Can global health security frameworks measure One Health implementation in West Africa?A mixed-methods study

Abstract

Background

The 2014 outbreak of the Ebola virus disease highlighted the importance of overhauling and transforming healthcare systems in West Africa to improve the ability of individual countries to deal with infectious diseases. As part of this effort, in November 2016 the West African Health Organization (WAHO) began the process of institutionalizing the One Health (OH) approach to health security across the Economic Community of West African States (ECOWAS). The lack of clear metrics and evaluation frameworks to measure the progress of OH implementation in West Africa has been reported as a challenge. Therefore, this study sought to assess and explore whether the existing metrics of global health security frameworks can measure the successful implementation of OH activities, evaluate the progress made since 2016, and identify key areas for improvement in the region.

Method

The study employed predetermined keywords to select indicators from the International Health Regulations (IHR) Monitoring Frameworks, specifically the State Party Self-Assessment Annual Report (SPAR) and Joint External Evaluation (JEE), deemed relevant to the OH approach. In addition, the COVID-19 performance index scores (severity and recovery) for June 2022 were extracted from the Global COVID-19 Index (GCI). The GCI Recovery Index evaluated the major recovery parameters reported daily to indicate how a country performed on the path to recovery from the COVID-19 pandemic compared to other countries. National documents were also analyzed using categorical variables to assess the performance status of OH platforms across implementing countries. A quantitative analysis of these indicators was conducted and supplemented with qualitative data gathered through interviews with key stakeholders. Between March and April 2022, we conducted 18 key informant interviews with purposively selected representatives from regional governmental agencies and international multilateral agencies, including ECOWAS member states. Interviews were conducted online, transcribed, and analysed following the tenets of thematic analysis.

Results

Our quantitative analysis revealed no significant association between the implementation status of OH activities and any of the selected indicators from SPAR and JEE. The descriptive analysis of the JEE scores at the country level revealed that countries with existing OH platforms scored relatively higher on the selected JEE indicators than other countries in the pre-implementation stage. OH implementation status did not significantly affect COVID-19 recovery and severity indices. The qualitative findings with relevant stakeholders revealed noteworthy challenges related to insufficient human capacity, inadequate coordination, and a lack of government funding for the sustainability of OH initiatives. Nonetheless, countries in the ECOWAS region are making progress toward the integration of OH into their health security systems.

Conclusion

Standardized metrics were used to assess the implementation and efficacy of OH systems in the ECOWAS region. Current indicators for monitoring global health security frameworks lack specificity and fail to comprehensively capture essential OH components, particularly at the sub-national level. To ensure consistency and effectiveness across countries, OH implementation metrics that align with global frameworks such as IHR should be developed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-024-19617-0.

Introduction

Disease transmission from animals to humans in our environment, known as zoonosis, is undeniably evident in many diseases such as Severe Acute Respiratory Syndrome (SARS), Middle East Respiratory Syndrome (MERS), Ebola Virus Disease (EVD), and influenza [1]. The outbreaks resulting from animal-to-human infections are carried out by various domestic and wild animals, accounting for millions of deaths each year and an estimated one billion cases globally [2]. To improve global health security, concerted efforts are needed to address approximately 75% of emerging pathogens from zoonotic outbreaks that arise from the interface between humans, animals, and the environment [3]. The 2005 outbreak of the Highly Pathogenic Avian Influenza (HPAI) H5N1 prompted greater emphasis on multidisciplinary approaches to disease prevention, detection, and response, which has accelerated the One Health (OH) approach to address global health security [4]. Numerous collaborative efforts that encourage long-term partnerships between interconnected groups in various fields exist worldwide. More than one hundred OH networks have emerged worldwide in response to rapid global threats, with twenty-four initiatives being reported in Africa [3, 5].

