How Has Guinea Learnt from the Response to Outbreaks? A Learning Health System Analysis

"[M]any health systems in low-and middle-income countries are not always capable of effectively generating and using the knowledge they need for good performance."



Learning is a key attribute of a resilient health system and, therefore, is central to health system strengthening. The main objective of this study was to analyse how Guinea's health system has learned from the response to successive and parallel infectious disease outbreaks, including Ebola Virus Disease (EVD), meningitis, measles, yellow fever, COVID-19, circulating vaccine-derived poliovirus type 2 (cVDPV2), Lassa fever, and Marburg virus disease between 2014 and 2021.



The researchers used a retrospective longitudinal single embedded case study design, employing a mixed-method systematic review carried out in March 2022 and an online survey conducted in April 2022. Seventy reports were included in the evidence synthesis.



Examples of some of the main lessons learned were from 2014 to 2016 EVD include:

• Engaging community early in the response
• Performing social mobilisation
• Strengthening community participation
• Ensuring multisectoral collaboration
• Involving social scientists/anthropologists early in the response
• Putting local professionals to the fore of the response, ensuring external agents are in the background
• Evading the deployment of armies, especially western armies on the ground, to avoid fear in communities and prevent mistrust and violent fatal attacks on healthcare workers and volunteers
• Preserving communities' values and addressing outbreak-related psychological effects
• Conducting crisis communication
• Building a multifaceted motivational approach that emphasises motivational messages that refer to patriotic values and moral responsibility when recruiting volunteers

Learning occurred through information (research and experts' opinions), action/practice, and double-loop (where the learning questions and influences fundamental frameworks, mental models, and assumptions around problems and their solutions, resulting in changes at the level of governing norms, policies, or objectives/goals). These lessons were progressively incorporated in the response to future outbreaks through deliberation, single-loop (adapting routines and practices within the system without checking assumptions or underlying root causes), double-loop, and triple-loop learning (questioning the very basis (learning frameworks and assumptions) through which single-loop and double-loop learning occur and influencing them to change).



Over the study period, the first outbreaks that community respondents were involved in fighting against were the EVD outbreak (2014-2016) and polio (cVDPV2: October 2021). They were tasked with awareness-raising on outbreak preventive measures, kit distribution, social mobilisation, and management of community reluctance. Respondents reported having learned lessons from the health system outbreak control strategies such as the involvement of all actors (including communities) in the response and the need to set up committees in the villages to task with alerts. They learned those lessons through deliberation (meetings) and action/practice (written recommendations or shared guidelines). They applied what they learnt across daily use, disease surveillance, awareness-raising, meetings with health professionals, community relays, and village committees.



Table 3 in the paper summarises the respondents' reported enablers and barriers to learning within Guinea's health system from all levels connected with outbreak response. One enabler was establishing decentralised coordination teams/local governing bodies; one set of barriers concerned cultural and political considerations. Common recommendations (see Table 4) included establishing a knowledge management unit within the Ministry of Health with representatives at regional and district levels, investing in human capacities, and improving the governance and management system.



In light of the findings and the resulting discussion, the researchers offer their own recommendations in Table 5. They particularly emphasise creating a sustainable collaboration frame between researchers and policy/decision-makers to motivate knowledge use and learning.



Thus, this study implies that the health system's achievements in controlling outbreaks such as COVID-19 could be attributable to fundamental learning aspects (at individual, team, and organisation levels, and through information, deliberation, and single-loop learning) that happened regularly at all the health system levels, as well as advanced learning aspects (double-loop and triple-loop learning and learning across action) that occurred sometimes and/or partially in the health system. Notably, "achieving knowledge translation into action requires an exchange of knowledge among key stakeholders, starting with cultivating appropriate relationships and establishing a shared understanding of what knowledge to action means and why it is crucial..."



One limitation of the study was the limited community voice in the learning discourse, as very few community actors participated in the survey. Per the researchers, future research should be conducted in face to face and be people centred - e.g., engaging service users to widely explore their perspective of

learning.



In conclusion, this study highlights the importance of learning. The health system performed well and achieved encouraging and better outbreak response outcomes over time with learning that occurred.