IHR capacity improved steadily in Sierra Leone from 2018 to 2021. Several factors facilitated this improvement, which was largely due to the successful planning and implementation of NAPHS. In this section, we discuss how coordination and financing were managed as well as the enablers and challenges that contributed to the results achieved.
NAPHS coordination
Successful implementation of NAPHS requires a well-articulated multi-sectoral and multi-disciplinary coordination mechanism. Unfortunately, this is a major gap in most African countries, as identified by their JEE (23). Coordination was also a major gap identified during the 2016 EJE in Sierra Leone and there was no structured IHR focal point capable of meeting the requirements of the IHR (2005) (18). A structure was therefore developed to coordinate the implementation of the IHR and NAPHS at the national level.
Overall coordination of NAPHS implementation in the country is carried out by the NAPHS Coordination Committee which includes the National IHR Focal Point and the One Health Secretariat. This coordination committee is responsible for liaising with the technical managers of the different ministries, departments and agencies. Technical area managers are responsible for coordinating activities in their technical areas at the national and subnational levels. The Coordinating Committee reports to the NAPHS Multi-Sectoral Technical Working Group (TWG) which includes technical area leads from all 19 technical areas as well as other stakeholders such as development partners. The TWG holds quarterly review meetings to review progress. The GTT reports to the National Interministerial Committee which meets twice a year and includes the government ministers concerned by the RSI (Fig. 5). This coordination model appears to work well in Sierra Leone and could be adapted in other countries.
NAPHS Coordination Structure in Sierra Leone
NAPHS Funding
Financing NAPHS constitutes a major challenge for most countries, mainly because it affects several sectors with different resource mobilization capacities (23). The NAPHS Operational Plan developed annually is the primary resource mobilization tool for Sierra Leone. The multi-sectoral coordination meetings (quarterly NAPHS review meetings) and the annual SPAR and JEE self-assessments were primarily funded by the World Health Organization. Each technical area manager in the sector was responsible for mobilizing resources from domestic and external sources to finance their activities under the operational plan.
Inadequate funding was a major challenge as there was no central fund for NAPHS. This has left some technical fields that do not have numerous or strong sources of funding, lagging behind. These include radiological events, chemical events and food safety. Low capacity in these technical areas poses a significant risk of morbidity and mortality to the country in the event of a serious emergency involving food, chemical and radiological events. A mechanism should therefore be put in place in the country to ensure adequate and sustainable funding for all technical areas. This would therefore benefit from further research into the best financing arrangements for NAPHS.
Success factors
Several factors were responsible for the successive implementation of NAPHS in Sierra Leone and we highly recommend them to other countries. This included strong political commitment, as evidenced by the launch of NAPHS by the President of Sierra Leone in 2019 (24). The implementation of the NAPHS has also been closely monitored by the various government ministers responsible for various sectors. A strong multi-sectoral coordination mechanism using the One Health approach ensured the participation and engagement of various stakeholders from government, non-governmental organizations, non-state actors, civil society and development partners.
Sierra Leone was the first country in the African region to use the JEE tool for self-assessment on a regular (annual) basis in addition to the mandatory SPAR tool. The openness to external evaluation and annual internal evaluations has provided a better understanding of the true state of health security in Sierra Leone and therefore promoted evidence-based planning. WHO facilitated the process of developing and implementing the NAPHS using new tools such as JEE 2sd edition (2018), JEE 3rd Edition (2022), Reference tool and REMAP tool for resource mobilization. The country uses these tools for the annual operational planning process, which has facilitated the completion of annual IHR assessments and operational planning.
Another success factor was the appointment of NAPHS technical area leads for the 19 technical areas, with clear written terms of reference on their roles and responsibilities. Technical area leads now act as catalysts for implementation by ensuring that follow-up on action points is carried out across all technical areas. These technical area leads also help update activities in the NAPHS Implementation Monitoring Online Platform, which ensures real-time information and dashboards are available to stakeholders.
Activities with development partner champions and those with multiple sources of funding also tend to be completed sooner than others. We also noted that where complex tasks were involved, such as developing a multi-hazard preparedness and response plan, using consultants to provide additional technical assistance made this achieved quite easily and more quickly.
Challenges
Despite progress in RSI capability, several challenges have limited the scope for success in certain technical areas. In addition to the financial challenges described above, NAPHS implementation has been negatively affected by the COVID-19 pandemic (25). Many activities planned for 2020 were therefore not implemented due to the reorientation of human resources and funding towards COVID-19. A NAPHS review conducted in the country in June 2021 showed that 51% of planned activities in the country had been completed compared to an expectation of 70% after three and a half years of implementation. The situation subsequently improved and implementation, by the end of 2021, was largely back on track, albeit at a slower pace. These lessons learned from COVID-19 call for better planning and more resilient systems that can withstand future pandemics without significantly disrupting routine programs.
The implementation of NAPHS has also been affected by insufficient human resources. During the 2014 to 2016 West Africa EVD outbreak, a total of 211 health workers died in Sierra Leone, reducing the availability of health workers in a country that was already suffering from a shortage health workers (13, 26). In 2020, Sierra Leone was estimated to have the lowest density of doctors in West Africa, with only 3 doctors per 100,000 inhabitants (27). This shortage of human resources has affected all sectors of the IHR and constitutes a major obstacle to the implementation of planned activities at all levels, particularly at the national, district and health facility levels. At the national level, participation in IHR meetings has often been low in some sectors due to competing tasks. To meet this challenge, the government must continue to put in place measures to increase human resource capacity in all sectors.
The IHR requires a progressive improvement of capacities at both national and subnational levels. This requires supporting infrastructure, which poses a challenge for Sierra Leone. The country was among the least developed countries in the world in 2018 and ranked 184 out of 189 in terms of human development (28). Infrastructure development halted during the period of civil unrest and was worsened by the EVD outbreak (13, 29). Health facilities in remote areas are not connected to the national grid and must rely on solar-powered equipment or generators. Power outages are common and some health facilities do not have generators. This limits the use of electricity to operate laboratory equipment and maintain the cold chain. The unavailability of running water also limits compliance with infection, prevention and control guidelines in healthcare settings. Infrastructure improvement is underway but must be accelerated.
