Assessment of Guinea-Bissau’s Pandemic Prevention, Preparedness, and Response Capacity Assessment of Guinea-Bissau’s Pandemic Prevention, Preparedness, and Response Capacity 2024 © 2024 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW, Washington, DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org This work is a product of the staff of The World Bank with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Nothing herein shall constitute or be construed or considered to be a limitation upon or waiver of the privileges and immunities of The World Bank, all of which are specifically reserved. Rights and Permissions This work is available under the Creative Commons Attribution 3.0 IGO license (CC BY 3.0 IGO) http:// creativecommons.org/licenses/by/3.0/igo. Under the Creative Commons Attribution license, you are free to copy, distribute, transmit, and adapt this work, including for commercial purposes, under the following conditions: Attribution—Please cite the work as follows: World Bank. 2024. “ Assessment of Guinea-Bissau’s Pandemic Prevention, Preparedness, and Response Capacity.” Washington, DC: World Bank Translations—If you create a translation of this work, please add the following disclaimer along with the attribution: This translation was not created by The World Bank and should not be considered an official World Bank translation. The World Bank shall not be liable for any content or error in this translation. Adaptations—If you create an adaptation of this work, please add the following disclaimer along with the attribution: This is an adaptation of an original work by The World Bank. Views and opinions expressed in the adaptation are the sole responsibility of the author or authors of the adaptation and are not endorsed by The World Bank. Third-party content—The World Bank does not necessarily own each component of the content contained within the work. The World Bank therefore does not warrant that the use of any third- party-owned individual component or part contained in the work will not infringe on the rights of those third parties. The risk of claims resulting from such infringement rests solely with you. If you wish to reuse a component of the work, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright owner. Examples of components can include, but are not limited to, tables, figures, or images. All queries on rights and licenses should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; e-mail: pubrights@worldbank.org. Executive Summary The COVID-19 pandemic was a sobering example of Governance, Partnership and Coordination how ill-prepared many countries were to respond to Guinea-Bissau was found to have poor a fast-spreading disease for which the world initially coordination, particularly across sectors, and had few tools to defend against, the results of high fragmentation within the health sector for which were many lives lost, economies devastated, addressing health emergencies. The country lacks and social order disrupted. It highlighted the strategic plans related to PPR and there is no One need for countries to increase their capacity for Health strategy in place. There is weak financing pandemic prevention, preparedness, and response of important public health institutions, which (PPR), including dedicating financial resources to prevents them from being able to effectively carry advance preparedness, ensuring robust planning out their mandates. Chronic political instability has at national and subnational levels, and establishing led to high turnover in leadership roles resulting strong coordination and collaboration mechanisms in the loss of institutional knowledge and a lack across sectors. To improve PPR capacity is to of continuity in health programs and initiatives. fundamentally make health systems stronger. Additionally, a few leaders are overburdened Stronger health systems are more resilient to with multiple appointments in key roles which shocks, better able to adapt during times of crises, contribute to delays in decision-making. and more capable at responding to and recovering from health emergencies. Laboratory Detection and Surveillance Guinea-Bissau is a small country in Western Africa Capabilities with a history of long-standing political instability, Guinea-Bissau’s laboratory detection and high poverty rates and increased vulnerability to surveillance capacity is low and inconsistent across climate change and zoonotic spillovers (disease the country. Laboratories lack infrastructure, spread from animals to humans). It has a basic supplies, quality control and proper waste chronically under-resourced health system that management. Any existing capacity is concentrated suffers from a lack of infrastructure and access in central laboratories leaving regional laboratories, to essential medicines, weak governance, and especially in rural areas, with low capacity to detect inadequate human resources, among other disease. Animal health laboratories are minimally issues. Understanding the biggest gaps in functioning, and in a state worse off than human Guinea-Bissau’s PPR capacity is essential to be health laboratories – the critical lack of equipment, able to prioritize investments that enhance the testing supplies and trained personnel results in country’s preparedness for future epidemics and the country being unable to test for any zoonotic pandemics. diseases for extended periods at a time. No laboratories are accredited in the country, and the This report represents a comprehensive specimen referral and transport system is highly assessment of Guinea-Bissau’s PPR capacity unreliable, particularly in rural areas. conducted by the World Bank. The report details key gaps and findings about Guinea-Bissau’s health Early warning systems are underdeveloped and system and sets out priority recommendations to suffer from a lack of resources at all levels for strengthen its PPR capacity and health system surveillance of both human and zoonotic diseases. resilience. Key findings are grouped into five areas Porous borders with neighboring countries pose identified as most critical and in urgent need of a risk for transnational disease transmission attention to prepare for future threats. yet cross border surveillance is weak. Disease surveillance is largely paper-based with limited 6 use of District Health Information System (DHIS2) of the national medicine procurement agency to software or any other electronic tools. One manage the country’s need for medicines have led encouraging aspect is that the community health to stockouts of essential medicines in the country. worker (CHW) program in Guinea-Bissau has the Similar to issues noted in human resources for potential to be scaled up to support community- health, there is a general lack of trained personnel based surveillance (CBS). to manage inventory and distribution, high staff turnover that is particularly pronounced with Human Resources for Health changes in government, and a lack of financial Health care workers in Guinea-Bissau are resources to appropriately address key supply chronically stretched thin and sometimes go chain needs. without being paid. The human resource situation is worse in rural areas than at the central level. Recommended interventions developed based Health care workers often suffer from burnout on the key findings above are presented in the and lack of training and are given few incentives, graphic that follows this executive summary. including professional opportunities, to stay on the job—this has resulted in significant absenteeism Guinea-Bissau is in a region with high risk posed and loss of workforce to other countries (‘brain by emerging and endemic zoonotic diseases. This drain’) that negatively affects service delivery. picture is complicated by progressive climate Mid- and senior-level health staff are frequently change that increasingly intersects with the replaced with changes in government, leading to human-animal interface, raising the potential for a lack of continuity and ineffectiveness of health spillover events that present a threat to health programs. security in the region and globally. The wide- ranging impact of zoonoses on human and Risk Communication and Community animal health necessitates improved collaboration Engagement between the human and animal health sectors using a multi-sectoral, One Health approach. This The approach to Risk Communication and is especially true in Guinea-Bissau where there is Community Engagement (RCCE) in Guinea-Bissau elevated risk from zoonotic diseases. has typically been top-down whereby basic risk communication measures are put in place, but no In summary, Guinea-Bissau requires foundational mechanisms exist to collect community feedback investments in core PPR capacities including on the receptiveness to prevention measures or surveillance, laboratories, human resources, know whether messages are reaching intended RCCE but also in building stronger institutions audiences. There is a lack of standard operating and improving operational planning for health procedures for RCCE, which leads to disordered emergencies. Multi-sectoral coordination to act on and ineffective risk communications during health the priority recommendations in this report can help emergencies. While a comprehensive National to carry forward plans to strengthen emergency Strategic Plan for Community Health (PENSC) preparedness and One Health capacities in the exists, it is in need of support from the government country. There is significant potential for synergy and donors for implementation. CHWs can be a between development organizations and the key resource to strengthen disease surveillance government to strategically address the country’s at the community level. PPR needs and complement each other’s efforts for more effective and efficient resource planning Health Supply Chain and utilization. Each of these steps are valuable The health sector supply chain in Guinea-Bissau investments that are foundational to strengthening is highly fragmented and uncoordinated. The Guinea-Bissau’s health system resilience and lack of a well-functioning national supply chain, ensuring better preparedness to respond to future inadequate pharmaceutical policies, and the failure health crises. 7 Key recommendations for strengthening pandemic prevention, preparedness, and response capacity in Guinea-Bissau Governance, Partnership and Coordination Short-term recommendations 1 Conduct a multi-sectoral stakeholder analysis, including the National Institute of Public Health (INASA) and MOH, to identify key players and resource gaps that are most needed for improved PPR coordination and prioritization. 2 Develop a multi-sectoral coordination mechanism (e.g., a convening committee) for PPR that convenes routinely, even in the absence of health crises. 3 Develop a National Response Framework that outlines command structures, roles, and responsibilities of every stakeholder. 4 Develop a costed multi-hazard and multi-sectoral PPR and health emergency plan. 5 Test the Operational Center for Health Emergencies (COES) coordination mechanism and develop relevant guidelines. 6 Document existing legislation related to PPR. Medium to long-term recommendations 7 Update and develop legal and regulatory frameworks relevant to health emergencies. 8 Develop a One Health national strategic plan and conduct an IHR-PVS National Bridging Workshop. 9 Strengthen the leadership and build capacity of INASA and COES. 10 Develop and implement plans for sustainable financing of INASA and COES operations. Laboratory and Surveillance Short-term recommendations 1 Conduct a laboratory capacity and surveillance needs assessment followed by asset mapping across sectors (public, private, human, animal) and across the country—including rural areas and points of entry (PoEs)—to identify the most pressing gaps and leverage strengths.   2 Develop a national infectious disease surveillance strategy including priority epidemic diseases and zoonotic diseases, seasonal prevalence of diseases in all regions, guidelines and SOPs for indicator-based surveillance (IBS) and event-based surveillance (EBS).  3 Strengthen community-based surveillance (CBS) by training CHWs in priority disease case definition and contact tracing and by establishing a functional multi-sectoral RRT. 4 Develop a process for and publish routine reports of epidemiological information for priority diseases at the national level. 5 Strengthen the specimen referral and transport system by reviewing existing capacities and needs, developing SOPs and training health care workers (HCWs) and other staff. Medium to long-term recommendations 6 Strengthen existing IBS and establish EBS for priority diseases. 7 Strengthen laboratory capacity for priority diseases by refurbishing laboratories (including animal health laboratories), training laboratory workers in priority disease diagnostics, and enrolling laboratories in accreditation programs. 8 Build sustainable capacity for a One Health approach to surveillance by coordinating with other relevant ministries/ focal points and through joint training and information exchange. 9 INASA, with support from MOH and other key stakeholders, could form a public-private partnership model for the procurement of essential testing supplies and reagents. 8 Human Resources for Health Short-term recommendations 1 Elaborate a multi-sectoral workforce strategy to develop human capital across the human and animal health sectors to enhance PPR. 2 Identify required training needs for IHR and institute cascade training (train-the-trainer) programs and hands-on training for detection and surveillance of priority epidemic-prone and zoonotic diseases, risk communication, contact tracing, and infection prevention and control.  3 Establish a three-month basic FETP-V joint training program based on a One Health curriculum and other in-service training programs for HCWs, CHWs, and animal health workers. 4 Appoint personnel within MOH to coordinate and manage health sector training by liaising with external partners and other agencies. Medium to long-term recommendations 5 Build capacity for animal health staff, laboratory workers, rapid response teams, and strengthen INASA’s capacity for coordination. 6 Develop rural training programs for final-year medical, nursing, and lab technician students for exposure to and to develop interest in practice in rural settings.  7 Strengthen policy reforms and develop programs to boost HRH retention, such as performance-based incentives, differential compensation schemes based on geographic distribution to boost recruitment and retention of rural HCWs, and a service repayment program. Risk Communication and Community Engagement (RCCE) Short-term recommendations 1 Identify and map key partners, community influencers, religious leaders, and champions at subnational levels to support community engagement for PPR.   2 Update RCCE strategy and SOPs for RCCE including managing the spread of rumors and misinformation by communicating scientifically validated data via political and technical leaders. 3 Test the RCCE system by planning and operationalizing simulation exercises (SimEx). 4 Provide support to cost the National Strategic Plan for Community Health (PENSC) 2021-2025 and support its implementation. Medium to long-term recommendations 5 Strengthen CHW retention and recognition to boost community engagement.    6 Develop and conduct cascade training on RCCE.  Health Supply Chain Short-term recommendations 1 Develop a national procurement and deployment plan for health emergencies, which should include the receipt, storage, distribution of necessary medicines and other health supplies. 2 Adopt a single, unified governance structure for supply chain. 3 Develop and validate national supply chain strategic plans and policies. Medium to long-term recommendations 4 Enhance the skills, knowledge, and performance of health workers, supply chain managers, and other stakeholders involved in the supply chain. 5 Introduce standardized inventory management, distribution and monitoring systems to strengthen procurement processes. 6 Invest in a comprehensive logistics management information system. 9 Acknowledgments This work was conceptualized and led by Sulzhan Bali and Yemdaogo Tougma. Shweta Sinha and Bomy Yun drafted the report with contributions from Clément Ndzemah Jaidzeka. Andrea Speranza provided support for in-country data collection and logistical coordination. Anne-Lucie Lefevbre and Gaston Sorgho provided strategic guidance to the team. We are thankful for the meticulous work of our editor, Karen Schneider, and skilled graphic design artists, Israel David Melendez Osechas and Diana Victoria De Leon Dardon. Our project also greatly benefited from the technical inputs of Prativa Baral and Preeti Kudesia. Our reviewers Adrienne McManus, Akiko Kitamura, and André L. Carletto deserve a special note of thanks for helping to enhance the quality of this report. Our heartfelt thanks are also extended to representatives from the government and World Health Organization (WHO), United Nations International Children’s Emergency Fund (UNICEF), United Nations Development Programme (UNDP), United Nations Population Fund (UNFPA), World Food Programme, The Global Fund, European Union Delegation in Guinea-Bissau, Instituto Marquês de Valle Flôr, Bandim Health Project, and Caritas. Their assistance in supporting qualitative data collection and providing technical documents was instrumental to our work. We extend our thanks to the administrative staff in the Guinea-Bissau World Bank country office—Walessa Melani Lopes Gomes, Ramatulay Heloysa Barbosa, Djacumbá Cassamá, Maria Rua Lopez and Mamadou Boi Ture —for their kind help. Last but not the least, we are most grateful to the Japan Policy and Human Resources Development (PHRD) Trust Fund for their financial contributions and support of this report. Their ongoing support is much appreciated and remains essential in scaling up the country work on resilience to health emergencies. ​​Table of Contents 06 Executive Summary and Key Recommendations 10 Acknowledgments 12 Abbreviations 14 List of tables, figures and boxes 15 Part I. Introduction, Objectives, and Methodology 16 1. Introduction to Strengthening Pandemic Preparedness and Response Capabilities for a Resilient Health System 17 2. Objectives 17 Objective of the report 17 Value-add 17 Limitations 18 3. Methodology 21 Part II. Country Context and Preparedness and Response Capacity 22 4. Country Context 24 5. Risk Drivers for Health Emergencies and Health Security Assessments 26 6. Preparedness and Response Capacity 31 Part III. Key Findings and Recommendations 32 Introduction 32 7. Governance, Coordination, and Partnerships for PPR 42 8. Laboratory Detection and Surveillance Capabilities 54 9. Human Resources for Health 60 10. Risk Communication and Community Engagement 66 11. Health Supply Chain 71 Part IV. Discussion and Next Steps 72 12. Discussion 73 13. Next Steps 74 Annex 77 References 11 Abbreviations ARFAME Regulatory Agency for Medicines and Health Products (Autoridade Reguladora de Farmácia, Laboratório, Medicamentos e outros produtos de saúde) AVAT African Vaccination Acquisition Trust CBPP Contagious bovine pleuropneumonia CBS Community-based Surveillance CDC Centers for Disease Control CECOME Central Store for Essential Medicines (Central de Compras de Medicamentos Essenciais) CFEIMS Center of Training, Education, Information, and Multimedia CHW Community Health Worker COES Operational Center for Health Emergencies (Centro de Operações de Emergências em Saúde Pública) COVAX AMC COVID-19 Vaccine Global Access Advance Market Commitment COVID-19 Coronavirus Disease 2019 CSS Cholera Surveillance System DALYs Disability-Adjusted Life Years DHIS2 District Health Information System EBS Event-based Surveillance Ebola Ebola Virus Disease ECOWAS Economic Community of West African States EIDS Emerging Infectious Diseases EOC Emergency Operations Center EU European Union FCV Fragility, Conflict, and Violence FETP-V Field Epidemiology Training Program for Veterinarians FGD Focus Group Discussion GDP Gross Domestic Product GHSA Global Health Security Agenda GHSI Global Health Security Index HC COVID-19 High Commission for COVID-19 (Alto Comissariado para a COVID-19) HCW Health Care Worker HIS Health Information System HRH Human Resources for Health IAR Intra-Action Review IBS Indicator-based Surveillance ICU Intensive Care Unit IDB Islamic Development Bank IGAS General Inspectorate for Health Activities (Inspector General das Atividades em Saúde) IHR WHO International Health Regulations IHR-PVS WHO International Health Regulations-Performance of Veterinary Services IMVF Instituto Marquês de Valle Flôr INASA National Institute of Public Health (Instituto Nacional de Saúde Pública) IOM International Organization for Migration JEE Joint External Evaluation JPU Jean Piaget University KI Key Informant KII Key Informant Interview 12 LMICs Low- and Middle-Income Countries LMIS Logistics Management Information System LNSP National Public Health Laboratory (Laboratório Nacional de Saúde Publica) LQAS Lot Quality Assurance Sampling MICS Multiple Indicator Cluster Survey MCH Maternal and Child Health MOA Ministry of Agriculture MOH Ministry of Health (synonymously referred to as Ministry of Public Health) MSF Médicins San Frontières NACP National AIDS Control Program NCD Non-Communicable Disease NGO Non-Governmental Organization NMCP National Malaria Control Program nOPV2 Novel Oral Poliomyelitis Vaccine type 2 OH One Health PCR Polymerase Chain Reaction PENSC National Strategic Plan for Community Health PHEOC Public Health Emergency Operations Center PNDRHS National Plan for the Development of Human Resources for Health PNDS National Health Development Plan PoE Point of Entry PPE Personal Protective Equipment PPR Pandemic Prevention, Preparedness, and Response RAS Health Area Manager (Responsável Área Sanitária) RCCE Risk Communication and Community Engagement REDISSE Regional Disease Surveillance Systems Enhancement RISLNET Regional Integrated Surveillance and Monitoring Network RRT Rapid Response Team SDGs Sustainable Development Goals SDI Service Delivery Indicators SEAB Secretary of State for the Environment and Biodiversity SIM-EX Simulation Exercises SIVE Department of Immunizations and Epidemiological Surveillance SLIPTA Stepwise Laboratory Improvement Process Toward Accreditation SLMTA Strengthening Laboratory Management Toward Accreditation SOP Standard Operating Procedure SPAR State Parties Self-Assessment Annual Reporting SWOT Strengths, Weaknesses, Opportunities, and Threats TA Technical Assistance TGF The Global Fund to Fight AIDS, Tuberculosis, and Malaria TORs Terms of Reference UNDP United Nations Development Program UNFPA United Nations Population Fund WAHO West African Health Organization WASH Water, Sanitation, and Hygiene WFP World Food Program WHO World Health Organization 13 List of tables, figures and boxes Tables 18 Table 1. Overview of methodology 19 Table 2. Breakdown of key Informant interviewees by organization/agency 19 Table 3. Sites visited in November-December 2022 27 Table 4. Summary indicator scores of IHR core capacities for Guinea-Bissau 34 Table 5. SWOT analysis of COES 37 Table 6. Composition of COES members 41 Table 7. Summary recommendations for Governance, Partnership and Coordination 45 Table 8. Priority zoonotic diseases in Guinea-Bissau 48 Table 9. Health regions of Guinea-Bissau 49 Table 10. Difference between SLMTA and SLIPTA 53 Table 11. Summary recommendations for Laboratory and Surveillance Capabilities 56 Table 12. Global ratio of professionals per 10,000 population, except for midwives, whose index is displayed as ratio of midwives per 1,000 women of childbearing age 59 Table 13. Summary recommendations for Human Resources for Health 65 Table 14. Summary recommendations for Risk Communication and Community Engagement 70 Table 15. Summary recommendations for Health Supply Chain Figures 22 Figure 1. Map of Guinea-Bissau 23 Figure 2. Distribution of types of natural hazards occurring in Guinea-Bissau 24 Figure 3. Drivers for emerging infectious diseases: Core and cross-cutting domains 25 Figure 4. Guinea-Bissau’s public health risk matrix, 2021 26 Figure 5. INFORM Risk Index for Guinea-Bissau, 2023 28 Figure 6. Comparison of average scores of SPAR capacities across Guinea-Bissau, the AFRO region and globally from 2018 to 2022 50 Figure 7. Health system organization in Guinea-Bissau 55 Figure 8. Health care workforce distribution in the public sector, 2022 61 Figure 9. Functional composition of the Department of Community Health Services and Promotion of Traditional Medicine within the MOH Boxes 43 Box 1. REDISSE II (2018-2023) in Guinea-Bissau 14 Part I. Introduction, Objectives, and Methodology Assessment of Guinea-Bissau’s Pandemic Prevention, Preparedness, and Response Capacity 1. Introduction to The case for investing in the prevention of, and Strengthening Pandemic preparedness for, pandemics and large-scale Prevention, Preparedness, health emergencies is quite evident, from and Response Capabilities for a both a health and an economic perspective. Resilient Health System Fostering health system resilience is a key enabler of pandemic prevention and preparedness and is Large-scale disease outbreaks pose significant critical in establishing a long-term, wide-front health threats to human life, impeding economic and system that allows a country to respond to, recover health systems, causing social disruption, from, and adapt to a myriad of health challenges and inflicting immeasurable damage on and crises. By preventing or mitigating the worst human life. As demonstrated by the COVID-19 impacts of a crisis, resilient health systems pre- pandemic, infectious outbreaks quickly spread emptively reduce the mortality, morbidity, and costs across borders, affecting millions of people associated with response to health emergencies. within a short time span, disturbing supply According to the ‘Change Cannot Wait’ report the chains and businesses, negatively affecting key features of resilient systems are integrated livelihoods, and exacerbating inequities. In the systems that are aware of threats; agile in response first year of the pandemic alone, it is estimated to evolving needs; absorptive of shocks; adaptive to that almost 20 million life-years were lost due minimize disruptions; and able to transform after to COVID-19 and that more than 120 million crises (5). In low- and middle-income countries years were spent in poverty (1). In Africa, poverty (LMICs), establishing health system resilience increased by an estimated 1.5-1.7 percent in is particularly important given their increased 2020 alone, with countries affected by conflict susceptibility to shocks and emergencies of all kinds and violence experiencing the greatest increase, including disease outbreaks, natural disasters, at 2.1 percent (2). conflicts, and economic crises. In addition to high morbidity and social Increased vulnerability in LMICs is most disruption, large-scale outbreaks and health often attributable to poor health system emergencies can cause severe financial and infrastructure, limited access to essential economic implications. The African Development medicines, and scarcity of health care workers. Bank estimates that economic growth declined A chronically resource-constrained health system significantly on the continent due to the COVID-19 therefore fares poorly when shocks arise, with pandemic (3). The immediate costs of the disrupted health service delivery and worsened economic and social burden of the Ebola outbreak health inequalities. In Guinea Bissau, large gaps were estimated to be at least US$53 billion in health infrastructure compound the negative globally, the majority of which was borne by the effects of shocks, with limited access to health directly affected countries of Guinea, Liberia, facilities. In 2017, health centers were asked to and Sierra Leone. A 2014 UN Development indicate the three main complaints received from Programme (UNDP) report estimated a loss in patients and the main issues that stood out were exports of 30%, 14%, and 10% for Guinea, Liberia, long distance (39 percent), long waiting times and Sierra Leone, respectively, as a result of the (25 percent) and the unavailability of medicines Ebola outbreak (4). (16 percent). There was a difference between urban and rural areas regarding these patient complaints with rural areas mentioning long distance more frequently (44 percent). (6). 