In line with the increasing importance of zoonotic disease control, the response to specific outbreaks has shaped global health strategies. In March 2014, the World Health Organization (WHO) reported a confirmed case of EVD in Guinea, West Africa. The subsequent epidemic claimed over 11,000 lives, causing it to be declared a public health emergency of international concern (PHEIC) and a significant threat to global health security [6]. As a result of the crisis, West African healthcare systems have undergone significant redesign and transformation to enhance their ability to handle infectious diseases. Moreover, investment in health security capabilities in West Africa, particularly in controlling zoonotic diseases, has been stimulated. In November 2016, the West African Health Organization (WAHO) institutionalized the OH approach for health security across the Economic Community of West African States (ECOWAS) [7]. The regional strategy aimed to boost cross-sectoral collaboration across the region in disease detection, response, and information sharing to strengthen regional capacities against health security threats. In line with this, international partners developed a regional strategic roadmap, which all ECOWAS representatives endorsed in Nigeria in 2017 [7]. Many countries have realized the advantages of the OH approach and have initiated the implementation of the OH platform. However, there is no clear framework for evaluating the progress in OH implementation, particularly in terms of assessing health security benefits.

To address the need for effective frameworks, the International Health Regulations (IHR), via its Monitoring and Evaluation Framework, provide a system of indicators and metrics critical for health security. The IHR is a legally binding international agreement established by the WHO to ensure that all WHO member states establish core capacities for detecting, assessing, reporting, and responding to potential PHEIC. This framework, which was established in 1969, aims to prevent infectious diseases by disrupting health, travel, and trade. In response to the SARS outbreak in 2002–2003, the IHR was revised and updated in 2005, requiring all state parties to communicate with the WHO and maintain the necessary surveillance and response capabilities to detect, assess, notify, and respond to any potential international public health emergency [8]. IHR has become a crucial tool for preventing and responding to PHEIC. These regulations have contributed significantly to national and international capacity-building, coordination, and collaboration in global health security. Since 2010, IHR has had processes and tools in place for the self-assessment of country core capacities. As of mid-2024, the framework includes a mandatory component, namely, annual reporting on compliance by state parties, and three voluntary components: Joint External Evaluation, simulation exercises, and after-action reviews [9]. These monitoring and evaluation components are intended to facilitate country implementation of and compliance with, the IHR and cover all core capacity areas, with an explicit emphasis on multisectoral coordination. While IHR has served as a valuable resource for national and international global health security, [10] events such as the COVID-19 pandemic revealed that many countries lacked robust preparedness and response capabilities in the event of a large-scale zoonotic disease outbreak.

Despite the well-recognized importance of OH approaches to tackle emerging zoonoses and epidemic threats, under the auspices of frameworks like the IHR, obstacles remain with respect to effective implementation, including fragmented and disconnected governance across human health, animal health, and the environment and a lack of clarity on the definition, concept, and scope of the OH approach [11]. This study aimed to assess and explore West Africa’s progress in implementing the OH approach by analyzing selected global health security indicators, COVID-19 recovery metrics, and severity index scores alongside qualitative key informant interviews. By integrating quantitative and qualitative methods, this study sought to offer insights into West Africa’s implementation of the OH approach with respect to health security, highlighting areas for improvement to enhance preparedness for future global health crises.

Materials and methods

Study design

This study employed a mixed-methods approach, utilizing both quantitative and qualitative data collection and analysis, along with document review, in a concurrent design.

Study sites

This study included all fifteen member countries of ECOWAS, as illustrated in Fig. 1. However, Mauritania is technically no longer in ECOWAS but is generally included in definitions of the region. It is estimated that there are 411 million people living in West Africa.

Fig. 1.

Map of the ECOWAS region

Source: ECOWAS Member States [12]

Data collection tools and processes

Quantitative component

Global health security metrics indexing and scoring

Pre-determined keywords, as shown in Table 1, were used to select indicators from the second edition (2020) of the States Parties Self-Assessment Annual Report (SPAR) tool and the second edition (2018) of the Joint External Evaluation (JEE) tool that were relevant to OH. Primary indicators were identified as those that explicitly mentioned keywords associated with OH, the human, animal, environment interface, and/or zoonotic diseases in the indicator description or targets. Secondary indicators were defined as those that referred to concepts consistent with OH, such as multisectoral or cross-disciplinary collaboration or communication. Additionally, indicators related to veterinary and environmental health were categorized as secondary indicators. The selected indicators are detailed in Table 2 for JEE and Table 3 for SPAR.

Table 1.

