainable development goals (SDG 6) in terms of universal access to water, sanitation and hygiene. While the sector has become a priority for international partners in recent years with Zambia receiving US$80-85 million annually since 2013 in official development assistance, the country will still need to supplement such aid to close the investment gap.

If you build it, will households connect?
There are also issues on the demand side. IGC research suggests that even when large scale infrastructure projects are completed in Lusaka, they have little effect on sanitary conditions partly because poorer Zambians are not willing to pay for a connection to the water and sewerage system (Ashraf et al., 2016). Poor households may either be too poor or fail to appreciate the health benefits of safe water and sanitation. Unclear property rights may also discourage landlords from investing in connecting houses to water and sanitation systems. The government can use either regulation or subsidies to induce households to connect to the system, to solve the “last mile” problem. However, the ability to impose regulations or effectively manage subsidies without massive waste, depends crucially on the capability of relevant institutions.

Recognising weak institutions as a root cause
It is tempting (but misleading) to believe that the problem could be fully addressed by boosting funding for infrastructure. While significant financial investments in water and sanitation infrastructure are clearly necessary, they are not sufficient. More money – without effective management and accountability systems – will fail to solve the cholera problem. Weak institutions, both within the sector but also in broader government processes and structures, may be a significant causal factor behind the cholera crisis.

An analysis by Kennedy-Walker et al (2015) suggests that the water and sanitation sector in Lusaka is plagued by deep-rooted institutional problems. These include policies that have lacked a strategic focus on peri-urban areas where water and sanitation provision pose the greatest challenge; under-investment in peri-urban areas by water and sanitation utilities due to a low perceived return on investment; and poor coordination between central and local governments. Neglected maintenance of water pipes and sanitation infrastructure lead to water supply interruptions, particularly in poorer parts of Lusaka, which forces poor households to turn to unsafe water sources.

Zambian analysts often speak candidly of the country’s track record of poor implementation of policies and plans. Both can be undermined by weak institutions that don’t match budgets and policy priorities within overall fiscal constraints.
Rapid growth of national debt in recent years requires that the government reduce overall spending. If the government wishes to increase investment in water and sanitation it must cut spending elsewhere. Should additional investment in water and sanitation be accommodated by reducing spending on roads or on power generation? These are the kinds of difficult choices that the political leadership must make through the institutions of a rational budget process.
Concluding remarks

The cholera outbreak in Lusaka offers a vivid illustration of the deep institutional roots of the problem. While there is clearly a need to increase public investment in the “hard” infrastructure of water and sanitation pipes and pumping stations, the “soft” infrastructure of institutions must also be enhanced, hand-in-hand, to improve overall access to water and sanitation and prevent future disease outbreaks.

Ashraf, N, E Glaeser and G Ponzetto (2016), “Infrastructure, Incentives and Institutions”, NBER Working Paper No. 21910

Ashraf, Glaeser, Holland and Steinberg (2017). “Water, Health and Wealth”. NBER Working Paper No. 23807. September 2017.

Heymans, C, R Ebehard, D Ehrhardt, S, Riley (2016), “Providing Water to Poor People in African Cities Effectively:
Lessons from Utility reforms”, World Bank Working Paper 10874.

Kennedy-Walker, R, J Amezaga and C Paterson (2015), “The role of power, politics and history in achieving sanitation service provision in informal urban environments: a case study of Lusaka, Zambia”, Environment and Urbanization, 27(2): 489-504.

Wash Watch Summary Statistics Zambia:

Wash Watch Summary Statistics Zambia:

2015 Living Conditions Monitoring Survey Report