Designing Intervention Pathways to Strengthen Health System Resilience to Cholera Outbreaks in Uganda Using Group Model Development and Systems Thinking

Abstract Background Cholera remains a major public health challenge globally, with sub-Saharan Africa bearing the highest burden. In recent years, several African Union Member States have faced severe and protracted cholera outbreaks, with the African CDC reporting a total of 73,806 cholera cases and 490 deaths (CFR: 0.66%) reported across 22 African Union Member States in 2025. In Uganda, recurrent outbreaks disproportionately affect vulnerable populations such as fishing communities, refugees, and border residents. Despite ongoing interventions, including vaccination campaigns targeting most at-risk populations, national cholera control strategies, and water, sanitation, and hygiene (WASH) improvements, gaps persist in local health system preparedness, surveillance, and response capacity. Using a system thinking workshop, this study engaged diverse stakeholders to analyze the system drivers of cholera vulnerability and identified strategic intervention pathways to strengthen health system resilience. Methods We employed a participatory group model development (GMD) approach guided by systems thinking to identify intervention pathways for strengthening health system resilience to cholera outbreaks in Uganda. A two-day workshop was conducted with 20 purposively selected stakeholders from government, academia, the private sector, NGOs, community organizations, and development partners. This process involved (1) reviewing the current situation using prior study findings, (2) identifying the desired outcomes and performance gaps, (3) analyzing key issues and underlying drivers, (4) developing a cause–effect system map (systemigram) using Kumu, (5) identifying and analyzing stakeholders, (6) identifying resilience change levers, and (7) prioritizing intervention pathways through a structured voting process. Data were analyzed using systems mapping and stakeholder analysis techniques. We applied a seven-phase process of systems thinking and cocreation in a two-day workshop involving 20 multisectoral stakeholders. Results Three key systemic challenges affecting the health system’s capacity to prevent and respond to cholera outbreaks were identified: inadequate water, sanitation, and hygiene (WASH) infrastructure; weak surveillance systems; and poor coordination among stakeholders. The participants also identified and prioritized nine intervention pathways to strengthen health system resilience. The highest-ranked interventions included strengthening multisectoral coordination and leadership, establishing a data-based surveillance system, and enhancing community engagement for sustainable WASH services, in addition to other measures such as innovative sanitation technologies, cross-border vaccination, alternative WASH financing models, local technical capacity building, and strengthened digital surveillance systems. Conclusion Group Model Development (GMD) provided a comprehensive framework that integrated a codesign approach and applied systems thinking in the design of intervention pathways to strengthen the resilience of the health system to the cholera outbreak. Future research is needed to evaluate these pathways within the most affected communities.