Predetermined Keywords for OH Approach 

Types	Keywords
Primary Indicator Primary indicators point in the same direction as the OH approach: they are conclusion- or premise-indicators, depending on which role they play in the statement OH.	One Health
	Animal Health-Human Health and Environment Health Interface
	Zoonotic Disease / Zoonosis
Secondary Indicator Secondary indicators are not directly related to the OH approach, though they may be related to some aspects of the context in which they occur in the OH approach.	Multisectoral
	Cross-Disciplinary Collaboration
	Ecosystem
	Collaboration/coordination
	Veterinary

Table 2.

Selected JEE Indicators

Prevention
Technical Areas	IHR Coordination, Communication, and Advocacy	Zoonotic Diseases			Food Safety
Selected Indicators	P.2.1 A functional mechanism established for the coordination and integration of relevant sectors in the implementation of IHR	P.4.1 Surveillance systems in place for priority zoonotic diseases/pathogens	P.4.2 Veterinary or animal health workforce	P.4.3 Mechanisms for responding to infectious and potentially zoonotic diseases established and functional	P.5.1 Mechanisms for multisectoral collaboration are established to ensure rapid response to food safety emergencies and outbreaks of foodborne diseases
Definition	The effective implementation of the IHR (2005) requires multisectoral/multidisciplinary approaches through national partnerships for effective alert and response systems.	Adopted measured behaviors, policies, and/or practices that minimize the transmission of zoonotic diseases from animals into human populations.	Adopted measured behaviors, policies, and/or practices that minimize the transmission of zoonotic diseases from animals into human populations.	Adopted measured behaviors, policies, and/or practices that minimize the transmission of zoonotic diseases from animals into human populations.	States Parties should have surveillance and response capacity for food and water-borne disease risks or events. It requires effective communication and collaboration among the sectors responsible for food safety and safe water and sanitation.
Type of Indicator	Secondary Indicator	Primary Indicator	Secondary Indicator	Primary Indicator	Secondary Indicator

Table 3.

Selected SPAR Indicators Based on Predetermined Keywords 

Categories	C1. Legislation and Financing	C2. IHR Coordination and National IHR Focal Point Functions	C3. Zoonotic Events and the Human-Animal Interface	C4. Food Safety
Selected Indicators	C1.1 Legislation, laws, regulations, policy, administrative requirements, or other government instruments to implement the IHR	C.2.2 Multisectoral IHR coordination mechanisms	C.3.1. A collaborative effort on activities to address zoonoses	C4.1 Multisectoral collaboration mechanism for food safety events
Definition	Legislation could serve to institutionalize and strengthen the role of IHR within the State Party. It can also facilitate coordination among the different entities involved in their implementation. The IHR serves to institutionalize through legislative frameworks, essential public health functions to sustain the continuous preparedness process for responding to public health events.	Establishing and maintaining IHR capacities requires collaboration among all relevant sectors and ministries, agencies, or other government bodies responsible for all aspects of of implementing capacities required under the IHR at the national, intermediate, and local levels. Fundamental to this multisectoral approach is the recognition that risks to human health can emerge from various sources, such as other humans, domestic animals/livestock, wildlife, food, chemicals, and/or radiation.	This capacity includes the ability of the country to prepare for, prevent, identify, and conduct risk assessment for, and report health concerns at the human-animal interface that may not currently be considered “zoonoses”. For example, diseases circulating in animals that may not be known as zoonoses.	Food safety is multisectoral and the agencies/sectors responsible for detection, investigation, and response to a food safety emergency vary across Member States.
Type of Indicator	Secondary Indicator	Secondary Indicator	Primary Indicator	Secondary Indicator

JEE indicator scores

All countries in the study had previously completed the JEE between 2016 and 2019 [13]. The evaluation tool assigns scores to each indicator, ranging from 1 to 5, based on the following interpretations: 1 indicates No Capacity; 2 signifies Limited Capacity and developmental stage; 3 denotes Developed Capacity with sustainability issues; 4 represents Demonstrated Capacity that is sustainable for a few years and measurable through the inclusion of attributes or IHR (2005) core capacities in the national health sector plan; and 5 reflects Sustainable Capacity, where attributes are functional and long-term, and the country aids other countries in implementation [13].