16 Part I. Introduction, Objectives, and Methodology 2. Objectives that have been validated by key stakeholders to reflect the needs and priorities in Guinea-Bissau. Guinea-Bissau is a low-income country with The recommendations are aligned with WHO’s a fragile health system, chronic systemic and monitoring and evaluation framework and structural challenges, and significant gaps in the prioritize the most critical strategies and capacity to mount an effective response to health investments to build PPR capacity in alignment emergencies, including maintaining the availability with the International Health Regulations (IHR). of routine essential health services. COVID-19 has highlighted the need to identify key gaps and Limitations priorities to reduce the risk of health emergencies The key informants (KIs) were chosen based on and strengthen Guinea-Bissau’s health system’s their unique knowledge of different aspects of capacity to contain, address, and withstand health PPR capacity in Guinea-Bissau, but the possibility emergencies. of bias in selecting the informants cannot be excluded. Researchers’ bias and subjective Objective of the report interpretations of the information in data The objective of this report, which is a sub-task of collection and analysis are possible. the human capital review for Guinea-Bissau, is to assess Guinea-Bissau’s health system resilience and pandemic prevention, preparedness, and response (PPR) capacity and identify priority country actions and investments that can strengthen Guinea- Bissau’s resilience to future health emergencies, including epidemics. These actions will ultimately promote and preserve human capital between, during, and after health shocks1. This report also provides policy recommendations to strengthen PPR capacity and support improving the overall health system in the country. It is intended for policymakers, stakeholders, and partners supporting PPR work in Guinea-Bissau. Value-add This report is the first of its kind to comprehensively synthesize capacity gaps and priority actions for PPR reform along with investments needed to address those gaps in Guinea-Bissau. The report lays the groundwork by identifying key PPR gaps relevant for strengthening health security and health system resilience in Guinea-Bissau. It provides evidence-based recommendations 1 A comprehensive report assessing Guinea-Bissau’s health system is available separately. Both the health system assessment and this report assessing Guinea-Bissau’s PPR capacity are part of a larger World Bank report on Human Capital and Epidemic Preparedness in Guinea-Bissau. 17 Assessment of Guinea-Bissau’s Pandemic Prevention, Preparedness, and Response Capacity Table 1. Overview of methodology Assessment Technical Data Key Informant Focus Group of PPR Site Visits Workshop for Collection Interviews Discussion Capacity Data Validation - Government - Key stakeholders - Hospitals - Key interim - Published and partners - 3 male CHWs* - Community findings from literature from multilateral - 3 female CHWs health centers Source data analysis - Documents agencies and - 1 male CHW - Laboratories - Feedback from - Websites NGOs supervisor (See full list in Table 3) stakeholders (See full list in Table 2) Sample 1 focus group N/A 60 key informants 9 sites visited 24 participants Size (7 participants) Purposive Sampling Desktop sampling Purposive Purposive Purposive Method review and Snowball sampling sampling sampling sampling *Community health workers 3. Methodology health system, recent health crises, and key PPR challenges. The desk review helped identify crucial The overall methodology for this report was a gaps in information, necessitating in-country data cross-sectional qualitative study. It included an collection by the World Bank team. extensive desk review of published literature, reports, and unpublished documentation, key Key informant interviews, focus group, and informant interviews (KIIs), and a focus group site visits: November-December 2022 discussion with key stakeholders. The data was collected in Bissau, Guinea-Bissau, and The purpose of the KIIs and focus groups was Washington, DC, USA between June 2022 and to supplement and fill gaps in the country’s April 2023. The methodology used is comparable PPR capacity data through extensive qualitative and aligned to other desktop PPR assessments interviews and site visits. The team conducted conducted by the World Bank (in Sierra Leone, 60 in-person key informant interviews and Ghana, Liberia) and included KIIs and focus group completed nine site visits (Table 3). The selection discussions to fill-in data gaps. Table 1 presents an of key informants was done by purposive sampling overview of the methodology. based on their knowledge and experience of working in Guinea-Bissau both before and during the pandemic. KIIs focused on questions about PPR Desktop review: June 2022 and related policies, partnership and coordination, The Guinea-Bissau health system overview was including the role of governance, availability of first done by a short desk review examining finances, absorptive capacity, health supply chain, publicly available literature about the country’s and lessons learned from past health emergencies. 18 Part I. Introduction, Objectives, and Methodology The KI interviewees had different roles in various Commission for COVID-19 (Alto Comissariado para sectors including governmental and non- a COVID-19) (HC COVID-19). Non-government KIIs governmental organizations (NGOs), multilateral were from NGOs, multilateral organizations, and organizations, universities, hospitals, and hospitals. A focus group with seven CHWs was community health centers (Table 2). Government also conducted. A local interpreter was used for KIIs were from the Ministry of Health (MOH), facilitating the interviews when the preferred National Institute of Public Health (Instituto language for the interview was Portuguese or Nacional de Saúde Pública) (INASA), and the High French. Table 2. Breakdown of key informant interviewees by organization or agency Government 1. INASA 2. MOH 3. HC COVID-19 Non-government 4. World Health Organization 6. United Nations Development 5. UNICEF (WHO) Program (UNDP) 7. European Union (EU) 8. United Nations Population 9. World Food Program (WFP) Delegation Fund (UNFPA) NGO, University 10. IMVF (Instituto Marquês de 11. Caritas 12. Bandim Health Project Valle Flôr) Focus Group 13. Community Health Workers in the Bairro Militar Health Area, Sector Autonomo Bissau Health Region Table 3. Sites visited in November-December 2022 1. WFP warehouse 2. Cold chain rooms in the Immunizations and Epidemiological Surveillance Service (SIVE) 3. CECOME warehouses 4. Simão Mendes National Hospital: Laboratory and intensive care unit (ICU) 5. Public Health National Laboratory (Laboratório Nacional de Saúde Pública) 6. Type C Health Center (primary health center) in Sector Autónomo Bissau, Luanda Health Area 7. Private hospital in Bissau (Clínica Madrugada) 8. Laboratory of Jean Piaget University (of Guinea-Bissau) 9. Central animal health laboratory in Bissau 19 Assessment of Guinea-Bissau’s Pandemic Prevention, Preparedness, and Response Capacity Triangulation of data was achieved by corroborating validity and contribute to a more well-rounded findings from KIIs and focus group discussions with picture of the country’s PPR capacity. review of physical documentation, online sources of information, and health security assessments, Data validation such as the Joint External Evaluation (JEE), State Parties Self-Assessment Annual Reporting The World Bank conducted a day-long technical (SPAR), Global Health Security Index (GHSI), and workshop on ‘PPR capacity in Guinea-Bissau’ in Intra-Action Reviews (IARs). Documents shared April 2023. During the workshop, which took place by stakeholders such as strategy and planning in Bissau, key findings and recommendations documents, presidential decrees, organizational from the assessment conducted for this report charts, public health surveys, health worker training were presented to stakeholders representing the modules, and organizational terms of reference government including the MOH and Ministry of (TORs) were also reviewed. Agriculture (MOA), NGOs, and multi- and bilateral development partners—specifically, WHO, Data analysis methods UNICEF, United Nations Development Programme Purposive sampling was used to generate and (UNDP), The Global Fund, European Union collect data (KIIs, focus groups), which led to an delegation in Guinea Bissau, West African Health initial set of codes. The codes were then collapsed Organization (WAHO), and Instituto Marquês into five PPR categories. This method generated de Valle Flôr (IMVF). The technical workshop an integrated grounded theory that strengthening served to validate findings from the assessment, governance and coordination, laboratory systems solicit input on the recommendations, and and disease surveillance, human resources, facilitated an understanding of areas of synergy risk communication, and health supply chain in PPR reform efforts already occurring in the are areas of significant gaps in PPR capacity in country. The feedback generated from the data Guinea-Bissau. Data was triangulated to enhance validation workshop also informed the feasibility of implementing many of the recommendations. 20 Country Context and Part II. Preparedness and Response Capacity Assessment of Guinea-Bissau’s Pandemic Prevention, Preparedness, and Response Capacity 4. Country Context rate reported by the government in 2021 was 55 percent (8). Lagging human development in Guinea-Bissau is a small state in West Africa, health and education and the per capita standard of ranked as the 19th poorest country in the world living have led to a ranking of 177 out of 191 countries and listed as a fragile, conflict and violent (FCV) on the 2021 UN Human Development Index (12). state2 given its institutional and social fragility Political instability, high rates of poverty, low human (7). Two-thirds (67 percent) of the country’s development, and widespread discrimination population of 2 million live below the poverty against women make Guinea-Bissau a country with line of US$1.90/day (7). The country is heavily high institutional and social fragility. reliant on external funding, with 75 percent of the state budget supported by international aid The country’s geographical location makes (8). Guinea-Bissau has been characterized by high it a hotspot for climate crises and zoonotic levels of political instability since its independence spillovers. Guinea-Bissau’s tropical climate makes from Portugal in 1974, including recurrent coups it highly susceptible to recurrent natural disasters and a civil war in 1998 (9). As an agro-economy, such as droughts and flooding (see Figure 2) the country is also heavily reliant on cashew nuts (13). Its lack of climate-readiness makes it one as its main export, making it vulnerable to price of the most vulnerable countries to the effects shocks (10). of climate change. Guinea-Bissau is a hotspot for both climate change and zoonotic diseases Guinea-Bissau lags in multiple dimensions of and the intersection of the two unfortunately human development. Today, nearly one-third increases the risk of zoonotic spillovers and of children between the ages of six and 11 have outbreaks (14). Frequent natural disasters such never attended school. Primary school completion as flooding has severe impacts on infrastructure, rates remain low, averaging only 27 percent (6). agriculture, and public health, including the spread According to 2019 Multiple Indicator Cluster Survey of vector-borne diseases (e.g., dengue, zika), and 6 (MICS6) data, only 12 percent of children aged 7-14 more broadly, the spread of other water- and have basic reading skills, and only seven percent food-borne diseases (e.g., salmonella and E. coli) demonstrate numeracy skills (11). The adult literacy (10). Malaria is endemic in the region and poses a significant and chronic threat to the country’s Figure 1. Map of Guinea-Bissau population and health system. The country has seen numerous cholera outbreaks and epidemics in the past 30 years (15). Furthermore, the region of West Africa where Guinea-Bissau is situated has seen several outbreaks resulting from zoonotic spillovers, including direct zoonotic events, from animals to humans, such as Lassa fever from 2016-2018, as well as secondary, human-to- human epidemiological cycles such as Ebola from 2014-2016 (16). Social and economic factors such as high in-country mobility, dense urban living conditions, and high gender inequality have further exacerbated the Guinea-Bissau’s susceptibility to infectious diseases and emergencies (10). 2 FY23 List of Fragile and Conflict-affected Situations https://thedocs.worldbank.org/en/doc/69b1d088e3c48ebe2cdf451e30284f04-0090082022/ original/FCSList-FY23.pdf 22 Part II: Country Context and Preparedness and Response Capacity Figure 2. Distribution of types of natural hazards The top five risk factors that drove death occurring in Guinea-Bissau, 1980-2020 (14) and disability between 2009 and 2019 were malnutrition; air pollution; water, sanitation, and hygiene (WASH); unsafe sex; and high blood pressure (17). Guinea-Bissau has a weak and poorly resourced health system with long-standing deficits in basic infrastructure, human resources for health (HRH), and essential drugs and equipment. Access to, and quality of, health care is poor, with the country scoring 24.3 out of 100 on the Healthcare Access and Quality Index in 2019, ranking it 194 out of 195 countries (19). There are multiple underlying factors contributing to this weak performance, including insufficient financial resources for The disease burden in Guinea-Bissau is still health, an urban-centric distribution of health largely attributable to communicable diseases. services, inadequate HRH, poor infrastructure, Life expectancy in Guinea-Bissau as of 2017 (most inadequate medicines and supplies, and a lack of recent forecast available) was 62.6 years for women accountability exacerbated by frequent turnover and 57.4 years for men (17). At 667 maternal of staff resulting from political instability (20). deaths out of 100,000 live births, the maternal In 2021, the Primary Health Care Performance mortality rate in Guinea-Bissau in 2017 was among Initiative (PHCPI) assessed Guinea-Bissau’s the highest in the world, in a region, West Africa, primary health care (PHC) system across the that also has a very high average rate of 708 out domains of financing, capacity, performance of 100,000 the same year (18). Child mortality and equity. It revealed that in the domain of rates were 76.8 deaths per 1,000 live births capacity, in particular, which looks at the ability of for the under-five age group and 51.4 deaths a system to deliver quality PHC, Guinea-Bissau’s per 1,000 live births for infants in 2020 (7). health system was weak in governance, inputs Malnutrition is prevalent, which leads to stunted (how well the system manages essential service growth in almost a third of the nation’s children (11). delivery inputs including drugs and supplies, While the epidemiological situation in Guinea-Bissau information systems, workforce, and funds at is slowly changing, most causes of death are still the facility level) and population health and from communicable diseases, such as diarrheal facility management, scoring 2.1 out of 4, 1.5 out diseases, lower respiratory infections, measles, of 4 and 1.9 out of 4, respectively (21). Overall HIV/AIDS, tuberculosis, and malaria, although non- health expenditures in the country constituted communicable diseases (NCDs) such as stroke and 8.41 percent of the gross domestic product (GDP) ischemic heart disease are becoming increasingly in 2019 (22). A significant problem contributing common (17). The risk from zoonotic disease to financial and poverty risk is high out-of-pocket spillover events remains ever high and the region health expenditures, which comprise 64.4 percent regularly sees outbreaks of zoonotic epidemics, of total health expenditures (23). At 34 percent, which contributes to high and ongoing potential there is a high rate of absenteeism among for disease burden due to new and existing HCWs, which compounds the problem of existing communicable diseases in Guinea-Bissau. shortages in HRH (24). 23 Assessment of Guinea-Bissau’s Pandemic Prevention, Preparedness, and Response Capacity (26). In Guinea-Bissau’s context, EIDs can be of 5. Risk Drivers for Health severe impact given the country’s weak detection Emergencies and Health and surveillance capacity, poor health service Security Assessments delivery and health supply chain with no PPR framework or One Health (OH) strategy. Drivers for health emergencies are complex and interconnected. There are several influencing 5.1 Diseases that pose a risk to factors, both upstream and downstream, that public health in Guinea-Bissau serve as risk drivers. Upstream drivers such as social, technological, environmental, economic and The risk matrix on the following page (Figure 4) political (STEEP) aspects focus on broader systemic is useful for gaining an understanding of the and structural causes, and affect access to quality diseases that pose the greatest threats to public food, safe communities, social support, and job health in the country; moreover, it can be used opportunities. Downstream drivers such as the as a tool to help determine the country’s priority health system, hospital care, service delivery, diseases. Given that risk to public health is not supply chain management, health communication, only conferred by diseases with outbreak potential and emergency response systems are more but also by sociopolitical instability, situations that immediate and observable drivers of health (25). lead to interruption of health services or have Guinea-Bissau is vulnerable to such risks owing the potential to cause mass casualties are also to deficits in health governance, health financing, reflected in the risk matrix. Figure 4 displays a insufficient HRH, poor health infrastructure and mapping of Guinea-Bissau’s public health risks limited PPR capacities. considering their likelihood of occurrence against health impact, measured by indicators such as A 2022 World Bank report on One Health Disability-Adjusted Life Years (DALYs). categorized risk drivers for health emergencies into three main domains of forests, farms, and Figure 3. Drivers for emerging infectious cities. These core domains are connected to diseases: Core and cross-cutting domains (26) climate change, inequality, fragility, and violence (Figure 3). Guinea-Bissau is prone to natural disasters including recurring floods, especially along the coast. Sea-level rise due to climate change is a serious threat to 70% of the coastal population in the country. Drought is also a recurring natural disaster in Guinea-Bissau (14). With rising temperature and humidity, malaria transmission increases, flooding incites waterborne diseases and drought escalates the risk of meningitis (14). Due to services being concentrated in urban areas, the rest of the country suffers from shortages in staffing and services causing disparities in health care. This can lead to the undetected spread of diseases making Guinea-Bissau more vulnerable to health emergencies. Global data reveals that 70 percent of all emerging infectious diseases (EIDs) are zoonotic in nature 24 Part II: Country Context and Preparedness and Response Capacity An in-depth analysis of the INFORM risk score very high 7.8 out of 10. This lack of institutional (Figure 5), in which a higher score indicates and infrastructural capacity and socio-economic higher risk, shows that the susceptibility of vulnerability pose a significant risk for threats both communities to hazards in Guinea Bissau is high originating in Guinea-Bissau and from outside. with the socio-economic vulnerability score of Although the overall Hazard and Exposure risk 6.1. Further, there is lack of resources to alleviate score is low (1.5 out of 10), the epidemic risk the impact of human or natural hazards, making score of Guinea-Bissau is high at 7.1 out of Guinea-Bissau’s lack of coping capacity score a 10 highlighting the vulnerability to epidemics. Figure 4. Guinea-Bissau’s public health risk matrix, 20213 (8) Elevated Moderate 1. Emergent diseases - chikungunya 6. Emergent diseases - chikungunya 2. Known epidemic diseases - cholera 15. Armed conflict - mass casualities 3. Zoonoses - carbunculo 4. Diseases transmitted by water and food - dysentery 5. Known epidemic diseases - yellow fever Weak 10. Political instability - interruption of health services 11. Strike - interruption of health services 7. Protests - mass casualities (preventable cause of death) 8. Terrorism - mass casualities 12. Emerging diseases - zika 9. Known epidemic diseases - influenza 13. Emerging diseases - dengue 16. Known epidemic diseases - meningitis 14. Armed conflict - interruption of health services 17. Known epidemic diseases - measles 3 This risk matrix was in the process of being updated to include COVID-19 in 2023; however, the updated version was not available for inclusion in this report at the time of its publication. 25 Assessment of Guinea-Bissau’s Pandemic Prevention, Preparedness, and Response Capacity Figure 5. INFORM Risk Index for Guinea-Bissau, 2023 6. Preparedness and an effective response to a health emergency. In Response Capacity particular, financing for health emergencies and implementation of IHR capacities, mechanisms 6.1 Prior assessments of PPR capacities for response to zoonoses, and multiple indicators in Guinea Bissau across emergency preparedness, surveillance systems and the national laboratory system only Joint External Evaluation scored 1 out of 5 – the lowest possible score. The Joint External Evaluation (JEE) is a voluntary Only one area, immunization, is considered to evaluation, initiated by countries and validated have developed capacity, with an average score by external experts, to assess national capacities of 3.5. Indicative of the country’s weak IHR capacity, to implement the IHR. Guinea-Bissau’s JEE demonstrated capacity was not identified in any assessment in 2019 identified huge gaps in technical areas. preparedness capacities (average score across all capacities was 1.48 out of 5). Its capacity is ReadyScore starkly limited in prevention (average score: ReadyScore, created by Resolve to Save Lives, is a 1.5), detection (average score: 1.5), response measure of a country’s ability to detect, respond (average score: 1.8), and other hazards (average to and prevent health threats by using information score: 1) (27). As shown in Table 4, the JEE from 19 preparedness areas assessed in the assessment identified minimal IHR core capacity JEE. The ReadyScore relays three levels of across 14 technical areas, scoring less than 2 out preparedness for countries that have completed of 5. The areas considered to have limited capacity a JEE, with a score higher than 80 indicating that a – national legislation, policy and financing, IHR country is better prepared for an epidemic, a score coordination, zoonotic disease management, of 40-79% indicating the country has work to do national laboratory system, surveillance, to prepare for the next epidemic, and countries reporting, human resource capacity, emergency scoring 39% or lower are not ready for the next preparedness, emergency response operations, epidemic. Guinea-Bissau’s ReadyScore is 30 (out and risk communication – are very deficient and at of 100), clearly showing that it is not ready for the a level that is insufficient for the country to mount next pandemic (28). 