Rethinking cholera response: an orchestration framework for future preparedness in fragile conflict-affected settings, a case study from Sudan, 2025

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Introduction: The ongoing conflict in Sudan has intensified the country's already fragile public health landscape. Since July 2024, Sudan has faced one of the most extensive cholera outbreaks in its modern history, affecting 17 states and 109 localities and resulting in 83,245 reported cases and 2,124 deaths by June 2025. Traditional, hierarchical outbreak response systems have proven insufficient in such a dynamic, volatile environment. Methods: , an innovative framework that integrates systems thinking and orchestration governance, to design a model for outbreak management in fragile and conflict-affected settings. Results: The model conceptualizes the Ministry of Health as a conductor leading an orchestra of diverse stakeholders. Each stakeholder represents an instrument section whose coordinated actions create a harmonized and adaptive response. Grounded in systems thinking theory, particularly the Iceberg and Biomatrix models, this framework identifies leverage points for governance, coordination, and resource optimization. Conclusion: The Orchestrated Symphony Model is proposed as a policy reform and practice improvement framework for cholera outbreak response generally and in conflict-affected settings particularly.

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