SPAR indicator scores

The SPAR scores are self-assessed annually for each country. SPAR scores are classified according to the performance percentage on a “1 to 5” scale [5]. The classification is as follows: Level 1: No policies and strategies exist to support and facilitate the development and implementation of IHR capacities; Level 2: National policies and strategies to support and facilitate the development and implementation of IHR capacities are in place; Level 3: Policies and procedures exist in all relevant sectors to support and promote the development and implementation of IHR capacities; Level 4: Policies and strategies in all relevant sectors support and facilitate the development and implementation of IHR capacities at national, intermediate, and local levels; and Level 5: Policies and strategies are regularly revised and updated to support and promote the development and implementation of IHR capabilities.

The performance percentage is calculated based on the indicator level selected by the country. For example, if a country selects Level 3, the indicator level is recorded as 3/5 × 100 = 60% [5]. This grading method was applied uniformly to select the indicators.

SPAR scores were extracted for each included country for the years 2018–2020. .

COVID-19 performance analysis

COVID-19 performance (recovery and severity index)

The COVID-19 performance index scores (severity and recovery) for all countries in the study were extracted from the Global COVID-19 Index (GCI) by PEMANDU Associates in June 2022 [14]. The GCI Recovery Index assesses major recovery parameters reported daily, indicating how a country is progressing on its recovery path relative to other countries. The GCI Severity Index presents up-to-date characteristics of countries adversely affected by COVID-19 in terms of health outcomes compared to countries that have been similarly affected but have since recovered.

Qualitative component - key informant interviews

Between March and April 2022, key informant interviews (KII) with stakeholders were conducted using the semi-structured interview guide attached as a supplementary file. Twenty key informants were identified from the ECOWAS region using purposive sampling, with at least one representative from each ECOWAS member state and international partner. The required sample size for qualitative data collection was reached when data saturation was achieved, which occurred upon interviewing 18 respondents. We conducted semi-structured interviews with key informants (supplementary file) to provide further information or depth on key issues concerning the five OH regional coordinating mechanisms, as shown in Table 4. The interviews were conducted to gain a better understanding of the ECOWAS region’s accomplishments, challenges, and gaps in implementing the OH approach, and as well as what measures, if any, have been put in place to monitor implementation progress. In addition, this study sought to understand how the approach of OH was employed to combat the COVID-19 pandemic. We conducted interviews online after respondents provided written and verbal informed consent. The interviews with each stakeholder lasted between 30–40 minutes. The majority of interviews were conducted in English. Two interviews were conducted in French. All interviews were audio-recorded and transcribed using a speech-to-text transcription program.

Table 4.

OH Regional Coordinating Mechanism Framework

Dimensions	Political Commitment	Institutional Structure	Management and Coordination Capacity	Joint Planning and Implementation	Technical and Financial Resources
Description	The approach that motivates stakeholders in the establishment and maintenance of OH.	There is a national health framework in place, as well as procedures for implementing OH coordination mechanisms.	Technical standards are established for engaged partners, to maintain commitment.	National strategies for involving stakeholders in the process of National Health Security Roadmaps are in place.	Mechanisms for mobilizing and identifying technical and financial resources to operationalize OH at the national level.
Components	Promotion of cross-sectoral goals. Existence of a National OH Advocacy Strategy. Funders for OH are available.	The existence of a national OH structure; the existence of laws and regulations for operationalization; as well as stakeholder involvement initiatives.	The availability of a national technical working group; a communication and information-sharing mechanism with guidelines; and the existence of a national framework for OH adoption.	National OH Strategic Plan; There is disease prioritization with guidelines in place and availability of a national preparedness and response plan.	There are tools and skilled labor available, national stimulation exercises, financial resources, and collaboration from donor partners.

Eligibility criteria of the key informants

Participants were selected using purposive sampling based on the following criteria: (1) ECOWAS nationals actively engaged in OH initiatives within their respective countries; (2) Officers from government agencies or international organizations [(e.g., World Organisation for Animal Health (WOAH), WAHO, WHO, Food and Agriculture Organization of the United Nations (FAO), and United States Agency for International Development (USAID)] involved in the implementation of OH in the ECOWAS region; (3) Representatives from the ECOWAS Commission whose job descriptions include active roles and routine involvement in the operationalization of the OH approach in the region.