26 Part II: Country Context and Preparedness and Response Capacity Table 4. Summary indicator scores of IHR core capacities for Guinea-Bissau, as per JEE No Capacity (1-1.9) Limited Capacity (2-2.9) Developed Capacity (3-3.9) Demonstrated Capacity (4-4.9) IHR coordination, National legislation, policy, communications, and Immunization No core capacities and financing advocacy Zoonotic diseases Reporting Emergency response National laboratory system operations Real-time surveillance Risk communication Human resource capacty Emergency preparedness Medical courtermessures and personal deployment Antimicrobial resistance Points of entry Food safety Biosafety and biosecurity Linking public health and security authorities Chemical events Radiation emergencies Global Health Security Index across all capacities is lower than regional and global The Global Health Security Index (GHSI) is an averages, and top challenges include capacities assessment of health security and related in policy and legal instruments to implement capabilities benchmarked across 195 countries. IHR, financing, points of entry (PoEs), zoonotic The country’s Global Health Security Index (GHSI) diseases, and chemical and radiation emergencies. similarly reflects poor ratings in capacities for A comparison of capacity averages over a five-year prevention (average score of 8.4 compared to period (see Figure 6) shows that in 2022 global average of 28.4), detection and reporting Guinea-Bissau has regressed to the same level (average score of 16.7 compared to global (40 percent) it was in 2018, while both regional and average of 32.3), rapid response (average score of global averages have consistently improved (30). 25.3 compared to global average of 37.6), and health system (average score of 7.2 compared to global A close examination of the JEE, GHSI, and SPAR average of 31.5) when compared to benchmarks assessments revealed that Guinea-Bissau’s across the 195 countries that make up the State emergency preparedness and response capacity Parties to the International Health Regulations (29). is weakest in zoonotic disease management, national laboratory system, disease surveillance, States Party Self-Assessment Annual preparedness financing, human resource capacity, Reporting emergency preparedness and response planning, The States Party self-assessment Annual Reporting medical countermeasures, personnel deployment, (SPAR) tool, an interim assessment to JEE, which infection prevention and control (IPC), PoEs, and consists of 35 indicators under 15 IHR capacities for institutional infrastructure (27, 29, 30). As will detection, notification, reporting, and responding to be explored later in this report, these findings public health risk events, has regularly highlighted largely align with gaps in preparedness that were gaps in PPR capacity. Guinea-Bissau’s average identified through key informant interviews. 27 Assessment of Guinea-Bissau’s Pandemic Prevention, Preparedness, and Response Capacity Figure 6. Comparison of average scores of SPAR Cholera capacities across Guinea-Bissau, the AFRO region and globally from 2018 to 2022 Cholera is an acute intestinal infection caused by ingestion of food or water contaminated with the bacterium Vibrio cholera. Guinea-Bissau has historically been prone to cholera outbreaks from poor water and sanitation infrastructure and urban overcrowding. While cholera is considered endemic to Guinea-Bissau, larger outbreaks have occurred every three to four years since 1994 with the most recent documented outbreak in 2013 (15). It is suspected that sporadic outbreaks of cholera might have continued since 2013; however, poor detection capacity in the country has led to underreporting of epidemiological data (32). Nevertheless, the country has learned valuable lessons from its prior responses to cholera outbreaks including: • Guinea-Bissau’s Cholera Surveillance System 6.2 Response to past and present public (CSS) created an effective disease-specific health crises surveillance system connecting regional and Guinea Bissau has faced several public health central authorities. CSS was a well-organized, decentralized disease surveillance structure crises—with ongoing public health challenges that identified cases at regional health centers today. Diseases with historically high outbreak and confirmed them centrally at National potential in Guinea-Bissau have been cholera, Public Health Laboratory (Laboratório Nacional meningococcal meningitis, measles, anthrax, de Saúde Publica ) (LNSP), and the data was and yellow fever (31). The country’s approach then aggregated at INASA. It is worth noting, to addressing challenges introduced by these however, that the efficiency of the system was emergencies has involved a myriad of strategies, hampered by reliance on paper forms and the including international collaboration and a variety lack of a centralized health information system of public health interventions. By examining (HIS) (33). responses and lessons learned from cholera, polio, measles, COVID-19, and preparedness for • CHWs helped mitigate human resource Ebola, this report hopes to gain critical insights shortages by assisting with the identification of into the country’s approaches, strategies, and community cases of cholera (33). ongoing efforts to mitigate the impact of health • MOH worked effectively with partners such as emergencies. Given Guinea-Bissau’s limited health Medicins Sans Frontières (MSF) to operate a infrastructure key challenges continue to remain Cholera Treatment Center in Bissau 24 hours a in the pursuit of efficient and effective responses day and multiple regional rehydration centers in to health crises. Collectively, observations of the addition to sending specialized medical teams country’s responses to prior health emergencies to most affected regions during outbreaks (34, have revealed a critical gap of weak surveillance 35). Though these efforts were inadequate to and detection capacity. serve all population needs, they demonstrated learning from previous cholera crises. 28 Part II: Country Context and Preparedness and Response Capacity • Military participation in the response to the diagnosis and response. With support from 1994 cholera epidemic contributed to its Portuguese and Chinese development cooperation control. Particularly helpful were boats and a agencies, the LNSP acquired a set of equipment to helicopter provided for response operations in perform testing of Murray Valley encephalitis (MVE) the Bijagós archipelago (31). virus, cholera, tuberculosis, malaria, and HIV/AIDS; however, today, LNSP still does not have the ability Preparedness for Ebola in the West Africa Region to test for Ebola. This gap in detection ability stems Ebola virus disease (Ebola) is a severe, often fatal, from multiple factors and is addressed in detail in illness originally transmitted to humans from wild a later section of this report. animals (e.g., fruit bats, non-human primates) and subsequently transmitted among humans through Specimen transport is another chronic deficiency direct contact with bodily fluids or the blood of in Guinea-Bissau because of poor transportation an infected person. While there were no Ebola infrastructure, lack of trained staff for safe and cases officially detected in Guinea-Bissau during efficient transport, and lack of enough functioning the 2014-2016 Ebola epidemic in West Africa, vehicles for specimen transport. Though the country is in a hotspot region for spillovers of fundamental barriers in improving specimen hemorrhagic fevers. transport persist, some efforts to enhance the technical capacity in this area have been made. With After the declaration of the Ebola epidemic in the support of WHO and the United States Centers neighboring Guinea in 2014, and within the scope for Disease Control and Prevention (US CDC), of IHR requiring strong detection and surveillance Guinea-Bissau was able to carry out a simulation capacity and preparation for a response within exercise on the transport of Ebola samples in 48 hours after an event, MOH created the March 2015 (8). Other simulation exercises Operational Center for Health Emergencies (Centro have been conducted at the local level since de Operações de Emergências em Saúde Pública) 2015 to train rapid response teams (RRTs). (COES) in August 2015, replacing its predecessor, Though the country was largely spared from the the National Multi-sectoral Epidemic Management Ebola epidemic in West Africa, Guinea-Bissau is Committee, which had existed since 1996 (31). unprepared to manage and respond to future Given Ebola’s high cross-border transmission risk outbreaks, particularly of diseases as transmissible and epidemic potential, Guinea-Bissau engaged and fatal as Ebola. in multiple activities to prepare for a potential outbreak, including stepping up COES operations COVID-19 to plan for a response, creating an emergency As of September 27, 2023, there have been high commissioner position under the office of the 9,614 cases of COVID-19 and 177 deaths in prime minister to lead and coordinate all Ebola Guinea-Bissau (37). These data are believed to response operations in collaboration with INASA, be underestimates, as testing resources were not and developing a National Contingency Plan for readily available in-country until mid-2020, likely Ebola (31). discounting deaths that occurred before this time (36). Additionally, WHO had estimated that six out One clear shortcoming during the crisis was the of seven COVID-19 infections went undetected country’s detection capacity. At the time of the in Africa early in the pandemic (38). Given that epidemic, there were no laboratories in the country many workers in Guinea-Bissau participate in the able to acquire and run the necessary diagnostic informal economy, and a positive diagnosis of tests; therefore, an emergency partnership with the COVID-19 confirmed by testing required isolation Pasteur Institute in Dakar, Senegal, was established (and subsequently a lack of income) throughout whereby the LNSP sent specimens to the Pasteur most of the pandemic, many people were hesitant Institute for testing (36). This led to delays in to get tested even when symptomatic to avoid 29 Assessment of Guinea-Bissau’s Pandemic Prevention, Preparedness, and Response Capacity not being able to work—this likely contributes to was a technical working group within HC COVID-19 underestimates of testing and cases. Furthermore, that duplicated some of INASA’s responsibilities, in the post-acute phase of the pandemic, testing particularly around developing recommendations rates have fallen globally. for COVID-19-related public health measures (36). In the early response to COVID-19, stakeholders According to key informants, there had been in Guinea-Bissau, including external donors much scrutiny on HC COVID-19’s management of working with MOH, prioritized investments in staff financial resources throughout the pandemic. In training, infrastructure for mitigating surges, and addition to the inflow of cash to HC COVID-19 from the distribution of health education materials (39). donors, there was a revenue-generating scheme As the pandemic progressed, the focus shifted in which INASA, through its partnership with the to increasing detection capacity and integrating Jean Piaget University (JPU) laboratory, performed testing and management of COVID-19 into routine all COVID-19 PCR testing for travelers, charged at clinical and public-health services (40). Rapid 25,000 CFA (equivalent to US$42) per test. A total antigen test kits were distributed to all health of 135,000 COVID-19 PCR tests were performed facilities, and COVID-19 testing was provided to with all revenue going back to HC COVID-19 and the public free of charge. PCR testing was made none of it shared with either INASA or the JPU available at a cost for outbound travelers only, most laboratory (36). of whom were foreigners (36). Because existing HRH were diverted to the COVID-19 response and Vaccine-derived Poliovirus and Measles there was no surge workforce, access to essential Immunization coverage declined significantly services was severely hampered. in line with a decrease in access to essential services across the board during COVID-19. This With funding support from the World Bank, African contributed to a vaccine-derived polio outbreak Vaccination Acquisition Trust (AVAT), African Union, in 2021 and a measles outbreak in 2022. There the COVID-19 Vaccine Global Access Advance were 214 confirmed cases of measles during the Market Commitment (COVAX AMC) financing outbreak and 12 fatalities (43). Both outbreaks mechanism, and bilateral donors, Guinea-Bissau were decisively addressed with significant efforts increased access to affordable vaccines at to increase immunizations through campaigns and the national level by early 2021. The national other vaccination intensification activities. There vaccination campaign began in April 2021 and has were two rounds of polio vaccination campaigns, administered 810,299 COVID-19 vaccine doses as with high-quality results produced by the second of April 2023 (41). campaign, validated by independent monitoring and Lot Quality Assurance Sampling (LQAS), with A hallmark of Guinea-Bissau’s response to 99.6 percent of children receiving the novel oral COVID-19 was the creation of the High Commission poliomyelitis vaccine type 2 (nOPV2) nationwide. for COVID-19 (HC COVID-19), a new financial and Furthermore, 90 percent polio vaccine coverage administrative body, which operated independently was reached for the first time in the capital city of the Ministries of Health and Finance and reported of Bissau (43). The effective response to these directly to the presidential office (42). HC COVID-19 outbreaks of vaccine-preventable diseases created advisory bodies such as various technical suggests that Guinea-Bissau’s immunization working groups, which provided guidance to the capabilities, when not disrupted, are a strength of Commission on important matters that informed the health system. This is validated by JEE, in which the national response. However, some of these Guinea-Bissau was assessed to have ‘developed technical working groups had overlapping functions capacity’ in immunizations—the one area in which with existing governance mechanisms within the country achieved the highest JEE score relative MOH, including with COES. For example, there to all other areas. 30 Part III. Key Findings and Recommendations Assessment of Guinea-Bissau’s Pandemic Prevention, Preparedness, and Response Capacity Introduction 7. Governance, Coordination, and This section focuses on the assessment of gaps and key findings from the data analysis followed by Partnerships for PPR priority recommendations. Based on the emerging Governance, partnerships, and coordination have themes from qualitative data analysis, key findings been key to building and supporting sustained and recommendations are prioritized and grouped implementation for effective and efficient response into five areas: to crises. The Sendai Framework for Disaster Risk Reduction emphasizes the importance of 1. Governance, Partnership, and Coordination governance and clear coordination across sectors 2. Laboratory and Surveillance Capabilities in managing risks (44). The preparedness and 3. Human Resources for Health response capacity of a country depends largely 4. Risk Communication and Community on the independent functioning of strong public Engagement (RCCE) health institutions, organized emergency operation 5. Health Supply Chain centers (EOCs) and the experience of past public health emergencies. Key partnerships including The findings and recommendations presented here with multiple stakeholders within and beyond refer to priority areas that can advance progress the government are instrumental in building a toward IHR benchmarks and strengthen health resilient health system. The value-add of regional system resilience in alignment with the enablers partnerships cannot be understated, especially in and core capacities outlined in the ‘Change low-resource and fragile countries. Additionally, Cannot Wait’ report. These recommendations do regional institutes and experts can bring skills and not constitute an exhaustive list of IHR activities resources that the country lacks. that should be undertaken by the country but outline priority areas for investment to help the Although there are further strides to be made, country prepare better to respond to public health Guinea-Bissau has taken steps to strengthen its emergencies and build a resilient health system4. public health institutions and the actors that are responsible for responding to emergencies, which It is also worth noting that the World Bank’s data include INASA, the National Institute of Public collection and analysis team found that some PPR Health, and COES, the Operational Center for strategies, procedures, and practices are functional Health Emergencies. but primarily in the central urban region of Bissau. The rural areas outside of Bissau are disconnected The National Institute of Public Health. The from the central region, and therefore many priority National Institute of Public Health ( Instituto actions in this report underscore that capacity Nacional de Saúde Pública) (INASA) was founded building and PPR strengthening efforts need to in August 2010, emerging from a decade of include all 11 health regions and the 114 health efforts that had been interrupted by war and areas in the country. political turmoil (45). Initial resistance to INASA Under each of the categories, where possible, key was overcome with high-level political support findings are supported by direct quotes from the and negotiation among ministries. INASA brought key informants using verbatim language used by together pre-existing and fragmented groups and the translator present at the interviews. functions that were spread across and outside 4 According to Kruk et al, 2015 a resilient health system is described as the capacity of health actors, institutions, and populations to prepare for and effectively respond to crises, maintain core functions when a crises hits, and is informed by lessons learned during the crisis, reorganizing if conditions require. 32 Part III: Key Findings and Recommendations MOH. INASA’s responsibilities include providing since become the central body responsible for recommendations to MOH for public health coordinating all health emergency response measures, providing laboratory reference services, activities. The COES structure is replicated in a training the workforce, developing a national decentralized manner in each health region and research agenda, and conducting research (45). is referred to as Regional COES. COES’s main One example of a function that was negotiated for aims are to strengthen the coordination of actors inclusion under INASA’s purview was the National in the public health emergency management School of Public Health, which trains nurses, system, ensure public health surveillance and early laboratory technicians, midwives, and other public detection of events based on risk, and organize a health workers. The school was previously under quick and effective response during crises. the Ministry of Education. COES is housed within INASA to allow for short Although INASA is not able to independently information and decision circuits for effective declare a health emergency, it plays a critical role in and rapid crisis management (31). Due to the determining whether a crisis meets the criteria for lack of a physical space out of which to operate, a health emergency. When INASA is first notified COES is effectively a virtual structure, with about a potential disease outbreak, it sends a the inability to physically convene, at times, team to the field to investigate with diagnostic impeding decision-making efficiency. COES has confirmation. In affirmative cases meeting the four strategic pillars around which health crisis health emergency criteria, INASA communicates management interventions are structured: to the presidential office via the minister of health, (i) operations preparedness; (ii) event monitoring after which the president declares the health and detection; (iii) operations response; and emergency (36). (iv) planning, administration, and finance (8). Additionally, there are eight subcommittees within INASA is unique as a public health institution COES organized around the following themes: in that it is financially, technically, legally, and planning and information, health surveillance and administratively autonomous. Financial resources monitoring and evaluation, case management, IPC, to support INASA operations are derived from social mobilization and community participation, three major sources: appropriations from the state rapid response, laboratory services, and logistics budget, revenues from services (e.g., laboratory), management (8). and donations and grants from other institutions (45). INASA is governed by a General Council An analysis of strengths, weaknesses, that has the authority to approve INASA’s annual opportunities, and threats (SWOT) of the plans, accounts, budget, and activity reports and functioning and performance of COES revealed works under the direction of MOH. The president mixed results (Table 5). This analysis was of INASA is appointed by the Council of Ministers developed using inputs from the COES 2021-2023 for a term of five years; however, the basis under Strategic Plan (8), which was the product of a which the president can be removed is not stated, collaboration between the MOH, WHO, COES, which offers room for decisions regarding changes and Dalberg Global Development Advisors, and in INASA’s leadership to potentially be made on additional qualitative data obtained from key political or other grounds (45). informants as part of this report’s review. A focused analysis on COES was thought to be valuable The Operational Center for Health Emergencies. given the importance of its role during health As noted previously MOH created the Operational emergencies and the relatively low capacity of Center for Health Emergencies (COES), which is Guinea-Bissau’s emergency response operations equivalent to the country’s Public Health Emergency as assessed by the JEE—the average score for this Operations Center (PHEOC), in 2015. COES has IHR core capacity was 2.3 (out of 5) (27). 33 Table 5. SWOT analysis of COES Strengths Weaknesses • Legitimate entity in the management of • Delays resulting from overburdened members – The health crises – Many government, technical, main functions of COES are entrusted to members in and financial partners recognize the need for its existing institutions such as INASA and MOH. As a result, existence and respect its authority. members have COES responsibilities added to their existing full-time duties, which has resulted in delays in • Stewardship – The COES coordinator, who at implementing actions. the time this report was written was also serving as the president of INASA, was viewed as highly • Temporary structure only active during crises capable of managing COES. – COES is recognized as a temporary structure that is resurrected during crises, in part from the dual • Streamlined structure – COES is part of INASA, responsibilities of its members and multiple positions which allows for fewer delays in information held by the coordinator. This presents a challenge processing and quick decision-making, which are for COES in activity planning to bolster preparedness, necessary for rapid crisis management. especially between epidemics and pandemics. • Defined terms of reference – COES has • Poor coordination – There is poor coordination of elaborated Terms of Reference (TOR), which activities between COES, technical partners, and delivery clarify its mandate, the composition of its partners, including NGOs. The absence of a collaborative members, and the tasks of each member. national emergency management framework heightens • Disease-specific national contingency plans this coordination issue. – COES has separate National Contingency Plans • Lack of operating budget – COES does not have a for Ebola, zika, and COVID-19. Its experience defined operating budget, which prevents the allocation in developing such contingency plans makes it of necessary resources for response management. likely it could do so for a new health crisis. Though COES is a virtual structure, there is often a need for physical convening, material resources, and dedicated administrative support for improved efficiencies in operations. Opportunities Threats • Contributions from technical partners • Challenges recruiting and retaining talent – – Technical partners such as WHO, UNICEF, Recruiting and retaining competent staff is a chronic World Bank, International Organization for challenge for COES. This is linked to precedents of Migration (IOM), and the US CDC are well-placed non-payment of wages in the civil service and the small to support capacity building by providing field pool of individuals with the required skillset in the local trainings to strengthen staff competencies. market. • External funding – External sources of • Redundancies between INASA and COES – There funding have and can continue to support the is confusion between INASA and COES from development and operations of COES; examples redundancies in representation and functions, risking include dedicated funds from GHSA5 to failure to effectively carry out the missions of either strengthen the emergency management system, structure due to members being overburdened with past grant funding received from the African responsibilities. Development Bank (ADB) for preparedness and • Lack of strategic attribution of decision-making response to the zika virus outbreak, and funds power – The roles and responsibilities of key COES from various donor agencies made available positions could be better defined such that excess during the COVID-19 pandemic (8). decision-making duties do not fall on the COES coordinator. • Lack of efficient resource distribution – Available resources tend to be concentrated in the central COES structure, leaving less support for regional COES entities. 