Exclusion criteria

The exclusion criteria were as follows: (1) Individuals from the ECOWAS Commission who had participated in the OH initiative but were no longer in active service; (2) ECOWAS nationals who were involved in the early stages of OH implementation but were no longer active stakeholders; (3) Individuals who did not consent to participate.

Document review: OH platform implementation status

National documents were reviewed and analyzed using specific categorical variables to assess the performance status of the countries implementing OH platforms. The performance status was categorized as follows:

1. Preliminary Status: This indicates that countries have initiated efforts by bringing relevant stakeholders together and have conducted their first National Bridging Workshops.

2. Pre-implementation Status: This denotes that countries have completed all relevant recommendations and are in the final stages of OH platform activities.

3. Implemented Status: This signifies the existence of a fully operational platform for the OH approach.

The information was collected from national documents and validated through interviews with the ECOWAS regional OH coordinator and national experts.

Analysis

Descriptive statistical analyses were used for quantitative analysis. The selected global health security indicator scores are presented as frequencies and proportions in a weighted form. The selected JEE indicator score was calculated and classified as follows: 1 = No capacity, 2 = Limited capacity, 3 = Capacity in the early stages of development, and 4 = Capacity in place but not sustainable. To check for associations, the chi-square test was used to compute the following implementation status: 1 = Discussion status, 2 = Finalization status, and 3 = Implemented. A two-fold analysis was performed to compare the SPAR, and the significance of the COVID-19 performance index scores was set at a p-value of < 0.05, for all analyses using Microsoft Excel and SPSS version 25.

Qualitative data were analyzed using thematic analysis. Interviews were transcribed using the Otter.ai transcription tool and subsequently imported into NVivo 12 for coding. This process facilitated the identification and comparison of recurring themes and key points across participants. The findings were organized sequentially within the five dimensions of the regional coordination mechanism framework in Table 4. The results were derived from the main themes and subthemes that emerged during the analysis, integrating the thematic analysis of the interviews with documentary evidence provided by the informants. To maintain confidentiality, the interview data were anonymized and only direct quotations were selected.

Ethical consideration

The Ethics Committee of Ruprecht Karls University of Heidelberg Medical Faculty approved the research concept, data collection tools, information sheets, and consent forms (No S-310/2022). The nature and scope of the study were verbally conveyed to participants. Participants were given a copy of the participant information sheet and were asked to sign an informed consent form. They were also given the option to terminate the interview and withdraw their permission at any moment without providing explanations or facing any consequences. Anonymity of the participants and confidentiality of the information were maintained by not using names in the transcripts.

Results

The findings indicate no significant association between the selected JEE indicator scores and the status of OH implementation platforms, as shown in Table 5. Among the 15 ECOWAS countries, 60% have implemented the OH platform but have no capacity in place for indicator P.2.1, which refers to a functional mechanism established for the coordination and integration of relevant sectors in the implementation of IHR. Additionally, 62.5% of the countries have limited capacity for indicator P.2.1, whereas 37.5% are in the pre-implementation stage of the OH platform. Regarding indicator P.4.3, which concerns established and functional mechanisms for responding to infectious and potentially zoonotic diseases, four countries have no capacity but have implemented the OH platform. Figure 2 presents a descriptive analysis of the implementation status of OH platforms across the ECOWAS region. Of the 15 countries analyzed, nine (60%) had already implemented the OH platform: Benin, Burkina Faso, Ivory Coast, Guinea, Liberia, Mali, Nigeria, Senegal, and Sierra Leone. The remaining six countries (40%), namely, The Gambia, Ghana, Guinea Bissau, Niger, and Togo, are still in the pre-implementation stage.

Table 5.