5 Global Health Security Agenda (GHSA) is a multilateral initiative that brings together 70 countries, international institutions, and NGOs to support the implementation of IHR for strengthened prevention, detection, and response systems through technical and financial support to requesting countries. 34 Part I. Introduction, Objectives, and Methodology Guinea-Bissau lacks both a PPR strategy and Several multilateral organizations and NGOs operational all-hazards PPR plan in the face of work in the country to support public health health emergencies. While COES developed programs, however, there is little coordination separate National Contingency Plans for Ebola, among them, which can lead to duplicative efforts. zika, and COVID-19, the country doesn’t have a PPR There is no knowledge-sharing mechanism or plan that can be deployed at national, regional, and platform. The government plays a minimal role in local levels (46). Given the country’s vulnerabilities coordinating with development partners and other including climate change, porous borders, and a organizations to synergize PPR activities. weak health system, the importance of having a comprehensive, costed PPR plan that is actionable a. Key gaps and findings and financed cannot be overstated. The PPR There is poor coordination among actors and strategy is missing for both human health and high fragmentation within the health sector for animal health, and the lack of multi-sectoral addressing health emergencies. Many governing coordination critically affects the country’s bodies have decision-making responsibilities One Health capacity. The MOH should lead the during health emergencies including MOH, INASA, process of preparing, costing, and implementing COES, and, more recently, HC COVID-19. Some a multi-sectoral PPR plan with the help of key of these bodies have unclear and/or overlapping technical partners. roles and responsibilities without effective coordination. As discussed above, HC COVID-19 Guinea-Bissau has several public health institutions was created in June 2020 as the primary agency to support PPR capacity building, but frequent to manage the country’s response. One reason government turnover weakens the country’s for creating this entity to manage the emergency public health system. With constantly changing response was for it to serve as a financially governments and resulting staff turnover, it autonomous body through which donor funds becomes difficult to implement policies and could be channeled given previous concerns with programs. Many staff members from government accountability with regard to the appropriate use ministries, public health institutes, hospitals, of funds. universities, and laboratories are often transferred elsewhere every few years, making it challenging to While HC COVID-19 oversaw the overall build institutional memory and knowledge. Many emergency response, other agencies with prior positions are filled without vetting candidates’ emergency response experience and expertise qualifications. also participated in the response. Multiple key 35 An examination of the coordination efforts during other health crises and routine health system administration and management shows high fragmentation, in part stemming from the frequent turnover of leadership when new government officials are elected. New leadership tends to result in new health agendas and priorities, thus creating an environment in which there is little continuity of health programs and initiatives. Key informants conveyed that there is frustration and lower motivation associated with the fragmentation of programs. informants indicated that HC COVID-19 did not effectively coordinate the response or seek While external partners provide significant input from relevant stakeholders and was resources and programmatic support in the health not transparent about the management of its sector, their scopes of work occasionally overlap, finances (36). After much scrutiny, HC COVID-19 creating duplication of activities in the absence of was dissolved in July 2022, and the government effective coordination, and MOH has insufficient created the COVID-19 Fund Management Support resources to play a coordinating role. As a matter Cell (Célula de Apoio à Gestão de Fundos COVID-19) of fact, several key informants indicated that in November 2022 to manage donor funds still some people received multiple similar trainings supporting the response (47). Like HC COVID-19, provided by different organizations owing to the this entity reports directly to the president’s office. lack of a central coordinator to manage training programs and trainee rosters. Having such a “The High Commission (for COVID-19) was central coordinator would enable the right people supposed to be a link between the donors, the to receive the right trainings at the right time, Ministry of Health and COES...but they didn’t minimizing duplication. take into account all of the prior efforts of COES (before the HC COVID-19 was formed).” “They (the government) need a mapping; - Government official they need to sit down with those stakeholders (including) technical and financial donors to The prevailing opinion among key informants was work more in complementarity. The government that while HC COVID-19 served a key function has to know who funds what, who does what... in channeling donor funds into the country to both among internal and external stakeholders.” support the emergency response, the structure’s - Government official public health value and perceived effectiveness in managing the emergency response was “The government, the ministry of health, the questionable. In particular, concern was expressed director general of health administration by key informants about the lack of financial (within MOH) should coordinate all the efforts, accountability and transparency in the management all the financial efforts of external donors (to of COVID-19 funds. While the HC COVID-19 used reduce duplication).” - Government official to routinely publish financial reports early in the pandemic this stopped as of July 2021. There have Multi-sectoral coordination is deficient, been at least three audits performed on the HC impeding a whole-of-government approach. A COVID-19, none of which have been made publicly rapid and effective response to a health crisis and available as of the publication of this report. preparedness between crises require intersectoral 36 Part III: Key Findings and Recommendations collaboration. The government of Guinea-Bissau MOH, INASA, and COES. A challenge specific to deserves credit for attempting such collaboration Guinea-Bissau has been frequent elections leading across sectors through structures such as to constant turnover of ministers overseeing COES, where ministries and secretaries of state various sectors; this has presented significant representing multiple sectors come together for issues in collaboration and ongoing planning. shared decision-making as part of an emergency response (Table 6). However, it is unclear who “Due to government’s political instability, assumes which responsibilities in the crisis response COVID-19 beginning was rough (for Guinea- and whether such roles and responsibilities are Bissau) as partners wouldn’t go to the clearly communicated to all actors. An additional government because there were two issue is duplication of, or confusion about, roles governments (two parties governing at the and responsibilities. These issues were apparent same time). Couple of months were lost in the in HC COVID-19, where there was overlap beginning (of COVID-19).” - Hospital staff with the scope of other institutions—namely Table 6. Composition of COES members (31, 36) No. Title Role in COES 1 President of INASA COES Coordinator 2 General Director of Health Promotion and Prevention (from MOH) Deputy COES Coordinator 3 Minister of Economy, Planning, and Regional Integration 1st Vice President 4 Ministry of Finance 2nd Vice President 5 Ministry of Agriculture Member 6 Ministry of Territorial Administration and Electoral Management Member 7 Secretary of State for the Environment and Biodiversity Member 8 Secretary of State for Transport and Communications Member 9 Ministry of National Education and Higher Education Member 10 Ministry of Women, Family and Social Protection Member 11 Ministry of Defense and Homeland Freedom Fighters Member 12 Ministry of Natural Resources and Energy Member Specialized commission for the Popular National Assembly (also known as the 13 Member Parliament) 14 Ministry of Commerce and Industry Volatile Member6 15 National Institute of Meteorology Volatile Member6 16 United Nations Coordination Advisory Member7 17 WHO, UNICEF, UNFPA, IOM, UNDP, World Bank, European Union Advisory Members7 18 Dean of Diplomatic Representations in the Country Consultative Member 19 International Committee of the Red Cross, MSF, and other NGOs Consultative Member 20 Representation of religious leaders and civil society Volatile Member6 6 Volatile (non-permanent) member: occasional sector member selected based on relevance of the institution to the current type of crisis 7 Advisory member: member with the expertise and capabilities to support coordination without needing to participate in deliberations 37 Assessment of Guinea-Bissau’s Pandemic Prevention, Preparedness, and Response Capacity The country does not have a PPR strategy nor A few actors in key roles accumulate most of an operational plan. After interviews with key the responsibilities. With high rates of turnover informants and review of multiple government in leadership staff, there is a significant risk of loss and stakeholder documents on health emergency of institutional knowledge and expertise every preparedness and response, this assessment time a senior civil servant is replaced. In Guinea- finds that a PPR framework is lacking at the Bissau, this is a common problem across multiple national level. While there are governance bodies sectors given that ministers tend to be replaced with a role in PPR-related decision-making, there when a new government is in power—there have is no overarching plan that prioritizes and guides been nine ministers of health and six presidents of the work. Several key informants confirmed this INASA in the past 10 years (36). This loss of crucial to be a high priority need. leadership results in stalled decisions during periods of transition and poor outcomes for the “The country does not have a national sector, some of which may be critical (e.g., lives emergency plan for pandemic preparedness... lost), depending on health crises being managed this emergency plan should involve all at the time. As noted previously, many of these components – human resources, finance, leaders hold multiple appointments in different planification...We have to sit down and elaborate governing bodies, which poses an even greater risk this national emergency plan...this exercise has for delays in decision-making, response operations, never been done.” - Government official and progressing other areas of preparedness. The country does not have a One Health Weak financing for public health institutions strategy. One Health, which sustainably balances at a national level. INASA is a prominent public and optimizes the health of people, animals, and health institution that plays a significant role in ecosystems, is critically important for a country health emergencies; however, it has a mandate too such as Guinea-Bissau, which is in a region of high large for its current financial and human resource epidemic risk. As climate change and increasing capacity. As mentioned previously, COES is human-animal interactions raise the risk for deficient in a number of essential resources, such zoonotic spillover events, a strategy to manage this as physical infrastructure, adequate staffing, and risk across the human, animal, and environmental a dedicated budget as shown by the COES SWOT interface becomes more important. Interviews analysis (table 5). with key informants in leadership roles in human and animal health clearly recognized the need for b. Key recommendations better collaboration and strategic alignment on Based on the above findings, the following are One Health, with key limiting factors being human key recommendations to improve governance, resources capacity to coordinate and convene coordination, and partnerships: alignment across actors and technical expertise in One Health. 1. Conduct a multi-sectoral stakeholder analysis to identify key players for “There was a working group that started meeting improved PPR coordination and in 2018 to elaborate a One Health strategic prioritization and their functions. plan, technically and financially supported by WHO, but they haven’t met again since the last It is recommended that this intervention precede evaluation done in 2020.” - Government official all others in the ‘governance, coordination, and partnerships’ section. A multi-stakeholder analysis would create better understanding among key 38 Part III: Key Findings and Recommendations players about who should participate in decision- related planning and activities. The heavily donor- making and information sharing at the national level. dependent environment in Guinea-Bissau means The analysis should include both governmental that better coordination among donors would be stakeholders and partner agencies, and focus on beneficial across partners and the government; the relevance, ownership, sustainability, and building government should drive this mechanism so that partnerships and alliances (48). the coordination is country-owned. Additionally, this coordination mechanism should work to address o Relevance: Stakeholders best understand the zoonoses and other existing and new threats at the activities that are relevant to their needs and human-animal interface, incorporating One Health realistic in specific contexts. priorities. o Ownership and sustainability: Local stakeholders The multi-sectoral coordinating body should have share information and jointly decide clear TORs and a clear command structure that is which actions to take. This leads to greater tested and includes financing authorities such as ownership of activities and outcomes, which the MOF. The need for routine convening even in make them more sustainable. the absence of crises is to ensure joint planning and implementation of the PPR plan once developed. o Partnerships and alliances: Having a common goal strengthens partnerships and creates 3. Develop a National Response Framework opportunities for dialogue and resource that outlines command structures, roles, sharing. and responsibilities of every stakeholder. This analysis is foundational to effectively carry out A National Response Framework establishes a all other governance-related interventions and is comprehensive, national, all-hazards approach an area where partners can contribute technical to preventing, preparing for, responding to, and assistance (TA). To implement improvements recovering from all types of national disasters based on the analysis, it is recommended that a and emergencies (49). Such a framework can memorandum of understanding (MoU) be signed be crucial in informing effective emergency among concerned participants defining decision- response planning. making responsibilities and the information chain. It will be beneficial to ensure that relevant documents 4. Develop a costed multi-hazard and multi- address cross-cutting areas including the human, sectoral PPR and health emergency plan. animal (domestic and wildlife), and environmental health sectors. As a sub-step, it would be useful to Conduct a baseline needs assessment for also look at resource gaps as part of this analysis. emergency operations capacity including infrastructure, information and communication 2. Develop a multi-sectoral coordination systems, workforce, and legislation. Based on the mechanism for PPR that convenes routinely, assessment, develop a costed multi-sectoral PPR even in the absence of health crises. plan for the next five years, with prioritization by sector and actions linked to measurable results for The multi-stakeholder analysis can help inform the the first two years, the next two years, and by the membership of this multi-sectoral coordinating end of the plan. Ensure the joint plan identifies key mechanism. The mechanism (e.g., a convening measures for all sectors to strengthen emergency committee) should allow for cross-sector governing preparedness for priority risks at the national level. bodies and funding agencies inside and outside the In addition, conduct exercises using the 7-1-78 government to better align and collaborate on PPR- approach (50) and incorporate learnings from this 8 The 7-1-7 approach is an early disease detection and response method in which a suspected disease outbreak is detected within seven days, public health authorities are notified within one day, and early response actions are completed within seven days. 39 Assessment of Guinea-Bissau’s Pandemic Prevention, Preparedness, and Response Capacity and after-action reviews to determine priority PPR preparing joint PPR plans and joint testing of the investments. plans as a follow-up step. The IHR-PVS National Bridging Workshop is a useful tool to operationalize 5. Test the COES coordination mechanism the collaboration between human and animal and develop relevant guidelines. health while identifying sector-specific goals in countries and would help Guinea-Bissau prioritize Conducting a simulation exercise to assess the needs for its weak animal health sector (51). functionality of COES coordination mechanisms and systematically documenting outcomes can 9. Strengthen the leadership and build lead to priority changes that optimize coordination. capacity of INASA and COES. Also, developing and implementing standard operating procedures (SOPs) for an ad hoc There are a few senior civil servants in leadership emergency coordination mechanism during events roles at INASA and COES who possess most of the can help prepare for an efficient response. INASA responsibilities for crisis management—this poses and COES can also be strengthened by developing a risk for coordination by introducing bottlenecks an emergency activation plan that includes scaling in decision-making and other downstream up response processes, communication, and other processes. The leadership at both INASA and immediate resources requirements at country COES can be strengthened by building technical level. and leadership capacity through trainings of mid- to-senior-level managers at both agencies such 6. Document existing legislation related to PPR. that the INASA president and COES coordinator (both roles were held by one individual from 2021 To update legal and regulatory frameworks, it is through the publication of this report) can delegate important to first understand the current legislation more responsibilities. in place with regard to PPR. 10. Develop and implement plans for 7. Update and develop legal and regulatory sustainable financing of INASA and frameworks relevant to health emergencies. COES operations. Legal frameworks must be updated according INASA and COES should explore revenue- to the PPR and health emergency plans that are generating solutions to sustainably support developed in order to ensure that there is support their operating and implement national strategic for their implementation, legally, operationally and plans. As part of this effort, COES should have a from a financing perspective. dedicated annual budget to allow for effective operations during health emergencies and a 8. Develop a One Health national strategic permanent structure during inter-epidemic and plan and conduct an International Health pandemic periods. Regulations-Performance of Veterinary Services (IHR-PVS) National Bridging A summary of the above recommendations with Workshop. suggested timelines, responsible entities, and JEE indicators anticipated to improve with adoption A One Health national strategic plan that includes of the recommendations are provided below in PPR planning is a high priority need. It should Table 7. provide a framework for the interactions between the human, animal, and environmental health sectors, which can help the country better prepare for spillover events. Additionally, it should include 40 Part III: Key Findings and Recommendations Table 7. Summary recommendations for Governance, Partnership and Coordination Recommendations Timeline Responsible entity JEE indicators improvement 1. Conduct a multi-sectoral stakeholder analysis, including INASA and MOH, P3.2 Multisectoral coordination to identify key players and mechanisms Short-term MOH resource gaps that are R1.1 Emergency risk most needed for improved assessment and readiness PPR coordination and prioritization. 2. Develop a multi-sectoral P3.1 National IHR Focal Point coordination mechanism Prime Minister’s office with functions (e.g., a convening the Ministry of Economy, Short-term P3.2 Multisectoral coordination committee) for PPR that Planning and Regional mechanisms convenes routinely, even in Integration and MOH the absence of health crises. P3.1 National IHR Focal Point functions P3.2 Multisectoral coordination mechanisms Ministry of Economy, P3.3 Strategic planning for 3. Develop a National Planning and Regional IHR, preparedness or health Response Framework Integration & INASA; also, security that outlines command Short-term multisectoral coordination structures, roles, and R1.1 Emergency risk committee (once set-up) responsibilities of every assessment and readiness stakeholder. R1.2 National multisectoral multi-hazard emergency preparedness R2.1 Emergency response coordination 4. Develop a costed multi- hazard and multi-sectoral P3.1 National IHR Focal Point Short-term MOH and MOF PPR and health emergency functions plan. R1.1 Emergency risk assessment and readiness 5. Test the COES coordination mechanism and develop Short-term INASA R1.2 PHEOC relevant guidelines. R1.3 Management of health emergency response 6. Document existing MOH with assistance by legal Short-term P1.1 Legal instruments legislation related to PPR. entity 41 Assessment of Guinea-Bissau’s Pandemic Preparedness and Response Capacity Recommendations Timeline Responsible entity JEE indicators improvement 7. Update and develop legal MOH and any other national and regulatory frameworks Medium to entity(-ies) with a role in relevant to health long-term drafting and passing new P1.1 Legal instruments emergencies. legislation P3.1 National IHR Focal Point functions 8. Develop a One Health P3.2 Multisectoral coordination national strategic plan MOH, MOA and Secretary mechanisms Medium to and conduct an IHR- of State of Environment and P3.3 Strategic planning for long-term PVS National Bridging Biodiversity IHR, preparedness or health Workshop. security R1.1 Emergency risk assessment and readiness P3.1 National IHR Focal Point functions 9. Strengthen the leadership R1.2 PHEOC Medium to and build capacity of INASA MOH and INASA R1.3 Management of health long-term and COES. emergency response D3.2 Human resources for implementation of IHR 10. Develop and implement P2.1 Financing for IHR plans for sustainable Medium to implementation MOH and MOF financing of INASA and long-term P2.2 Financing for public health COES operations. emergency response 8. Laboratory Detection and Surveillance Capabilities In Guinea-Bissau, both laboratory testing and surveillance systems need strengthening. Comprehensive laboratory testing and surveillance Laboratory capacity is basic and limited to urban systems are the first line of defense against areas, leaving rural areas prone to delayed epidemics and pandemics involving humans and testing. Unreliable sample transport adds to the animals. The key to understanding how laboratory testing and detection gap. There are some early and surveillance networks can be strengthened is warning systems in place including standard identifying the root cause of dysfunction, measuring operating procedures (SOPs), but they are used the gaps that are causing it, and then developing a inconsistently across the country. Surveillance at strategy to address them (52). PoEs and borders is occurring minimally. 42 Part III: Key Findings and Recommendations Applications of a One Health approach are very Guinea-Bissau was one of four countries that are weak in the country, with almost no laboratory part of World Bank’s Regional Disease Surveillance testing or surveillance capacity for animal health Systems Enhancement (REDISSE) Phase II (2018- diseases. JEE ranks all indicators under National 2023) project, which pursued strengthening Laboratory System in Guinea-Bissau as 1 out regional and cross-sectoral capacity for disease of 5, where 1 means no capacity and 5 means surveillance and epidemic preparedness. The sustainable capacity. Similarly, for surveillance project faced a number of challenges in Guinea- indicators, JEE scores are 1 and 2, highlighting Bissau with many activities planned under REDISSE the fact that there is a need to strengthen both II not implemented. The project closed in August laboratory testing and surveillance capacities. (27). 