Association Between Selected Joint External Evaluation (JEE) Indicator Scores and OH Initiative Implementation Status 

Selected JEE Indicators		One Health Platforms Platform Implementation Status
		Implemented	Pre-Implementation	P-value
		n (%)	n (%)
P.2.1: A functional mechanism established for the coordination and integration of relevant sectors in the implementation of IHR	No capacity in place	3 (60.0)	2 (40.0)	1.00
	Limited Capacity in the development stage	5 (62.5)	3 (37.5)
	Capacity in place but not sustainable	1 (50.0)	1 (50.0)
P.4.1: Surveillance systems in place for priority zoonotic diseases/pathogens	No capacity in place	1 (50.0)	1 (50.0)	1.00
	Limited Capacity in the development stage	5 (55.6)	4 (44.4)
	Capacity in place but not sustainable	3 (75.0)	1 (25.0)
P.4.2: Veterinary or animal health workforce	No capacity in place	1 (33.3)	2 (66.7)
	Limited capacity in the development stage	3 (50.0)	3 (50.0)
	Capacity in place but not sustainable	5 (83.3)	1 (16.7)
P.4.3: Mechanisms for responding to infectious and potentially zoonotic diseases established and functional	No capacity in place	4 (100.0)	0 (0.0)	0.27
	Limited capacity in the development stage	4 (57.1)	3 (42.9)
	Capacity in place but not sustainable	1 (50.0)	1 (50.0)
P.5.1: Mechanisms for multisectoral collaboration are established to ensure rapid response to food safety emergencies and outbreaks of foodborne diseases	No capacity in place	4 (66.7)	2 (33.3)	1.00
	Limited capacity in the development stage	5 (66.7)	4 (33.3)
	Capacity in place but not sustainable	9 (55.6)	6 (66.7)

Fig. 2.

OH Implementation Status in the ECOWAS Region

Figure 3 depicts the scores of the selected JEE indicators across countries. Ghana scored higher on the selected indicators and in the pre-implementation stage of the OH platform, as shown in Fig. 2. Ivory Coast and Liberia came second with 16 points each, followed by Benin and Togo with 14 points each.

Fig. 3.

JEE Indicator Scores for ECOWAS Member Countries 

Table 6 shows the descriptive analysis of the mean and standard deviation of the scores of the selected e-SPAR of ECOWAS countries. The findings show that the calculated average score for the indicator (C.1.1, legislation, laws, regulations, policy, administrative requirements, or other government instruments to implement the IHR) increased from 40 in 2018 to 41.25 in 2020. However, scores decreased in the selected indicator (C.2.2 Multisectoral IHR coordination mechanism) from 50 in 2018 to 48.75 in 2019 and 2020.

Table 6.

Summary Statistics of Selected SPAR (State Party Annual Report) Indicators for 16 West African Countries (2018-2020) 

SPAR Selected Indicators	West African Countries
	2018	2019	2020
	Mean (± SD)	Mean (± SD)	Mean (± SD)
C.1.1: Legislation, laws, regulations, policy, administrative requirements, or other government instruments to implement the IHR	40.00 (17.88)	43.75 (20.94)	41.25 (22.47)
C.1.3: Financing mechanism and funds for the timely response to public health emergencies	33.75 (20.38)	36.25 (16.68)	37.50 (19.15)
C.2.2: Multisectoral IHR coordination mechanism	50.00 (23.09)	48.75 (24.19)	48.75 (20.62)
C.3.1: A collaborative effort on activities to address zoonoses	53.75 (25.00)	50.00 (19.32)	55.00 (23.66)
C.4.1: Multisectoral collaboration mechanism for food safety events	41.25 (21.25)	36.25 (23.35)	41.25 (23.63)

Table 7 presents the results of an independent t-test examining the association between OH implementation status and the COVID-19 recovery and severity index as of June 2022. No significant difference was found in the COVID-19 recovery index between countries with OH implementation (M = 57.63, SD = 6.95) and those at the finalization stage (M = 56.75, SD = 6.74); t(13) = 0.243, p = 0.811. Similarly, the COVID-19 severity index showed no significant difference between countries with OH implementation (M = 21.82, SD = 3.75) and those at the finalization stage (M = 22.17, SD = 4.49); t(13) = -0.162, p = 0.874.

Table 7.

COVID-19 Recovery and Severity Indices in Relation to OH Platform Implementation Status 

OH PlatformsPlatform Implementation Status	Covid-19 Recovery Index
	N	Mean	Standard Deviation	t(df), p-value
Implemented	9	57.63	6.96	0.243(13), 0.811
Pre-implementation	6	56.75	6.74
	Covid-19 Severity Index
Implemented	9	21.82	3.76	-0.162(13), 0.874
Pre-implementation	6	22.17	4.49

In terms of COVID-19 pandemic recovery and severity index scores, the three top-performing countries were Guinea Bissau, Burkina Faso, and Benin while the lowest-ranked countries were Liberia and the Gambia respectively as shown in Table 8.

Table 8.

COVID-19 Pandemic Recovery and Severity Scores from the Global COVID-19 Index 

Countries	Overall Performance	Recovery Index Scores out of 100 (100 = Best, 0 = Worst)	Severity Index Scores out of 100 (0 = Best, 100 = Worst)
Guinea Bissau	161	45.87	23.38
Burkina Faso	152	47.80	18.73
Benin	151	48.05	28.75
Sierra Leone	116	54.31	17.46
Ghana	105	55.54	18.94
Cabo Verde	104	55.87	29.24
Guinea	100	56.44	26.60
Cote d Ivoire	99	56.56	23.04
Niger	97	57.19	19.35
Togo	90	59.26	24.84
Mali	87	59.90	21.16
Nigeria	64	62.86	20.73
Senegal	50	66.00	21.28
Liberia	45	66.72	18.63
The Gambia	44	66.74	17.25

Stakeholders’ perspective OH in the region

This section presents a qualitative analysis of data collected from 18 stakeholders within the ECOWAS region, including three national-level representatives, ten regional-level participants, and five individuals at the international level.

Demographic description of participants

The participants included program officers, coordinators, and specialists from the human, animal, and environmental sectors. National-level representatives came from The Gambia, Nigeria, Benin, and Mali, while regional-level participants included those from Sierra Leone, Ghana, Liberia, Senegal, and various international organizations such as the WHO, Africa Centers for Disease Control and Prevention (CDC), ECOWAS, FAO, and the United Kingdom (UK) Health Security Agency. The human sector had the largest number of participants, with eight individuals, followed by four participants representing the animal sector, and four representing all three sectors (human, animal, and environmental), as indicated in Table 9.

Table 9.

Demographic Characteristics of Key Informants

Country / Organisation	Geographic Focus	Position	Human, Animal, or Environment Representative
The Gambia	National	Program Officer EDC Unit	Human Sector
Nigeria	National	Country Representative of OH	Human Sector
Benin	National	Focal Point OH Ministerial	Human Health
Sierra Leone	Regional	OH Specialist	Human Health
Ghana	Regional	OH Health Co-Chair Ghana Vet	Animal Health
Liberia	Regional	National OH Coordinator	Human Health
Mali	National	Deputy Technical Coordinator for Global Health Security Agenda	Human Health
Senegal	Regional	National OH Coordinator	Animal Health
WHO	Regional	Regional OH Coordinator	Human, Animal and Environment
Africa CDC	Regional	OH Coordinator for The ECOWAS Region	Human, Animal and Environment
WHO	International	Regional Operational Tools Coordinator	Human, Animal and Environment
WHO	Regional	Technical Officer Preparedness and IHR	Human Health
ECOWAS Regional Animal Health ector	Regional	Program Officer and OH Focal Point	Animal Health
World Organisation for Animal Health (WOAH)	International	Regional Program Officer of OH	Animal Health
FAO	International	Consultant FAO	Food and Agriculture
FAO	Regional	OH Specialist	Food and Agriculture
WHO Regional Representative on OH	Regional	OH ECOWAS Facilitator	Human Health
UK Health Security Agency	International	ECOWAS Representative	Human,Animal and Environment

Stakeholders’ perspectives on the position of OH at the country and regional level

Key stakeholders were asked to provide their views and perspectives on the position of OH in the ECOWAS region. Their responses revealed several major themes. The first theme centered on improving strategies for global health security, whereas the second involved the need for extensive cross-sectoral awareness. Many participants emphasized the need for more comprehensive OH measurement tools. While acknowledging the potential of existing frameworks to measure OH, they suggested that these tools should evolve to incorporate other components, such as animal health, economic impacts, security considerations, and ecosystem dynamics into these measurement frameworks.