2023. The national laboratory system in Guinea-Bissau COVID-19 underscored the importance to resilient comprises a total of 43 public laboratories and health systems of a strategic, multilevel, and seven private labs. For human health, at the central robust laboratory network for the development level there are four public laboratories—LNSP, and dissemination of targeted diagnostic tests, Simão Mendes National Hospital (HNSM), Hospital handling of samples and their transportation, and Militar Principal, and Hospital Raoul Follereau. regional and national coordination of laboratories There are five laboratories in regional hospitals and (54). It also highlighted the importance of improved 34 laboratories in regional health centers (53). For data collection, interpretation, and timely for animal health, there are four laboratories (53). systematic surveillance. Box 1. REDISSE II (2018-2023) in Guinea-Bissau REDISSE II project highlights9 Objective: To strengthen national and regional cross-sectoral capacity for collaborative disease surveillance and epidemic preparedness in West Africa Challenges faced in Guinea-Bissau: • Turnover of key staff involved in project oversight at midterm of project implementation, including the country task team leader and REDISSE II project coordinator, and subsequent extended delays in filling their roles • Slow disbursement of funds, in part due to the limited absorption capacity at the country level • Bottlenecks in procurement processes resulting in delays in project implementation, and at one point requiring outsourcing of the procurement of laboratory equipment to a partner organization Accomplishments: • Procurement of some equipment and supplies in human health laboratories (though far less than originally planned) • Procurement of PPE • Construction of a water tower at the central animal health laboratory • Partial support for INASA to conduct FETP trainings • 17 health professionals were sent to Portugal for One Health training 9 This information was obtained from KIs and does not represent a comprehensive assessment of the REDISSE II project in Guinea-Bissau. The list of challenges and accomplishments is not exhaustive. 43 Assessment of Guinea-Bissau’s Pandemic Prevention, Preparedness, and Response Capacity a. Key gaps and findings The Jean Piaget University’s (JPU) lab in Bissau is the best-equipped laboratory in the country. The The key findings in this section are divided into two JPU laboratory has some genomic surveillance categories—laboratories and surveillance. equipment for limited genomic testing of the SARS-CoV-2 virus, although lack of reagents Laboratories hindered its use during most of the COVID-19 Laboratories are severely underequipped in pandemic (36). Though the JPU laboratory belongs infrastructure, equipment, basic supplies, to a private institution, it performed laboratory waste management, quality management testing on a host of diseases, including COVID-19, and personnel. The laboratories, both human throughout the pandemic free of charge to the and animal, in Guinea-Bissau need immediate public with reagents acquired with support from infrastructure improvement including reliable international partners. The JPU laboratory is stated running water and electricity, uninterrupted to have the capacity to test for Ebola according to internet connectivity, and physically secured one of the KIs. buildings. LNSP, the central human laboratory in Animal health laboratories are in particularly Bissau, has basic infrastructure and modest testing poor condition, severely affecting One Health capacity including Polymerase Chain Reaction capacity. A functioning animal health laboratory (PCR) machines to test for a small group of is key to a resilient health system and is critical infectious diseases. Additionally, it has cold chain for preparedness and response capacity. There equipment including ultracold freezers, though the are four animal labs in the country: one central temperature monitoring system was not working in lab, two regional labs in the Eastern region, and several of them. At LNSP, there are six laboratory one regional lab in the Northern region (53). The technicians but no epidemiologists, which is a huge team only visited the central lab in Bissau, but a gap given that it is the only national reference key informant reported that the regional labs are laboratory in the country. INASA, however, does in the same condition, if not worse. have epidemiologists (55). The central animal health laboratory had poor “There is no budget allocated (by the infrastructure and it was only minimally functional, government) for the National Public Health with limited personnel and testing capacity despite Laboratory for buying reagents, for buying basic being the main animal reference laboratory in the lab supplies...Government only pays salary. country (56). This lab was reported to have running INASA has to support the need for of supplies water and electricity, but neither was functional and everything.” - Government official during the site visit. The building compound was 44 Part III: Key Findings and Recommendations physically insecure, there were no testing supplies, personal protective equipment (PPE), or cleaning supplies. The condition of the animal health laboratory makes it impossible to build up reliable One Health testing and detection capabilities in Guinea-Bissau for zoonotic diseases. “They would like to have a functional lab..many of these diseases are economical diseases... [needs money for diagnoses, testing and treatment] it is important to have our own capacity to test and diagnose instead of sending the samples to Senegal. Once again stressing the fact that they are unable to carry out basics.” - Government official There is a list of priority diseases for animal health that need epidemiological surveillance, but the laboratory’s testing capacity is very low and at the time of the site visit in December 2022, the laboratory could only test for Avian Flu, which is not a priority disease (see Table 8). All other samples are sent to Dakar though the LNSP is able to test for Anthrax (56). As there is no protocol If they have vaccine, they can vaccinate the on how many samples need to be tested yearly affected population but currently they can only as part of One Health surveillance, it is currently do antibiotic treatment.” - Government official performed on an as-needed basis. There is no online database to record the results of the Based on the conditions observed during the site samples that are tested, and it is unclear how and visit, it appeared that many parts of the central when the list of priority diseases is updated. animal laboratory were not being used at all, signaling the lack of maintenance of the facility “..there is a new disease coming to the country and equipment. The key informant confirmed that so they have to confirm the disease (and its testing capacity is very low and there is a lack of spread), they collected 145 samples but this was budget allocation for the animal health lab by the specific (action) and not a regular practice. government and partners. Table 8. Priority zoonotic diseases in Guinea-Bissau 1 Hematic 2 Symptomatic 3 Foot and mouth 4 Contagious bovine carbuncle carbuncle disease pleuropneumonia (CBPP) 7 Plague of small ruminants 6 Rabies (goat and sheep plague) 8 African swine fever 9 Newcastle disease 45 Assessment of Guinea-Bissau’s Pandemic Prevention, Preparedness, and Response Capacity Central animal health laboratory in Bissau, December 2022 site visit Central animal health laboratory in Bissau, December 2022 site visit There is a lack of human resources at the LNSP rehabilitation of the central animal health and animal health laboratories. Key informants laboratory and One Health capacity building in reported that the animal health lab is understaffed, diagnostics and surveillance. While a contract and that departing staff are rarely replaced. One was awarded to a private company in May of the reasons for the deficient animal health staff 2023 to rehabilitate the central animal health capacity is the absence of a veterinary school in laboratory, it was unclear how the work would the country, which severely hampers One Health be completed after the project closing date (57). capacity building. Veterinarian training or education One notable accomplishment through REDISSE mostly occurs outside of the country and students was its support for 17 health professionals to often do not return home after completing their attend a One Health training in Portugal (56). studies. As noted earlier, LNSP also has a limited number of lab technicians and no epidemiologists. Waste management is poor across public health institutions, hospitals and laboratories. Waste Under the REDISSE II project in Guinea-Bissau, management at the laboratories, hospitals, and one of the original activities to be completed primary health care center was poor, with many by the project end date of August 2023 was of these facilities throwing waste, including toxic 46 Part III: Key Findings and Recommendations and biohazardous waste, into an open pit on the testing and diagnosis, there needs to be systematic premises or burning it nearby. The central animal surveillance, sample collection and transport health laboratory’s waste management practices safety training to increase efficiency of detection. were no different. The waste management system The strengthening of laboratory networks can be was not functional at the Simão Mendes National achieved by first having clear lines of responsibility, Hospital at the time of the visit. The staff informed accountability, and SOPs at every level, from the that they had been outsourcing waste management community level to the national level, followed by services for months as the hospital’s incinerators regional partnerships. Guinea-Bissau’s detection were not functional. and testing capacity for priority disease score is 1 according to the JEE assessment, and the GHSI The national and regional laboratory network score is 0 for capacity to test for five of 10 WHO- is weak, affecting sample referrals and speed defined core tests (27, 29). One reason for these of surveillance. While there is some capacity for low scores is the fragmented and disconnected sending samples to neighboring countries for national and regional laboratory network. The existing capacity doesn’t cover all rural areas. Waste management at Luanda area primary health center in the Autonomous Bissau Sector, December 2022 site visit Waste management at the central animal health laboratory, December 2022 site visit 47 Assessment of Guinea-Bissau’s Pandemic Prevention, Preparedness, and Response Capacity Guinea-Bissau is a member of the Regional for health regions). The lab does have some Integrated Surveillance and Monitoring Network transportation available (e.g., sample collection (RISLNET), which was established by Africa and transport cars) but they are often used for CDC to coordinate and integrate public health other lab-related work or are not in a condition to laboratories and monitoring and emergency travel long distances. responses to effectively support the prevention and detection of current and emerging public Some sample transport (e.g., for tuberculosis health threats, but it was not mentioned by any samples) is done on motorbikes but more training of the key informants, suggesting its low relevance is needed for safe transportation of specimens in the country. Guinea-Bissau is also part of the containing infectious pathogens (57). According Economic Community of West African States to a key informant, LNSP has an RRT comprised (ECOWAS), collaborating on laboratory networks of five bacteriologists and a driver who is sent to in 15 countries whose aim is to strengthen health regions for sample collection and transport regional laboratory networks by ensuring during outbreaks, but the limited availability of proper coordination and technical support and transportation, especially when samples need to be integrating disease surveillance systems. collected from more than one region, hinders the efforts (55). Although INASA has its own national The sample referral process from rural areas is RRT and supports LNSP with sample transportation unclear, and there are no documents demonstrating and collection, their own processes are generally that a process is in place or followed for collection unreliable. and referral. There is collaboration with local hospitals for human sample referral but the Table 9. Health regions of Guinea-Bissau absence of diagnostic tools, SOPs, and a laboratory No. Health Regions network weaken the entire process. Deficiencies in effective diagnostics and processes increase Eastern Regions turn-around time for testing, create confusion 1. Bafata during emergencies, and leave the country highly 2. Gabu vulnerable to the spread of diseases. Northern Regions “The biggest lessons learned from COVID-19 3. Cacheu was that we (Guinea-Bissau) need diagnostic and surveillance capacity, well-structured 4. Oio and resourced national laboratory, and 5. Farim digitalization of health technology.” - Government official Southern Regions 6. Quinara The limited and unreliable sample collection 7. Tombali and transport system hinders laboratory detection. LNSP has a basic protocol for sample Central Regions collection and transport, but there often is no 8 Sector Autonomo Bissau (SAB) transportation available for sample transport. Poor 9. Biombo road conditions, especially during the rainy season, make some remote areas completely inaccessible Island regions by road for months. For example, health areas 10. Bijagos located in the Bijagos archipelago are inaccessible during the peak of the rainy season (see table 9 11. Bolama 48 Part III: Key Findings and Recommendations The challenge of having limited modes of laboratories, including the central human and transportation also affects supervisory visits in animal health labs, have accreditation. health regions (55). Although supervisory visits are scheduled quarterly, it may take up to one year Accreditation is a systematic approach to quality before a visit can take place, mainly due to logistical management, but it has been a challenge to constraints (inadequate fuel and equipment). have quality-assured laboratory diagnosis in Guinea-Bissau. Key barriers in moving There are no standard or reliable procedures Guinea-Bissau toward a Strengthening Laboratory in place for animal sample transport. Given the Management Toward Accreditation (SLMTA) poor testing capacity at the animal health lab, or Stepwise Laboratory Improvement Process often samples are sent to Dakar, Senegal for Toward Accreditation (SLIPTA) accreditation testing. With no SOPs and limited funding, lab system (see Table 10 for a comparison of these officials have to take the samples in a box on two accreditation approaches) include the absence passenger planes. Sometimes the samples are of essential infrastructure, laboratory supplies, shipped using personal funds by laboratory equipment, skilled technicians (in number and officials. A mobile clinical laboratory contributed type), and reliable or standard procedures for by the Islamic Development Bank with technical laboratory testing (58). installation supported by WHO is expected to be established. This mobile laboratory is projected to Given that LNSP is the only reference laboratory in be a Biosafety Level 3 (BSL-3) laboratory10 and is the country, it is imperative that the government intended to serve rural areas on a rotating basis prioritize the enrollment of laboratories in SLIPTA. (36). Though this will improve laboratory capacity, While there has been some correspondence much more needs to be done to strengthen between INASA and WAHO about LNSP undergoing sample collection and testing in rural areas. a regional accreditation process, no timeline or strategy has yet been agreed upon (55). “Once the Director [of the animal health lab] took the sample, in a proper box, transported Surveillance the sample himself by plane...there are no funds Early warning surveillance systems need to be or personnel available” - Government official strengthened for both human and zoonotic diseases. Early warning surveillance ensures No laboratories, human or animal, are accredited awareness of risk drivers and captures data that in Guinea-Bissau. A quality management system is needed by decision makers to inform disease is critical for any laboratory, as it is an effective way control measures and emergency response. to set standards and demonstrate the technical Early warning systems in Guinea-Bissau are competence of the lab. None of the 43 public unreliable, lacking clarity at various levels, and Table 10. Difference between SLMTA and SLIPTA SLMTA SLIPTA A toolkit for training and mentoring A framework for auditing and monitoring Checks and monitors the improvement process using Prepares and supports laboratory quality improvement the SLIPTA checklist Implemented by laboratory personnel (laboratory Audits performed by ASLM-certified SLIPTA auditors managers) Determines star level and provides Certificate of Graduates on SLMTA and prepares for inspection Recognition (1-5 star levels) 10 Biosafety Level 3 (BSL-3) laboratories are equipped to work with infectious agents or toxins that may cause serious or potentially lethal disease through inhalation. 49 Assessment of Guinea-Bissau’s Pandemic Prevention, Preparedness, and Response Capacity insufficiently resourced at all levels to successfully Figure 7. Health system organization in conduct surveillance including data collection, Guinea-Bissau data analysis, and reporting for both human and animal diseases. There are 145 health centers across 114 health areas (Figure 7). For surveillance, health area focal points are supposed to inform officials at the health region level, via phone, regarding outbreaks or suspected cases of priority diseases of pandemic potential. There is no protocol to review this information in real-time. The health region then notifies the center via phone regarding its determination. 10 of 11 health regions have Surveillance Epidemiology Centers supported by REDISSE II and WAHO. Every health center has are entered in DHIS2 on electronic tablets by electronic tablets for real-time reporting, but some health area managers (known as Responsável Área of those devices no longer work or there are not Sanitária or RAS). However, many HCWs at local enough trained staff to use them. level health centers still use paper-based methods for data collection and then communicate the There is no capacity to routinely monitor PoEs in data by phone to the RAS, who enters it digitally the country. According to IHR, Guinea-Bissau has on the tablets. one airport, three ports, and 15 ground crossings, but the overall capacity score for surveillance at According to the 2021 GHSI scores, no evidence these PoEs is 1 out of 5, indicating that there is exists to show that the national public health no capacity. The airports have basic measures system has access to electronic health records in place for surveillance (e.g., checking COVID-19 for processing epidemiological data or that any and yellow fever vaccination cards), but two out reported data is used to inform the international of three ports have no competent authorities community of relevant surveillance information. For identified or designated at PoE level. animal health and zoonotic diseases, there is no active surveillance or record keeping. “….we need centralized real-time surveillance, digital health so that people can have access Community health workers can play a to their results (medical tests result). We need more significant role in community-based to have a One Health Initiative that is testing surveillance. CHWs are involved in regular seafood as it arrives.” - Government official community engagement in all health regions, each of which has a community health focal point. Detection and reporting are largely paper- At health area level, CHWs are supervised by an based, with limited use of DHIS2 software. operational field supervisor (health technician). The use of DHIS2 software on an electronic tablet CHWs sensitize the community on 18 key family was observed at type C level primary health practices such as hygiene, breastfeeding, family centers but poor internet connectivity, inadequate planning, and immunization and carry out human resources, few HCWs trained in the use community-based treatment for mild cases of of the technology, and the fact that DHIS2 is not malaria, pneumonia and diarrhea (59). In 2023, capturing data from private health facilities highly some “specialized CHWs” carry out community limits detection capacity in Guinea-Bissau. Data treatment of TB and HIV (57). 50 Part III: Key Findings and Recommendations During COVID-19, CHWs performed contact development of a PPR strategy and support tracing, but those efforts did not continue beyond laboratory accreditation. the first few weeks. According to key informants, this was primarily because of resource challenges 2. Develop a national infectious disease such as a shortage of health workers and testing surveillance strategy including -priority capacity. There was also misinformation in the epidemic diseases and zoonotic community regarding the spread and seriousness diseases, seasonal prevalence of of COVID-19, making it difficult to continue effective diseases in all regions, guidelines and surveillance and contact tracing. During the Ebola SOPs for indicator-based surveillance crisis of 2014-2015, CHWs received training in and event-based surveillance. community-based surveillance (CBS), and since then structural changes have been made to This is important as a national strategy for improve the community health program, but it detecting and reporting priority diseases at all needs support from the government and partners levels where guidance, SOPs, training, and human to perform at full capacity. With the structure of resource needs are identified. This is particularly reporting and CHW distribution in every health true for zoonotic diseases where there is no in- area, CHWs are in a good position to regularly country capacity to detect, report, and respond to identify and report public-health events. a possible emerging threat. 3. Strengthen community-based “During the pandemic, the CHWs formed an surveillance (CBS) by training CHWs ‘association of CHWs’. They connected to CHWs in priority disease case definition and in other regions and helped in (establishing) contact tracing and by establishing a CHWs association in different health regions. They used this (platform) for communication and functional multi-sectoral RRT. share updates about pandemic.” - Focus group The country has basic capacity in CBS but many discussion participant advanced capacities are non-functional. COES created an SOP for basic CBS functions in the b. Key recommendations event of a disease outbreak, however, CHWs Based on the above findings, the following are key were never trained to it. Thus, there is a need to recommendations to improve laboratory detection further strengthen the training of CHWs in contact and surveillance capabilities: tracing and the identification of epidemic-prone diseases— this need exists for both urban and 1. Conduct a laboratory capacity and rural areas of the country. There is also a need surveillance needs assessment followed for active regional response teams, similar to by asset mapping across sectors (public, INASA’s and LNSP’s national RRTs, to promote private, human, animal) and across and strengthen community-based surveillance the country—including rural areas and and build capacity for early detection. PoEs—to identify the most pressing gaps and leverage strengths. 4. Develop a process for and publish routine reports of epidemiological A needs assessment and assets mapping are information for priority diseases at the critical for a resource-scarce setting such as national level. Guinea-Bissau, as efficient need-based distribution of resources is necessary. The findings from the INASA collects and reports on epidemiological assessment and mapping should inform the information, but it is very hard to access; a process 51 Assessment of Guinea-Bissau’s Pandemic Prevention, Preparedness, and Response Capacity is needed to publish it and make it accessible to This requires having clear guidelines and SOPs the national and international community. An for both IBS and EBS. In these guidelines, online platform to publish epidemiological data, priority diseases should be addressed including record disease trends by season and geography, case definitions, measures for detection, and and report on clusters or outbreaks should be reporting at both central and regional levels. The developed and maintained. The development and guidelines should also include training of health maintenance of this platform can be done with the workers for case identification and reporting. help of a technical partner. 8. Build sustainable capacity for 5. Strengthen the specimen referral and One Health approach to surveillance transport system by reviewing existing by coordinating with other relevant capacities and needs, developing SOPs ministries/focal points, and through and training HCWs and other staff. joint training and information exchange. A system of specimen referral and transport exists but is not efficient across the country, This is critical, as there is a need for a multi- underscoring the need for strengthening existing sectoral capacity for surveillance of zoonotic capacities. A coordinated system for animal health diseases, information management, research, and sample collection and transport also needs to be technical expertise. With vulnerability to climate developed. This process can include identifying the change amongst other factors in Guinea-Bissau, type and number of drivers and vehicles needed it is important to build a robust One Health and the ability to access different geographical surveillance capacity to monitor and detect threats regions, keeping in mind further transportation- and be prepared for both response and recovery. related barriers created by the three-month As recommended earlier, an integrated digital intense rainy season every summer. platform with focus on One Health is needed for efficient surveillance and response to emerging 6. Strengthen laboratory capacity for one health threats. priority diseases by refurbishing laboratories (including animal health 9. INASA, with support from MOH and laboratories), training laboratory other key stakeholders, could form a workers in priority disease diagnostics, public-private partnership model for and enrolling laboratories in the procurement of essential testing accreditation programs. supplies and reagents. This priority action not only improves infrastructure, A partnership can support testing for priority technical competence, and capacity for priority diseases as Guinea-Bissau strengthens its health disease testing at the national lab but also system. Public-private partnerships for securing strengthens the sample referral and transport essential supplies and improving health care system. This action needs leadership in recognizing delivery, especially during the COVID-19 pandemic, the importance of quality control and its effect have been successful in many countries (60). on controlling a disease outbreak and therefore requires proactive efforts from both MOH and A summary of the above recommendations with INASA. This one priority action can strongly improve suggested timelines, responsible entities, and JEE laboratory testing and detection capacity. indicators anticipated to improve with adoption 7. Strengthen existing IBS and establish of the recommendations are provided below in EBS for priority diseases. Table 11. 52 Part III: Key Findings and Recommendations Table 11. Summary recommendations for Laboratories and Surveillance capabilities Recommendations Timeline Responsible entity JEE indicators improvement 1. Conduct a laboratory P5.1. Surveillance of zoonotic capacity and surveillance diseases needs assessment followed Director of National Public D1.3. Laboratory testing by asset mapping across Health Laboratory (LNSP) and capacity modalities sectors (public, private, INASA under the guidance of Short-term D2.1. Early warning surveillance human, animal) and across General Director of Health function the country—including rural Promotion and Prevention areas and PoEs—to identify (from MOH) PoE1. Core capacity the most pressing gaps and requirements at all times for leverage strengths. PoEs (airports, ports and ground crossings) 2. Develop a national infectious disease R1.1 Emergency risk surveillance strategy assessment and readiness including -priority epidemic P5.1. Surveillance of zoonotic diseases and zoonotic disease MOH, INASA, LNSP and diseases, seasonal Short-term General Director of Livestock P5.2. Response to zoonotic prevalence of diseases in all regions, guidelines and diseases SOPs for indicator-based P6.1. Surveillance of foodborne surveillance and event- diseases and contamination based surveillance. 3. Strengthen community- General Directorate of D2.1. Early warning surveillance based surveillance (CBS) by Prevention and Health training CHWs in priority Promotion, Department of function disease case definition Short-term Community Health Services D2.2. Event verification and and contact tracing and by and Promotion of Traditional investigation establishing a functional Medicine (under MOH) and multi-sectoral RRT. LNSP R5.2 Risk communication 4. Develop a process for and publish routine reports of MOH D2.3. Analysis and information epidemiological information Short-term sharing for priority diseases at the national level. 5. Strengthen the specimen referral and transport P5.2. Response to zoonotic diseases system by reviewing INASA, LNSP and existing capacities and Short-term Secretary of Transport D1.1. Specimen referral and needs, developing SOPs and Communication transport system and training HCWs and D1.2. Laboratory quality system other staff. D2.1. Early warning surveillance 6. Strengthen existing IBS and Medium to function establish EBS for priority INASA long-term diseases. D2.2. Event verification and investigation 53 Assessment of Guinea-Bissau’s Pandemic Preparedness and Response Capacity Recommendations Timeline Responsible entity JEE indicators improvement 7. Strengthen laboratory capacity for priority diseases D1.1. Specimen referral and by refurbishing laboratories transport system (including animal health D1.2. Laboratory quality system Medium to Prime Minister’s Office, MOH, laboratories), training long-term INASA D1.3. Laboratory testing laboratory workers in priority disease diagnostics, capacity modalities and enrolling laboratories in accreditation programs. P5.1. Surveillance of zoonotic diseases P5.2. Response to zoonotic 8. Build sustainable capacity diseases for One Health approach MOH, INASA, Focal to surveillance by P6.1. Surveillance of foodborne points from Ministry of coordinating with other Medium to diseases and contamination Veterinary service, Ministry relevant ministries/focal long-term D2.1. Early warning surveillance of Agriculture and local points and through joint function stakeholders training and information exchange D2.2. Event verification and investigation D2.3. Analysis and information sharing 9. INASA, with support from MOH and other key D1.1. Specimen referral and stakeholders, could form a MOH and INASA with transport system Medium to public-private partnership Ministry of Commerce and long-term D1.2.Laboratory quality system model for the procurement Industry of essential testing supplies and reagents. In Guinea-Bissau, there is a dearth of HRH at all 9. Human Resources levels, and the existing health workforce functions for Health under demanding conditions such as high workloads, low salaries, and limited prospects People are the backbone of every country’s health for professional growth. The country’s JEE ranks system. HRH challenges especially affect the ability three of four indicators for human resources as 1 of LMICs and countries affected by fragility, conflict, out of 5, where one indicates no capacity and five and violence (FCV) to deliver essential health indicates the presence of sustainable capacity. The services. The COVID-19 pandemic highlighted the three indicators are as follows: 1) having an up- need for a cross-sectoral, trained, and diverse to-date multisectoral workforce strategy in place, health workforce to deal with surges in cases, 2) having human resources available to effectively ensure continuity of essential health services, implement IHR, and 3) the availability of in-service and perform roles beyond their traditional trainings (WHO-IHR, 2019). Though Guinea-Bissau responsibilities to meet patient care needs. scored a 4 out of 5 on the fourth JEE human 54 Part III: Key Findings and Recommendations resource indicator for having an FETP training Figure 8. Health care workforce distribution program in place, a key informant reported that in the public sector, 2022 (61) the training is being provided on a limited and irregular basis for human health workers only. Physicians and nurses in public hospitals routinely work extended hours, increasing the risk of burnout and poor performance. In the intensive care unit (ICU) of the Simão Mendes National Hospital in Bissau, a key informant reported that two doctors alone typically covered the day and night shifts, respectively, going weeks at a time without taking days off. Similarly, many of the nurses were said to work longer than assigned shift durations. the HRH workforce showed that the country is Training, retention, and motivation of the health deficient in skilled health workers across every workforce are also issues in Guinea-Bissau. There role, sometimes by a factor of more than 10-20 are insufficient training opportunities, contributing less than the minimum recommended density to an under-skilled workforce and challenges in (63). Table 12 displays the global ratio of health retention, and subsequently leading to an uneven professionals in the country in 2016 vs. 2022. distribution of the health workforce, in which rural areas with the highest needs end up with the In absolute numbers, there were 363 physicians fewest HCWs (Figure 8). Skilled HCWs (e.g., doctors, and 1,231 nurses for the entire country in 2022 nurses) tend to be concentrated in central and (64). There is a critical shortage of specialist urban areas, leaving the other regions vulnerable. physicians in all clinical areas, particularly for Obstetrics, Gynecology, Pediatrics, Surgery, a. Key gaps and findings and Public Health (63). As of May 2023, the only There is a shortfall in human resources at pediatric surgeon in the country was also serving every level of the health system. Health facilities as the Minister of Health. Another problem is the of all types in both urban and rural areas of asymmetric geographic distribution of HCWs, Guinea-Bissau are understaffed. WHO’s 2006 with more than 40 percent of all HCWs, including World Health Report identified a minimum health specialist physicians, concentrated in the capital, professional density of 2.3 skilled health workers Bissau, which is home to approximately 25 percent (e.g., physicians, nurses, midwives) per 1,000 of the population (66). population to be generally necessary to reach 80 percent coverage of essential health services in Compounding the chronic shortage of HCWs are a population. A Sustainable Development Goals frequent strikes, which were pronounced in 2022 (SDGs) composite index accounting of 12 key as HCWs demanded payment of overdue wages population health indicators identified by WHO and and incentives. There was also a dismissal of a the World Bank resulted in an ‘SDG index threshold’ large contingent of approximately 1,200 health with an updated minimum recommended density technicians in September 2022, all of whom had of 4.45 skilled health workers per 1,000 population been newly hired in 2021(61). This dismissal is (62). According to the 2023-2032 National Plan for said to have resulted from restructured health the Development of Human Resources for Health financing at the national level due to health system (PNDRHS) in Guinea-Bissau, a recent survey of expenditures exceeding revenue (32). 55 Assessment of Guinea-Bissau’s Pandemic Prevention, Preparedness, and Response Capacity During much of the pandemic, there were severe There is also low in-country HR capacity disruptions in essential service delivery because of in epidemiology. In 2022, there were only the diversion of physical and human resources to 4 epidemiologists in the entire country. As of the COVID-19 response. Evidence of this is seen in May 2023, 280 health workers in Guinea-Bissau decreased routine immunization coverage leading had received a three-month basic FETP training to outbreaks of vaccine-preventable diseases (43). and 15 health workers received a nine-month The COVID-19 experience demonstrated that intermediate FETP training (36). While these FETP Guinea-Bissau’s health system has insufficient trainees have included workers from the animal HRH to fulfill essential service delivery needs while and environmental health sectors, the content supporting an emergency response (36). of the training has been predominantly focused on human health and does not incorporate a “When COVID-19 came, one of the main gaps One Health approach (36). Partner agencies in terms of human resources was not having have invested significantly to provide various enough lab technicians...in both quality and trainings, including FETP courses, to build capacity quantity. As an example, in the COVID-19 among HCWs. However, as discussed earlier, wards in the hospitals there was a team of poor coordination on training curricula and on health technicians taking care of COVID-19 managing the roster of trainees has resulted in patients, and there were no anesthesiologists duplicated training content for some individuals. or surgeons (on the teams); there was a lack of skilled health technicians in the hospitals.” “...training of human resources, capacity building – Government official of human resources, (is needed) to be more prepared to face challenges in these kinds of There is an inadequate skillset and knowledge pandemics in the future.” – Government official among the health workforce. A 2019 World Bank Service Delivery Indicator (SDI) survey revealed “Before 2012, the HR department of the MOH significant gaps in health care provider knowledge. maintained a database with profiles of human The survey results showed that few HCWs could resources and the trainings they had received accurately diagnose the leading causes of child to coordinate future trainings and prevent mortality—only two percent could diagnose a duplication. But this doesn’t happen anymore, case of malaria with anemia and less than one- which increases the risk of duplicated trainings.” third could correctly manage cases of postpartum – Government official hemorrhage, the leading cause of maternal death in Guinea-Bissau (62). When asked, a primary There is frequent turnover of health staff health center worker in Bissau acknowledged and high rates of absenteeism. The causes of being unaware of how to deal with a suspected frequent turnover differ depending on level of Ebola case (62, 67). seniority. For those in more senior or administrative Table 12. Global ratio of professionals per 10,000 population, except for midwives, whose index is displayed as a ratio of midwives per 1,000 women of childbearing age (WCA) (63-65) Midwives/ Lab Pharmacy Radiology Year Population Physicians Nurses 1,000 WCA technicians technicians technicians 2016 1,743,652 1.22 6.08 2.30 1.00 0.20 0.005 2022 2,046,289 1.77 6.01 0.38 0.71 0.33 0.21 56 Part III: Key Findings and Recommendations positions, the turnover is directly related to accompanying PNDRHS covering the period political parties in power; it is not uncommon 2008-2017. Once again, successful implementation for leaders in the health sector to be replaced was prevented by a coup d’état in 2012 that wholesale with a change in government, which has resulted in an unstable political environment with occurred frequently in the past 10 years. There frequent changes in government that continued have been at least six ministers of health in the for several years. past eight years. The frequent turnover in health sector administrators and leaders has detrimental Certain groups of HCWs may be underutilized effects on public-health programs—with each and have the potential to take on a greater new administration, there is a new health agenda scope of work to mitigate staffing shortages. and often scrapping of previous programs. For Examples include CHWs who can perform disease frontline HCWs, especially those in technical surveillance and health care tasks and final-year roles (e.g., physicians or nurses), the turnover is medical and nursing students who can take on related to years of instability, low and unreliable tasks shifted to them from doctors and nurses. renumeration, and poor working conditions. Laboratory technician students in their final term This has led to an exodus of clinicians to other of study can also do formal apprenticeships in countries in search of better job prospects which they work as lab technicians in practical and salaries. Those who remain often seek job settings. opportunities in the more lucrative private sector. Finally, others who train abroad rarely return to b. Key recommendations Guinea-Bissau for work after their studies. Based on the above findings, the following are key recommendations to improve HRH: Absenteeism among HCWs is another chronic issue, with reported reasons including 1. Elaborate a multi-sectoral workforce strategy dissatisfaction with salaries, payment arrears, to develop human capital across the human and long commutes. Data from the World Bank and animal health sectors to enhance PPR. 2019 SDI report suggests that HCW absenteeism reaches 55 percent in Bissau and 50 percent Guinea-Bissau has the foundation to develop in Quinara, with the lowest rate in Gabu at 19 a multi-sectoral workforce strategy based on percent (Table 10) (24). the multiple versions of PNDRHS elaborated in previous years. The most recent PNDRHS, covering “They’re not motivated due to poor working the period 2023-2032, is the most comprehensive conditions, low salaries, and the cost of living yet and can be utilized as a base from which a is constantly rising while salaries are not multi-sectoral strategy can be developed. Having increasing...the main problem of absenteeism such a strategy is key to maximizing human is a lack of motivation.” – Government official potential across sectors for enhanced PPR capacity and health system resilience. There is a need for a multi-sectoral workforce strategy to enhance health system resilience. 2. Identify required training needs for IHR The first National Development Plan of HRH and institute cascade training (train-the- (PNDRHS) was established in 1997 following the trainer) programs and hands-on training adoption of the first National Health Development for detection and surveillance of priority Plan (PNDS I) (63). However, the military conflict epidemic-prone and zoonotic diseases, in 1998 compromised both plans. In 2007, an risk communication, contact tracing, and assessment of the HRH situation in Guinea-Bissau infection prevention and control. was conducted, which informed the PNDS II and 57 Assessment of Guinea-Bissau’s Pandemic Prevention, Preparedness, and Response Capacity Based on known gaps in in-country expertise in 6. Develop rural training programs for detection and surveillance of priority diseases, risk final-year medical, nursing, and laboratory communication, contact tracing, and IPC, there is technician students for exposure to and to a need for targeted investments to build capacity develop interest in practice in rural settings. in these key IHR areas. Exposing soon-to-graduate students to practice in 3. Establish a three-month basic FETP-V joint rural settings can serve as a recruitment strategy. training program based on a One Health Given the general preference for workers to seek curriculum and other in-service training employment in urban areas, an intervention programs for HCWs, CHWs, and animal such as this one can expose future HCWs to health workers. needs in rural areas and allow them to develop connections with rural communities—for some, Although INASA, with support from partners this can become a motivating factor for seeking such as US CDC, WHO and World Bank, has employment in rural parts of the country. implemented FETP trainings for workers from the human, animal, and environmental health sectors, 7. Strengthen policy reforms and develop the curriculum is almost exclusively focused on programs to boost HRH retention, such as human health. A three-month basic FETP-V performance-based incentives, differential course with a curriculum based on One Health is compensation schemes based on geographic recommended to be developed and implemented distribution, and a service repayment for HCWs, including laboratory technicians, CHWs and animal health workers. program. 4. Appoint personnel within MOH to Given the chronic nature of the problem, HRH coordinate health sector training. retention should be a focal area of long-term policy reform. Performance-based incentives are There is a need to better equip the existing one way of motivating skilled HCWs. Monetary workforce through strategic steering and and non-monetary incentives can be considered, coordination of training activities, including such as paid time off and structured opportunities continual education and training. This will require for career advancement for high-performing appointing at least one-to-two persons within the individuals. Differential compensation schemes HR department of MOH to liaise with partners and could be designed with both recruitment and other agencies to manage and coordinate training retention in mind—increased salaries or other programs. benefits can incentivize employment in rural areas. Finally, a service repayment program is one in 5. Build capacity for animal health staff, which tuition is paid for individuals (or exempted laboratory workers, rapid response teams, in public educational institutions) in exchange for and strengthen INASA’s capacity for a certain number of years of service in the health coordination. sector. This could be particularly beneficial as a means of expanding the availability and retention For improved PPR capacity, there is a need to train of HCWs in rural areas. and recruit staff at all levels in laboratories, both human and animal, as part of RRTs and at INASA A summary of the above recommendations with for efficient functioning and coordination. The suggested timelines, responsible entities, and JEE cascade training program recommended above indicators anticipated to improve with adoption can be a starting point for building staff capacity of the recommendations are provided below in at labs and INASA. Table 13. 58 Part III: Key Findings and Recommendations Table 13. Summary recommendations for Human Resources for Health Recommendations Timeline Responsible entity JEE indicators improvement 1. Elaborate a multi-sectoral MOH and multisectoral D3.1 Multisectoral workforce workforce strategy to develop coordination committee strategy human capital across the Short-term (with sponsorship from the human and animal health Prime Minister’s Office) D3.4 Workforce surge during a sectors to enhance PPR. public health event 2. Identify required training needs for IHR and institute cascade training (train-the- D3.3 Workforce training trainer) programs and hands- on training for detection INASA, MOH, multisectoral P7.2. Biosafety and biosecurity Short-term training and practices in all and surveillance of priority coordination committee epidemic-prone and zoonotic relevant sectors (including diseases, risk communication, human, animal and agriculture) contact tracing, and infection prevention and control. 3. Establish a three-month basic FETP-V joint training program based on a One Health curriculum and other in-service Short-term INASA D3.3 Workforce training training programs for HCWs, CHWs, and animal health workers. 4. Appoint personnel within MOH D3.2 Human resources for to coordinate and manage implementation of IHR health sector training by liaising Short-term MOH D3.3 Workforce training with external partners and other agencies. 5. Build capacity for animal health D3.2 Human resources for staff, laboratory workers, implementation of IHR Medium to rapid response teams, and INASA, MOH and MOA D3.3 Workforce training long-term strengthen INASA’s capacity for D3.4 Workforce surge during a coordination. public health event 6. Develop rural training programs for final-year medical, D3.2 Human resources for nursing, and lab technician Medium to implementation of IHR MOH students for exposure to and long-term to develop interest in practice D3.3 Workforce training in rural settings. 7. Strengthen policy reforms and develop programs to boost HRH retention, such as performance-based incentives, D3.2 Human resources for differential compensation implementation of IHR Medium to MOH, MOF and MOE schemes based on geographic long-term (Ministry of Education) D3.3 Workforce training distribution to boost recruitment and retention of rural HCWs, and a service repayment program. 59 Assessment of Guinea-Bissau’s Pandemic Prevention, Preparedness, and Response Capacity 10. Risk Communication for risk communication strengthening. and Community The country was able to perform some RCCE Engagement activities during the COVID-19 pandemic Risk communication and community engagement including contact tracing, communication through (RCCE) focuses on systematically engaging, radio messages, media campaigns, and health consulting, and communicating with at-risk promotion activities such as hand washing and populations (68). As seen during COVID-19, before hygiene best practices. The proactive leadership any pharmaceutical intervention was possible, RCCE at INASA is working to bring more structure and was the strongest tool available for the response. A clarity to COES’s functions, especially to prepare government’s ability to communicate risks, such as and respond to the next public health crisis. JEE information on emerging outbreaks, precautionary score for Address perceptions, risk behaviors measures, and best practices, to communities was and misinformation in Guinea-Bissau is 2 out of critical in the absence of vaccines. Even after the 5 suggesting strong reinforcement of RCCE across development and distribution of vaccines, RCCE all health regions is needed. played a crucial role in spreading the word about their availability and encouraging vaccine uptake to Community health workers provide a good enable a resilient response. foundation for the RCCE work in most regions of the country. Community engagement falls under Guinea-Bissau has a basic risk communication the General Directorate of Prevention and Health structure in place but is mostly one-sided—top- Promotion in the Department of Community Health down— not used uniformly and most importantly Services and Promotion of Traditional Medicine (see its real-time exchange of information is highly Figure 9). Across the 11 health regions, 3,481 CHWs11 limited. It is not clear if risk communication were selected to be operational in the field (59), messaging reaches all health areas and if the but their overall distribution by region is uneven. populations are receptive to the communication. CHWs are recruited by community leaders and JEE score for Public Communication for supposed to work two hours a day on a voluntary Emergencies and for Commitment to Communicate basis, although there are some financial incentives with Affected Communities is 2 out of 5 for both according to the number of households visited indicating significant implementation gaps in risk monthly. communication. CHWs receive 17 days of training and implement the INASA and COES are responsible for risk 18 key family practices (e.g., hygiene, immunization) communication activities. Within INASA, the in their communities. Each CHW is assigned to an Health Information and Communication Center average of 50 households (69). During the Ebola and Center of Training, Education, Information, crisis of 2014-2015, CHWs received training for and Multimedia (CFEIMS), headquartered at the CBS, and since then structural changes have been Ministry of Social Communication, undertake RCCE made to improve the community health program. activities. COES has a Strategic Plan of the Health A key lesson that emerged during the pandemic Emergencies Operations Center of Guinea-Bissau was that in many countries RCCE is an important 2021-2023, which includes objectives and planning yet the weakest link in the response. 11 This number was confirmed during KIIs in December 2022; however, the actual number may be lower as some CHWs were in the midst of leaving their jobs due to late payment of incentives at the time this report was written in 2023. 60 Part III: Key Findings and Recommendations Figure 9. Functional composition of the Department of Community Health Services and Promotion of Traditional Medicine within the MOH a. Key gaps and findings RCCE are absent, leading to inefficiencies and delays that can be detrimental in an emergency Risk communication procedures are weak and existing measures need streamlining to response including during COVID-19. Roles and build PPR capabilities, both within the country communication, especially during emergencies, and with regional partners. During COVID-19, need to be clarified and strengthened. KIIs confusion over roles and responsibilities caused underscored that even the existing skillset in the delays in risk communication and overall response country was not fully utilized during the pandemic activities. There was no procedure to reassure for risk communication and CBS. This was because populations and no rumor management system, of lacking SOPs and procedural guidance in the which affected contact tracing efforts. CHWs country and poor visibility into COVID-19 risks at received little guidance on the risks of COVID-19, the global level. At the beginning of the pandemic, which caused panic and fear among them, several months were lost in clarifying roles and interrupting the essential health services that CHWs responsibilities. There was also no evaluation of were providing to communities. The government any interventions that were introduced. tried to conduct risk communication on COVID-19 using social media platforms such as Facebook In the absence of a clear RCCE plan, messaging and community radio but there was no follow-up to the public was top-down with no measure to determine if the messaging reached the target of how it was received. The communication populations. Also, there was no identified platform between the government and HC COVID-19 was for risk communication to the public in different one-sided, leaving no systematic way to collect regions although messages to the community were feedback and use it to improve communication translated into local languages (70-72). mechanisms. Further, to control the spread of the COVID-19 virus, a state of emergency was “Some of the biggest gaps in the system are lack declared by the president of the country and strict of focus at the community level and community- curfews were implemented for extended periods. based surveillance, sensitizing communities During the initial weeks of the curfew, people and work on behavior change. Also, we cannot were allowed to be outside for only a few hours neglect traditional medicine (and its importance per day, which caused massive crowding in the in the communities).” - Government official markets, making them sites for ‘super spreader’ 61 Assessment of Guinea-Bissau’s Pandemic Prevention, Preparedness, and Response Capacity events. Warm temperatures made it difficult to authorities for mapping risk areas for epidemics, enforce mandatory mask-wearing. Police officers natural disasters and a plan for continued reportedly imposed fines and jailed people who community-level support to those areas in the did not comply with the mask-wearing mandate. event of an emergency. Fair selection of CHWs Despite people’s distress about this situation, the and roles and responsibilities of actors at regional government relaxed the curfew only partially and and local levels are detailed in the PENSC. With the it remained in place for several months (57). right stakeholder and proactive co-coordination support from the government, efforts to cost and The community health program has a good implement this plan will strengthen the structure structure and can play a key role in extending and functioning of the community health program. RCCE efforts in communities of Guinea-Bissau. Given that CHWs are embedded in communities, The Department of Community Health Services they can serve as a link between the community and Promotion of Traditional Medicine’s and the local level health infrastructure. They central office in Bissau has infrastructure and can help people adopt protective behaviors, logistical needs. Infrastructure and logistics are listen to concerns, and collect feedback on risk key resource gaps as they limit coordination and communication measures that can be used by information sharing which is critical for RCCE. The the government to tweak measures, making them department lacks enough office space, computers, more likely to be accepted. CHWs need more transportation, among other infrastructural needs support in carrying out these RCCE activities primarily due to financial barriers. As many as especially because the program is donor- eight staff work in two rooms packed with paper dependent (69). They can benefit from receiving materials for data collection and community promised incentives on time, getting basic gear education that obstruct the work space. such as bicycles to travel across vast areas, a carry bag for their supplies, a thermometer, and a badge “Some of the biggest challenges are advocating for to identify themselves when working. space...there are no meeting rooms, equipment’s not working properly.” - Government official “A national network of CHWs is in place. CHWs play a leading role in infant mortality In the absence of necessary forms, operational prevention, promotion and curative work but field supervisors have difficulty tracking meetings the program is highly dependent on external with CHWs and subsequent reporting to their funds (donor funds) and their support is respective regional community health focal point. critical.” - Government official Supervisory visits from the Bissau central office to the health regions cannot take place regularly There is a National Strategic Plan for due to unavailable transportation and other Community Health (PENSC) 2021-2025. This logistical issues (59). This leads to interrupted comprehensive document jointly prepared by communication and engagement strategies the Ministry of Health, General Directorate of exposing the community to negative impacts Prevention and Health Promotion, Department during a public health emergency. of Community Health Services and Promotion of Traditional Medicine has identified priority issues b. Key recommendations and laid out objectives, strategic targets, and Based on the above findings, the following are key expected outcomes for community health (73). recommendations to improve RCCE: This plan also includes advocacy measures to 62 Part III: Key Findings and Recommendations 1. Identify and map key partners, RCCE strategies need updating and adapting community influencers, religious to different regions, taking into account local leaders, and champions at subnational languages, best ways to communicate validated levels to support community information, and measurement of the impact engagement for PPR. of RCCE activities. SOPs should be updated to eliminate confusion about roles within a dedicated This strategy can help build capacity for RCCE for team to support RCCE efforts. These should also both human and animal diseases. In Guinea-Bissau, be done for zoonotic diseases to build One Health identifying and mapping community resources capacity. INASA and COES already have written can be a valuable tool in strengthening community some of the needed documents and those can engagement efforts. Local partners and community be modified and adapted. leaders have people’s trust and know how best to communicate with community members. Technical 3. Test the RCCE system by planning and partners and NGOs working at local levels can operationalizing simulation exercises support the government to carry out this mapping (SimEx). exercise. This action can be very useful to identify strengths 2. Update RCCE strategy and SOPs and weaknesses of Guinea-Bissau’s RCCE system. for RCCE including managing These exercises can be table-top, operations-based misinformation by communicating (e.g., a drill to test a specific function), field-based, scientifically validated data via political or a combination of methods. and technical leaders. Supervisory and data collection forms for CHWs piled up in the office of the General Director of the Dept. of Community Health Services, December 2022 site visit 63 Assessment of Guinea-Bissau’s Pandemic Prevention, Preparedness, and Response Capacity 4. Provide support to cost the National useful for professional development and build Strategic Plan for Community Health motivation such as experience certificates, training (PENSC) 2021-2025 and support its certificates, free health care for CHWs’ families and implementation. other relevant opportunities and incentives. It is also noted that female CHWs are more accepted The costing and implementation of the PENSC for health and risk communication measures 2021-2025 plan can help improve community- in Guinea-Bissau, but their number is very low based health programs including guidance compared to their male counterparts in all health and actions for policymakers and technical regions. There is a need to engage more women partners needed to build a resilient community as CHWs for better RCCE outcomes. health system. This plan also includes advocacy measures to authorities for mapping risk areas 6. Develop and conduct cascade training for epidemics, natural disasters and a plan for on RCCE. continued community-level support to those areas in the event of an emergency. Given limited resources, cascade training can work very well in Guinea-Bissau. This training 5. Strengthen CHW retention and can be supported by key technical partners recognition to boost community and developed under INASA or COES. It should engagement. include strengthening technical capacity and data collection/analysis on RCCE. CHWs are critical in Guinea-Bissau’s fragile health system as they not only carry out disease A summary of the above recommendations with prevention and health promotion activities but suggested timelines, responsible entities, and JEE also effectively engage with the local population. indicators anticipated to improve with adoption Guinea-Bissau can support its CHWs by of the recommendations are provided below in introducing non-monetary incentives that can be Table 14. 64 Part III: Key Findings and Recommendations Table 14. Summary recommendations for Risk Communication and Community Engagement Recommendations Timeline Responsible entity JEE indicators improvement 1. Identify and map key General Directorate of partners, community Prevention and Health influencers, religious Promotion, Department of leaders, and champions Short-term R5.3 Community engagement Community Health Services at subnational levels and Promotion of Traditional to support community Medicine (under MOH) engagement for PPR. 2. Update RCCE strategy and SOPs for RCCE including R5.1 RCCE systems for managing the spread of emergencies rumors and misinformation Short-term MOH and INASA by communicating R5.2 Risk communication scientifically validated data R5.3 Community engagement via political and technical leaders. R5.1 RCCE systems for 3. Test the RCCE system emergencies by planning and Short-term MOH operationalizing simulation R5.2 Risk communication exercises (SimEx). R5.3 Community engagement General Directorate of Prevention and Health R5.2 Risk communication 4. Provide support to cost Promotion, Department of the PENSC 2021-2025 and Short-term R5.3 Community engagement Community Health Services support its implementation. and Promotion of Traditional D3.3. Workforce training Medicine (under MOH) 5. Strengthen CHW retention R5.2 Risk communication Medium to and recognition to boost MOH and INASA long-term R5.3 Community engagement community engagement. R5.1 RCCE systems for 6. Develop and conduct Medium to emergencies MOH and INASA cascade training on RCCE. long-term R5.2 Risk communication D3.3. Workforce training 65 Assessment of Guinea-Bissau’s Pandemic Prevention, Preparedness, and Response Capacity 11. Health Supply Chain significant implications for gap assessments and the pre-positioning of medicines and other health Despite their importance during health commodities. emergencies, health supply chains are often not prioritized in health security assessments—the During the COVID-19 pandemic, supply chain JEE does not have a dedicated indicator for supply disruptions in many sectors, including the health chain and while there is one in the GHSI it tends to sector, negatively impacted service delivery and the focus on laboratory supplies. A poorly functioning effectiveness of the emergency response in many health supply chain can lead to stockouts, wastage (76). Guinea-Bissau was no exception. Including of medicines and supplies, and increased costs, supply chain in health security assessments is all of which can have adverse impacts on service therefore important to identify gaps for targeted delivery and health outcomes (74). Inadequate interventions and encourage investments to supply chain management has been identified as a strengthen what is increasingly being recognized major challenge in Guinea-Bissau by organizations as a critical component of health systems (77, 78). such as The Global Fund to Fight AIDS, Tuberculosis, and Malaria (TGF), UNICEF, and A detailed review of supply chain capacity was WHO (75). Neglecting supply chain in health included as part of the assessment for this system assessments can therefore have report to highlight significant shortcomings in 66 Part III: Key Findings and Recommendations Guinea-Bissau’s health supply chain weakening its on pharmacovigilance strategy, guidelines and overall PPR capacity and posing a risk to its health related SOPs have not been officially adopted system resilience. or enforced despite having been validated by a technical committee in 2018 (81). a. Key gaps and findings “We received basic supplies, PPE...five months CECOME, the national medicines procurement after the peak of COVID-19 in 2020. Many agency with financial and administrative patients died due to COVID-19. We lost many authority to purchase and distribute essential health care workers, they died due to COVID-19.” medicines and other health products, has - Hospital staff failed to deliver on its mandate to manage the country’s health supply chain (79). There Fragmented, uncoordinated supply chains by are challenges with delayed procurement, lack of various partners and national agencies mean transparency, and poor quality of available health that there is no unified end-to-end supply products. In addition, the logistics system for chain management structure. Most partners distribution of products is inadequate, with poor have parallel supply chains that operate alongside infrastructure and limited human resources. As a the national supply chain, and there is little to no result, most procurement for the country’s National sharing of information about activities including Malaria Control Program (NMCP) and National AIDS procurement. There is no integrated inventory Control Program (NACP) is conducted by partners of all health commodities at the national level. such as UNFPA, UNICEF, and TGF, while IMVF There is a need for such a national inventory is managing the procurement and distribution that is shared between international financial of drugs and medical supplies for Maternal and technical stakeholders, such as UNICEF, TGF, and Child Health (MCH). These programs rarely World Bank, WHO and IMVF (82). The lack of an experience stockouts. CECOME is responsible for integrated inventory leads to interventions at the procurement of essential medicines for other various points of the supply chain, often without diseases, for which there have been frequent communication with other partners, which leads stockouts in the past several years (80). to duplication and absorption capacity issues. This has resulted in unreliable and delayed data on The absence of national pharmaceutical and product availability, stock levels, and consumption, supply chain policies and guidance documents making it difficult to plan and manage the supply hampers sound supply chain management chain (83). A 2017 study by WHO found that the during health emergencies. There is no national procurement process for medicines and medical pharmaceutical policy governing the importation supplies in Guinea-Bissau was characterized by and registration of pharmaceutical products. A inefficiencies, delays, and corruption (84). national Regulatory Agency for Medicines and Health Products (ARFAME) has been established Poor financial management and accountability in name but is not yet fully operational, and it is compound the heavy dependence on external unclear how this agency would function in relation donor funding, which can be unpredictable to the existing national General Inspectorate for and insufficient. Donors usually focus on Health Activities (Inspector General das Actividades short-to-medium-term results of immediate em Saúde) (IGAS). A national committee to manage access to lifesaving medicines and certain the procurement of health products has not been disease-specific medicines, instead of long-term functional due to inadequate financial support capacity building of CECOME and national staff. and government leadership (51). A few policy and International organizations including WHO, the guidance documents developed in recent years World Bank, UNICEF, and TGF have provided 67 Assessment of Guinea-Bissau’s Pandemic Prevention, Preparedness, and Response Capacity significant support to Guinea-Bissau’s health 2. Adopt a single, unified governance sector (85). As of 2021, TGF had invested over structure for supply chain. US$100 million to support a range of health programs, including medicines and diagnostics This structure would provide coordination and procurement and supply chain management oversight for supply chain activities including (86). However, the COVID-19 response was quantification and supply planning, warehousing marked by poor coordination and role clarity and distribution, logistics information management, between HC COVID-19 and MOH, resulting in waste management, and management of human delayed disbursement of available funds for resources. Among the key steps would be the activity implementation, which in turn negatively development of profiles and responsibilities for members of this structure as well as a protocol for impacted the supply chain (87). selecting its members. The structure would ensure that appropriate resources are allocated to all Lack of sufficiently trained personnel leads supply chain functional areas to facilitate smooth to challenges with inventory management, operations across the system. TGF is among the distribution, and quality control (88). Most of the key stakeholders that have invested significantly in supply chain tasks are carried out by partners who building up the country’s health supply chain and hire technical staff and make them available to the are committed to helping the government bring government for TA. High turnover whenever there about needed improvements. is change of government leadership usually means that experienced technical staff get replaced by 3. Develop and validate national supply less capable staff or the positions remain unfilled chain strategic plans and policies. due to inadequate funding (89). Policies for drug importation, a national health supply chain strategic plan and national supply chain b. Key recommendations policies, should be developed, in addition to a plan Based on the above findings, the following are to operationalize the pharmaceutical regulatory key recommendations to improve the health authority. The effort would include finalizing, supply chain: validating, and officially adopting draft plans and policies that currently exist, and updating older 1. Develop a national procurement versions to meet global standards. To accomplish and deployment plan for health this, it is critical to have high-level political support emergencies, which should include – technically validated strategic plans and policies the receipt, storage, distribution of should be presented to the minister of health for necessary medicines and other official adoption with the support of key partners, health supplies. such as the World Bank and TGF. 4. Enhance the skills, knowledge, and This is an important first step to ensure a performance of health workers, reduction of supply procurement times and supply chain managers, and other improve the effective acquisition and distribution stakeholders involved in the of high-quality drugs and medical consumables supply chain. to better serve population needs. Additionally, it would allow for necessary medicines to be made Capacity building and training programs for supply available more quickly while reducing costs, chain managers and HCWs involved in supply particularly for their transport. chain management are essential to improve the health supply chain capacity in Guinea-Bissau. 68 Carrying out a mapping of all health personnel it can enhance the capacity and effectiveness of involved in supply chain followed by a workforce regulatory processes, including mechanisms for needs assessment based on profiles that oversight to ensure accountability, transparency, respond to current standards would allow for and coordination among stakeholders. the identification of knowledge deficits and shortcomings in training programs. Deficits in 6. Invest in a comprehensive logistics knowledge and skills can be addressed through management information system. targeted trainings for capacity building, mentoring A Logistics Management Information System (LMIS) programs and skills-transfer initiatives such as integrates stock status data from different sources the coaching of national supply chain workers and enables real-time monitoring and analysis to by external stakeholder experts. In addition to inform decision-making and optimize resource strengthening training and establishing mentoring allocation. Carrying out a broad assessment of the and coaching programs, enhancing performance current LMIS, review of information systems that management systems among supply chain workers would be the best fit for GB’s situation followed by is another key part of building capacity. a business case of the value-add of an improved 5. Introduce standardized inventory visibility of supply data to all stakeholders can help management, distribution, and to minimize duplication in procurement processes monitoring systems to strengthen and alert to potential stockouts early enough so procurement processes. that action can be taken to prevent the stockouts. Developing standard operating procedures (SOPs) A summary of the above recommendations with for demand and supply planning, warehouse suggested timelines, responsible entities, and management, distribution and quality assurance JEE indicators anticipated to improve with would help to minimize stockouts and wastage adoption of the recommendations are provided and improve supplier management. In parallel, below Table 15. 69 Assessment of Guinea-Bissau’s Pandemic Preparedness and Response Capacity Table 15. Summary recommendations for Health Supply Chain Recommendations Timeline Responsible entity JEE indicators improvement 1. Develop a national procurement and deployment plan for health R1.5 Emergency logistic and MOH and the national supply chain management emergencies, which should Short-term procurement agency (once include the receipt, storage, R3.3 Continuity of essential established) distribution of necessary health devices medicines and other health supplies. 2. Adopt a single, unified R1.5 Emergency logistic and governance structure for Short-term MOH supply chain management supply chain. General Directorate of Prevention and Health R1.5 Emergency logistic and 3. Develop and validate Promotion, Department of supply chain management national supply chain Short-term Community Health Services strategic plans and policies. and Promotion of Traditional R3.3 Continuity of essential Medicine (under MOH) and health devices LNSP 4. Enhance the skills, knowledge, and R1.5 Emergency logistic and performance of health MOH and Ministry of supply chain management Medium to workers, supply chain Economy, Planning and long-term R3.3 Continuity of essential managers, and other Regional Integration stakeholders involved in the health devices supply chain. 5. Introduce standardized R1.5 Emergency logistic and inventory management, supply chain management Medium to MOH and the national distribution and monitoring long-term procurement agency R3.3 Continuity of essential systems to strengthen procurement processes.. health devices R1.5 Emergency logistic and 6. Invest in a comprehensive supply chain management Medium to MOH and the national logistics management long-term procurement agency R3.3 Continuity of essential information system. health devices 70 Part IV. Discussion and Next Steps Assessment of Guinea-Bissau’s Pandemic Prevention, Preparedness, and Response Capacity 12. Discussion surveillance, human resources, health supply chain, community health, One Health, and risk Health emergencies throw the health and social communication. The plans must be evidence-based, sectors into disarray, which, combined with multi- and cross-sectoral, and involve all relevant fear among the public, present challenges to stakeholders (both technical and non-technical). effectively manage crises and implement effective The costing, implementation, and monitoring and interventions. Considering these multi-faceted evaluation activities must be planned and executed disruptions, the importance of preparedness, in the context of the different characteristics of robust health systems, and multi-sectoral the 11 health regions in Guinea-Bissau. It is also collaboration cannot be overstated. COVID-19 has important to take into account the country’s highlighted many acute and chronic vulnerabilities climate vulnerability when prioritizing PPR- in health systems globally. As the world moves enhancing activities given the intersection between on from the emergency phase of the pandemic, climate change and increasing risk for zoonoses. assessing lessons learned and understanding gaps PPR plans should consider both current and future in health systems are necessary to ensure that we climate impacts and how the country can adapt to get closer to our goal of achieving health for all minimize harm. and are better equipped to prevent, prepare for, respond to, and recover from health emergencies. The gaps in PPR capacity in Guinea-Bissau are evident. The country is in need of a national PPR Given Guinea Bissau’s fragile health system, plan, a national disease surveillance strategy, the country has limited capacity to effectively a platform for information sharing, and other prevent and detect outbreaks. This has significant capacity building plans previously discussed as implications for the country’s capacity to mount an recommendations in this report. Many of the effective response to shocks and prevent future key gaps and findings in this report came up health emergencies. One of the biggest barriers repeatedly among KIs from different sectors and to building a resilient health system in Guinea- organizations. The findings also align with those Bissau is weak governance and leadership coupled in other evaluations and assessments such as JEE, with a poor coordination. To build a strong public SPAR, GHSI, and Ready Score. If implemented, the health system that is resilient to health shocks, the recommendations put forth in this report can help government must take the lead in strategizing and to improve PPR readiness and evaluation scores, planning Guinea-Bissau’s course of action for the thus better preparing Guinea-Bissau to respond to next 10-15 years to strengthen PPR capacity. There and recover from health emergencies. should be continuous monitoring and evaluation of the programs for efficiency and adaptability. The country is in need of financial resources to build PPR capacity and is largely dependent “The biggest barrier in building a resilient on external funders for this. At the same time, health system here [in Guinea-Bissau] is lack of in-country capacity for absorption of funds governance and leadership. Leadership [of the is poor and should be a factor considered in country] needs to plan for the next 5-10 years... financial resource management for PPR activities. there needs to be an agreement for the future of For example, during the pandemic, the country the country.” - Government official received donor funds to support the COVID-19 emergency response, however, the utilization of The country needs to develop several government- those funds was not systematic. The funds were driven plans in key areas that enable robust PPR, used in an unstructured and nontransparent such as capacity building for laboratory and manner, leading to concerns of misuse. Thus, a key recommendation for Guinea-Bissau is to 72 prepare a costed multi-sectoral PPR plan. Plans must include multi-year cost estimates to achieve their objectives. Investments made with a costed plan and in collaboration with stakeholders across sectors will increase the absorptive capacity to boost PPR functions. Technical partners such as WHO and World Bank can support activity costing. The findings of this report emphasize the importance of a coordinated, multi-sectoral, and government- driven approach to build comprehensive PPR and One Health capacity, while considering the country’s fragile context. The recommendations are a starting As an example, TGF has significant investments in point to build capacity over time to achieve a more the country that aim to strengthen capacity for resilient health system in Guinea-Bissau. the prevention and management of HIV/AIDS, tuberculosis and malaria. These investments exist With the risk posed by constantly emerging in supply chain, laboratory testing, and surveillance zoonoses, exacerbated by the progressively programs. The government can collaborate with narrowing intersection between climate change TGF to complement and build upon existing and the human-animal health interface, COVID-19 national resources, such as utilizing the strong may well be a foreshadowing of future pandemics CHW base to expand disease detection, early to come. Investing in resilient health systems is warning, and surveillance functions, with capacity therefore critical to improve preparedness against building supported by TGF. Partners such as WHO the devastating spread of disease in epidemics and UNICEF are well-placed to support MOH to and pandemics. As stated earlier, to improve PPR strengthen preparedness and response planning capacity is to fundamentally make health systems for health emergencies as they already guide the stronger, and stronger health systems are more government on policies and legal frameworks resilient to shocks and better able to respond to for other health and social sector interventions. and weather health crises. Regional organizations such as WAHO can continue collaborating with INASA to strengthen capacity for preparedness among the workforce by providing 13. Next Steps One Health and FETP training. There is forward momentum on PPR-related capacity building in Guinea-Bissau based on Guinea-Bissau’s fragility, attributable to long-standing programs being designed and activities planned political and socio-economic instability, has been by development partners for the coming years. an impediment to developing a resilient health In Guinea-Bissau’s case, technical, financial and system. Action at the highest level of government delivery partners are instrumental to developing is needed to ensure that appropriate investments PPR functions in the country. However, synergies are prioritized to address the most urgent gaps among stakeholders and close collaboration with in the country’s pandemic preparedness. With the government are requisite to invest strategically, collaborative action between the government maximize resources, and streamline efforts. and key actors, there is potential for significant enhancements in PPR capacity to be achieved in There is a window of opportunity for the Guinea-Bissau such that it emerges with a health government to align with partner organizations to system more resilient and better prepared to work toward addressing the most urgent PPR needs. respond to multi-layered health crises. 73 Assessment of Guinea-Bissau’s Pandemic Prevention, Preparedness, and Response Capacity Annex 1. Joint External Evaluation of IHR core capacities of Guinea-Bissau (2019) Capacities Indicators Score National legislation, P.1.1 Legislation, laws, regulations, etc. sufficient for IHR implementation 2 policy and financing P.1.2 Legislation, policies, etc. enable compliance with IHR 1 P.1.3 Availability of funds for timely response to health emergencies 1 IHR coordination, communication P.2.1 Functional mechanism for the coordination and integration of sectors in 2 & advocacy the implementation of IHR Antimicrobial P.3.1 Effective multisectoral coordination on AMR 1 resistance P.3.2 Surveillance of infections caused by AMR pathogens 1 P.3.3 HCAI prevention and control programs 1 P.3.4 Antimicrobial stewardship activities 1 Zoonotic disease P.4.1 Coordinated surveillance systems for priority zoonotic pathogens 2 P.4.2 Response to zoonotic diseases 1 Food safety P.5.1 Surveillance of foodborne diseases 1 P.5.2 Functional mechanisms in place for the management of food safety emer- 1 gencies Biosafety and P.6.1 Government biosafety and biosecurity system 1 biosecurity P.6.2 Biosafety and biosecurity training and practices 1 Immunization P.7.1 Vaccine coverage (measles) is part of national program 3 P.7.2 National vaccine access and delivery 4 National D.1.1 Laboratory testing for detection of priority diseases 1 laboratory D.1.2 Specimen referral and transport system 1 system D.1.3 Effective national diagnostic network 1 D.1.4 Laboratory quality system 1 Real-time D.2.1 Surveillance systems 1 surveillance D.2.2 Use of electronic tools 2 Reporting D.2.3 Analysis of surveillance data 2 D.3.1 System for efficient reporting to FAO, OIE and WHO 2 D.3.2 Reporting network and protocols in country 2 Human D.4.1 An up-to-date multi-sectoral workforce strategy 1 resource D.4.2 Human resources available for IHR implementation 1 capacity D.4.3. In-service trainings are available 1 D.4.4 FETP or other applied epidemiology training program 4 Emergency R.1.1 National Public Health Emergency Preparedness and Response Plan 1 preparedness R.1.2 Priority public health risks and resources utilized 1 74 Part IV. Discussion and Next Steps Capacities Indicators Score Emergency R.2.1 Emergency response coordination 2 response R.2.2 Emergency Operations Center capacities, procedures, and plans 2 operations R.2.3 Emergency exercise management program 3 Linking public health and security R.3.1 Public Health and Security Authorities linked during a biological event 1 authorities Medical R.4.1 System for sending medical countermeasures during an emergency 1 countermeasures R.4.2 System for mobilizing health personnel during an emergency 1 and personnel deployment R.4.3 Case management procedures for IHR-related hazards 2 Risk communication R.5.1 Risk communication systems 3 R.5.2 Internal and partner coordination 3 R.5.3 Public communication for emergencies 2 R.5.4 Engagement with affected communities 2 R.5.5 Dynamic listening and rumor management 2 Points of entry PoE.1 Routine capacities established at PoEs 1 PoE.2 Effective public health response at PoEs 1 Chemical events CE.1 Mechanisms for detecting and responding to chemical events 1 CE.2 Enabling environment for management of chemical events 1 Radiation RE.1 Mechanisms for detecting and responding to radiation emergencies 1 emergencies RE.2 Enabling environment for management of radiation emergencies 1 75 Assessment of Guinea-Bissau’s Pandemic Prevention, Preparedness, and Response Capacity Annex 2. World Bank technical workshop on PPR, Ceiba Hotel, Bissau, Guinea-Bissau, April 2023 CHW focus group discussion, SAB region, Guinea-Bissau, December 2022 76 Part IV. Discussion and Next Steps References 77 Assessment of Guinea-Bissau’s Pandemic Prevention, Preparedness, and Response Capacity 1. Ferreira FHG, Sterck O, Mahler D, org/en/publication/documents-reports/ Decerf B. Death and Destitution. documentdetail/294721561652896187/ openknowledgeworldbankorg [Internet]. guinea-bissau-service-delivery-indicators- 2021 May 1 [cited 2023 Jul 10]; Available report-health from: https://openknowledge.worldbank.org/ 7. Bank W. World Development Indicators- entities/publication/8f00a832-ddab-5aeb- DataBank [Internet]. The World Bank. 2023. b2af-e28a700dd0c4 Available from: https://databank.worldbank. 2. Abay KA, Nishant Yonzan, Kurdi S, Kibrom org/source/world-development-indicators Tafere. Revisiting Poverty Trends and the 8. Strategic Plan of the Center for Health Role of Social Protection Systems in Africa Emergencies Operations of Guinea-Bissau. during the COVID-19 Pandemic [Internet]. Ministry of Health, Guinea-Bissau; 2021 World Bank policy research working paper. 2022 [cited 2023 Aug 7]. Available 9. Bank W. The World Bank in Guinea-Bissau from: https://elibrary.worldbank.org/doi/ [Internet]. World Bank. 2023. Available from: epdf/10.1596/1813-9450-10172 https://www.worldbank.org/en/country/ guineabissau/overview#1 3. Anyanwu JC, Salami AO. The impact of COVID-19 on African economies: An 10. Bank W. Guinea-Bissau COVID-19 Vaccine introduction. African Development Review Project, PAD PAD4521. 2021. [Internet]. 2021 May 5 [cited 2021 Jun 2];33. Available from: https://pubmed.ncbi.nlm.nih. 11. UNICEF. Multiple Indicator Cluster Surveys. gov/34149237/ 2018-2019. 4. Huber C, Finelli L, Stevens W. The Economic 12. UNDP. Human Development Index Ranking. 2021. and Social Burden of the 2014 Ebola 13. Ernst KC, Morin CW, Brown HE. Extreme Outbreak in West Africa. The Journal weather events and vector-borne diseases. of Infectious Diseases [Internet]. 2018 In: Watson RR, Tabor, JA, Ehiri JE, Preedy [cited 2019 Jun 7];218(5):S698–704. VR, editors. Hand book of public health in Available from: https://academic.oup. natural disasters Nutrition, food, remediation com/jid/article-abstract/218/suppl_5/ and preparation [Internet]. Wageningen, S698/5129071?redirectedFrom=fulltext Netherlands: Wageningen Academic 5. Bank W. Change Cannot Wait: Building Publishers; 2015. p. 489–512. Available from: Resilient Health Systems in the Shadow of https://www.wageningenacademic.com/doi/ COVID-19. openknowledgeworldbankorg abs/10.3920/978-90-8686-806-3_28 [Internet]. 2022 [cited 2023 Sep 10]; 14. Bank W. World Bank Climate Available from: https://openknowledge. Change Knowledge Portal [Internet]. worldbank.org/entities/publication/ climateknowledgeportal.worldbank.org. ba3e856d-245f-55bf-a6fa-6361cb580c76 [cited 2023 Jun 23]. Available from: https:// 6. Bank W. Guinea-Bissau : Service Delivery - climateknowledgeportal.worldbank.org/ Indicators Report - Health [Internet]. World country/guinea-bissau/vulnerability Bank. 2019 [cited 2023 Oct 11]. Available from: https://documents.worldbank. 78 References 15. Azman AS, Luquero FJ, Rodrigues A, Palma 23. Bank W. Out-of-pocket expenditure (% of PP, Grais RF, Banga CN, et al. Urban current health expenditure) -Guinea-Bissau: Cholera Transmission Hotspots and Their World Bank; 2023 [Available from: https:// Implications for Reactive Vaccination: data.worldbank.org/indicator/SH.XPD.OOPC. Evidence from Bissau City, Guinea Bissau. CH.ZS?locations=GW. Vinetz JM, editor. PLoS Neglected Tropical 24. Bank W. Guinea-Bissau: Service Delivery Diseases. 2012 Nov 8;6(11):e1901. Indicators Report Health. 2019. 16. Bausch DG, Schwarz L. Outbreak of Ebola 25. Evans DrT, Baral P, Clark K, Magurno E, Rayes Virus Disease in Guinea: Where Ecology D, Mullen L. Global Monitoring of Upstream Meets Economy. PLoS Neglected Tropical Determinants of Health Emergencies Diseases [Internet]. 2014 Jul 31;8(7):e3056. [Internet]. Global Preparedness Monitoring Available from: https://www.ncbi.nlm.nih.gov/ Board. WHO; 2023 May [cited 2023 Aug]. pmc/articles/PMC4117598/ Available from: https://www.gpmb.org/ 17. IHME. Guinea-Bissau: Institute for Health annual-reports/overview/item/global- Metrics and Evaluation. 2019 [Available from: monitoring-of-upstream-determinants-of- https://www.healthdata.org/guinea-bissau. health-emergencies 18. Onambele L, Ortega-Leon W, Guillen- 26. Berthe F, Bali SR, Batmanian GJ. Investing Aguinaga S, Forjaz MJ, Yoseph A, Guillen- in One Health to Reduce Risks of Aguinaga L, et al. Maternal Mortality in Africa: Emerging Infectious Diseases [Internet]. Regional Trends (2000–2017). International Washington, D.C.: World Bank Group; Journal of Environmental Research and 2022 [cited 2023 Mar]. Available from: Public Health [Internet]. 2022 Oct 12 [cited http://documents.worldbank.org/ 2022 Oct 16];19(20):13146. Available from: curated/en/099530010212241754/ https://pubmed.ncbi.nlm.nih.gov/36293727/ P17840200ca7ff098091b7014001a08952e 19. GBD 2019 Healthcare Access and Quality 27. Joint External Evaluation (JEE). WHO-IHR; 2019. Collaborators. Assessing performance of the 28. Prevent Epidemics [Internet]. Resolve to Healthcare Access and Quality Index, overall Save Lives; 2023. Available from: https:// and by select age groups, for 204 countries preventepidemics.org/?s=guinea-bissau. and territories, 1990–2019: a systematic analysis from the Global Burden of Disease 29. Guinea Bissau [Internet]. GHS Index. 2021 Study 2019. The Lancet Global Health. 2022 [cited 2023 May]. Available from: https://www. Oct 6;10(12):E1715–43. ghsindex.org/country/guinea-bissau/ 20. Key Informant 50. PPR Interview. 2022. 30. IHR-SPAR. IHR Score Details. WHO; 2022. 21. PHCPI. Guinea Bissau Primary Health Care 31. Terms of Reference for Guinea-Bissau Vital Signs Profile. 2021. Operational Center for Health Emergencies. Ministry of Health, Guinea-Bissau; 2020. 22. Bank W. Current health expenditure (% of GDP)-Guinea-Bissau. 2023. 32. Key Informant 38. PPR Interview. 2022. 79 Assessment of Guinea-Bissau’s Pandemic Prevention, Preparedness, and Response Capacity 33. Sanchez-Padilla E, Carrillo-Santisteve P, 42. Republic of Guinea-Bissau Presidential Luquero SFJ. Evaluation of the cholera Decree. Office of the President, Guinea- surveillance system in Guinea-Bissau. Bissau. 2020. Epicentre [Internet]. Epicentre; 2009 Dec. 43. UNICEF. Guinea-Bissau Country Office Annual Available from: https://plateformecholera. Report 2022. 2022. info/sites/default/files/2022-11/8-GNB_2009_ SLL_UNICEF_ECSS_EN.pdf 44. UNDSRR. Sendai Framework for Disaster Risk Reduction 2015-2030 2015 [Available 34. Frontières MS. Over 10,000 affected by from: https://www.undrr.org/publication/ cholera in Guinea Bissau2008 [cited 2023 sendai-framework-disaster-risk- June 2]. Available from: https://www.msf.org/ reduction-2015-2030. over-10000-affected-cholera-guinea-bissau. 45. IANPHI. Case study on National Public Health 35. Cholera resurgent in Guinea-Bissau - Institute: Guinea-Bissau Experience: IANPHI; Guinea-Bissau | ReliefWeb [Internet]. n.d. [cited 2023 June 3]. Available from: reliefweb.int. 2013 [cited 2023 Aug 11]. https://ianphi.org/tools-resources/index.html. Available from: https://reliefweb.int/report/ guinea-bissau/cholera-resurgent-guinea- 46. Key Informant 17. Supply Chain Interview. 2022. bissau#:~:text=DAKAR%2C%2016%20 August%202013%20(IRIN 47. Republic of Guinea-Bissau Presidential Decree. Office of the President, Guinea- 36. Key Informant 39. PPR Interview. 2022. Bissau. 2022. 37. Global-Guinea-Bissau, WHO. 2023 [Available 48. Facilitating Effective Multi-stakeholder from: https://covid19.who.int/region/afro/ Processes: Food and Agriculture Organization country/gw. of the United Nations; n.d. [Available from: https://www.fao.org/capacity-development/ 38. Six in seven COVID-19 infections go resources/practical-tools/multi-stakeholder- undetected in Africa [Internet]. WHO | processes/en/. Regional Office for Africa. 2021 [cited 2021 Nov 18]. Available from: https://www.afro. 49. National Response Framework [Internet]. who.int/news/six-seven-covid-19-infections- FEMA. US Department of Homeland Security; go-undetected-africa 2019 Oct. Available from: https://www. fema.gov/sites/default/files/2020-04/NRF_ 39. Guinea-Bissau: International Organization for FINALApproved_2011028.pdf Migration; IOM. 2020 [Available from: https:// www.iom.int/countries/guinea-bissau. 50. Frieden TR, Lee CT, Bochner AF, Buissonnière M, McClelland A. 7-1-7: an organising 40. Report of the Intra-Action Review on principle, target, and accountability metric to COVID-19. Ministry of Health, Guinea-Bissau; make the world safer from pandemics. The 2023. Lancet. 2021 Aug;398(10300):638–40. 41. Coronavirus (COVID-19) Vaccinations; 51. Belot G, Caya F, Errecaborde KM, Traore T, Our World in Data. 2022 [Available Lafia B, Skrypnyk A, et al. IHR-PVS National from: https://ourworldindata.org/covid- Bridging Workshops, a tool to operationalize vaccinations?country=GNB. the collaboration between human and animal health while advancing sector-specific goals in countries. PLOS ONE. 2021;16(6):e0245312. 80 References 52. Sands P. Investing in Health: World Bank. 63. National Plan for the Development of Human 2017. [cited 2023]. Available from: https:// Resources for Health from Guinea-Bissau, blogs.worldbank.org/health/first-line-defense- 2023-2032. Ministry of Health, Guinea- against-outbreaks-finance-pandemic- Bissau. 2023. preparedness-national-level. 64. Guinea-Bissau Human Resources for 53. Joint external evaluation of IHR core Health Dataset. Ministry of Health, Guinea- capacities of the Republic of Guinea-Bissau. Bissau.2022. WHO. Mission Report. 2019. Report No.: WHO/WHE/CPI/2019.17. 65. Department of Immunizations and Epidemiological Surveillance (SIVE). Ministry 54. Strengthening the Role of Regional of Health, Guinea-Bissau. 2022. Public Health Institutions to Improve Cross-Border Disease Surveillance and 66. Guinea-Bissau Health Labor Market Response in Eastern and Southern Africa. Analysis [Internet]. World Bank; 2019 Jun PRESS RELEASE NO: 2021/103/AFR [cited 2023 Jul]. Available from: https:// [Internet]. 2021 Mar 18 [cited 2022 Mar]; documents1.worldbank.org/curated/ Available from: https://www.worldbank. en/838831561651765948/text/Guinea- org/en/news/press-release/2021/03/18/ Bissau-Health-Labor-Market-Analysis.txt strengthening-the-role-of-regional-public- health-institutions-to-improve-cross-border- 67. Key Informant 37. PPR Interview. 2022. disease-surveillance-and-response 68. Factors that contributed to undetected 55. Key Informant 30. PPR Interview. 2022. spread of the Ebola virus and impeded rapid containment WHO. 2015 [cited 2023 56. Key Informant 45. PPR Interview. 2022. Jun 3]. Available from: https://www.who.int/ 57. Key Informant 60. PPR Interview. 2023. news-room/spotlight/one-year-into-the- ebola-epidemic/factors-that-contributed-to- 58. What We Do [Internet]. African Society for undetected-spread-of-the-ebola-virus-and- Laboratory Medicine. [cited 2023 Jun 3]. impeded-rapid-containment. Available from: https://aslm.org/what-we-do/ 69. CHW. Focus Group Discussion with 59. Key Informant 37. PPR Interview. 2022. Community Health Workers on lessons 60. N. Dwivedi RB. How public-private learned during COVID-19. 2022. partnerships could be the booster dose for 70. Key Informant 18. PPR Interview. 2022. India’s healthcare ecosystem. 2022 [cited 2023 Jun 3]. Available from: https://www. 71. Key Informant 19. Supply Chain Interview. 2022. weforum.org/agenda/2022/09/public-private- partnerships-india-healthcare-ecosystem/. 72. Key Informant 10. Supply Chain Interview. 2022. 61. Health System Assessment in Guinea-Bissau 73. MOH G-B. National Strategic Plan for Draft. World Bank. Report. 2023. Community Health (PENSC) Medicine DoCHSaPoT; 2021. 62. The world health report:2006 : working together for health [Internet]. www.who. int. 2006 [cited 2023 May]. Available from: https://www.who.int/publications/i/ item/9241563176 81 Assessment of Guinea-Bissau’s Pandemic Prevention, Preparedness, and Response Capacity 74. Nair A, and Mayesha A. Strengthening Supply 82. UNICEF Guinea-Bissau Country Office Annual Chain Resilience to Safeguard Health in Low- Report 2019 [Internet]. Available from: and Middle-Income Countries 2023 [Available https://www.unicef.org/reports/country- from: https://fpanalytics.foreignpolicy. regional-divisional-annual-reports-2019/ com/2023/04/14/strengthening-supply-chain- guinea-bissau resilience-to-safeguard-health-in-low-and- 83. Key Informant 19. Supply Chain Interview. middle-income-countries/. 2022. 75. Joint Appraisal Guinea Bissau 2019 [Internet]. 84. UNDP. COVID-19 Socio Economic Impact Gavi- The Vaccine Alliance; 2019 Aug [cited Analysis for Guinea-Bissau. n.d. 2023 Jun]. Available from: https://www.gavi. org/sites/default/files/document/2020/ 85. Qaderi S, Ahmadi A, Lowe M, Ochuba C, Guinea%20Bissau%20Joint%20Appraisal%20 Lucero-Prisno DE. The daunting task of 2019%20EN.pdf fighting against COVID-19 in Guinea-Bissau. Public Health in Practice (Oxf) [Internet]. 2021 76. Szczepański M. Resilience of Global Mar [cited 2021 Mar 11];2:100097. Available Supply Chains: Challenges and Solutions. from: https://www.ncbi.nlm.nih.gov/pmc/ European Parliamentary Research Service articles/PMC8417461/ [Internet]. 2021 [cited 2023 Jun 5]. Available from: https://www.europarl.europa.eu/ 86. Regional Impact Report – Lusophone RegData/etudes/BRIE/2021/698815/EPRS_ Countries. The Global Fund. 2022. BRI(2021)698815_EN.pdf. 87. Key Informant 22. Supply Chain Interview. 2022. 77. Donato S, Susann Roth, Jane Parry. Strong Supply Chains Transform Public Health. ADB 88. Guerreiro CS, Zulmira Hartz, Clotilde Briefs [Internet]. 2016 [cited 2023 Jun 7]. Neves, Paulo Ferrinho. Training of Human Available from: https://www.adb.org/sites/ Resources for Health in the Republic of default/files/publication/214036/strong- Guinea-Bissau: Evolution of Structures and supply-chains.pdf. Processes in a Fragile State. Acta Med Port. 2018;31(12):742-53. 78. Handfield R, Finkenstadt DJ, Schneller ES, Godfrey AB, Guinto P. A Commons for a 89. Key Informant 15. Supply Chain Interview 2022. Supply Chain in the Post-COVID-19 Era: The Case for a Reformed Strategic National Stockpile. The Milbank Quarterly [Internet]. 2020 Nov 2;98(4):1058–90. Available from: https://pubmed.ncbi.nlm.nih.gov/33135814/ 79. Key Informant 16. Supply Chain Interview. 2022. 80. Key Informant 12. Supply Chain Interview. 2022. 81. Key Informant 14. Supply Chain Interview. 2022. 82 Photo Credits Page 35: Page 66: Front Cover: World Bank / Vincent Tremeau Dominic Chavez / World Bank Dominic Chavez / World Bank Page 36: Page 69: Page 04: Curt Carnemark / World Bank Dominic Chavez / World Bank Henitsoa Rafalia / World Bank Page 44: Page 71: Page 15: Shweta Sinha Vincent Tremeau / World Bank Dominic Chavez / World Bank Page 45: Page 73: Page 17: Dominic Chavez / World Bank Trevor Samson / World Bank Henitsoa Rafalia / World Bank Page 46: Page 76: Page 20: Shweta Sinha Shweta Sinha / Bomy Yun Vincent Tremeau / World Bank Page 47: Page 77: Page 21: Shweta Sinha Dominic Chavez / World Bank Vincent Tremeau / World Bank Page 63: On this page: Page 31: Shweta Sinha Dominic Chavez / World Bank Dominic Chavez / World Bank Page 64: Back Cover: Vincent Tremeau / World Bank Dominic Chavez / World Bank