National and regional stakeholders exhibited different opinions regarding the COVID-19 pandemic response strategy and OH approach. Regional partners highlighted the significance of the approach, stating that the COVID-19 pandemic provided countries with a clearer understanding of its importance and they observed many countries effectively using it. In contrast, national representatives indicated that the OH approach did not impact the COVID-19 response, noting that, although other sectors contributed to the pandemic response, the health system did not utilize the OH platform to coordinate activities.

“It is vice versa. So, the pandemic has helped countries realize that they need such a platform to collaborate. Those who already had such a platform and used it were more efficient in the initial stages of the [COVID-19] response because they were more coordinated and organized.” Stakeholder 14

“During the [COVID-19] response, other sectors, like security, animal health, education, and information, all supported, but it was not under the umbrella of One Health.” Stakeholder 15

“So, I think the key challenge that we are experiencing is looking at One Health as something that is needed for an only response for zoonoses outbreaks, and not understanding that it’s important for us to have a joint effort to all public health concerns.” Stakeholder 4

Improving strategies for global health security

Many stakeholders have acknowledged that OH is an established approach that has been around for a considerable amount of time. Nevertheless, they noted that it required time for people to appreciate the urgent necessity of implementing an OH approach. Furthermore, many stakeholders noted that the Ebola virus disease outbreaks in West Africa from 2014 to 2016 played a significant role in catalyzing the operationalization of the approach. Additionally, almost all regional stakeholders emphasized the link between global health security and OH. They concluded that, although OH can undoubtedly assist in the implementation of IHR core capacities, IHR is predominantly focused on human health and is much more extensive. Therefore, if OH is measured using the IHR monitoring and evaluation framework, it should be revised to be more inclusive. Some national stakeholders concurred that evaluating the OH approach should rely on specific activities and goal sets reviewed on a quarterly or annual basis. They suggested that these metrics could be incorporated into existing IHR frameworks to track the progress of OH initiatives effectively.

“The Joint External Evaluation encapsulates multisectoral collaboration in terms of joint planning, joint assessment, and joint response, all of which benefit One Health. However, in terms of overall measuring One Health, the indicator still needs to be strengthened to capture other components of One Health and not just humans as IHR is more about human health.” Stakeholder 5

“Well, let us start with: in 2006, our country was affected by the event H5N1 influenza outbreak, and so, I believe that is when the idea of the One Health initiative started. So that’s when we realized the need for collaboration between actors to address the issues and other future outbreaks.”Stakeholder 9

“Because of health security, we adopted the Joint External Evaluation from the International Health regulation (2005) and therefore this be observed to measure One Health, but it should include the current activities in places at the regional and national level.” Stakeholder 11

Extensive cross-sectoral awareness

Participants frequently cited the OH approach as instrumental in establishing a cross-sectoral network capable of more effectively addressing public health concerns. Stakeholders emphasized that working across various sectors fosters a deeper understanding of interdependence and promotes mutual support. Additionally, the OH approach was perceived as highly successful in promoting cross-sectoral training, which, in turn, enhanced teamwork, relationships, and knowledge sharing among different sectors. The participants highlighted that sharing expertise across sectors enables more effective responses to public health threats and significantly enhances global health security.

“With the One Health approach, different sectors bring their perspectives on board that could adequately help address the issues we face in our countries.” Stakeholder 8

“We have now realized how interconnected we are and therefore health cannot do it alone without other sectors’ involvement to share their viewpoints for better health outcome.” Stakeholder 4

Stakeholders’ view on progress and challenges of OH implementation at the national level

Political commitment

Participants generally agreed that countries were implementing the OH strategy at varying stages, with political commitment from member countries being a crucial driver of overall effort. The human, animal, and environmental sectors, along with multilateral organizations such as the WHO, FAO, and WAOH, have shown significant interest in this approach. However, participants highlighted challenges in achieving consistent political commitment due to differing interpretations and understandings of the OH approach.

“Strong political commitment from the government is the strength of the regional One Health platform we have observed in most countries.” Stakeholder 7

“Misunderstanding of the concept is a challenge to fully operationalize One Health. We observed other countries establishing a separate ministry, which deviates from the concept.” Stakeholder 11

Institutional structures

Stakeholders share a consistent perspective of the progress of institutional structures. Most participants agreed that, while a regional framework exists, there is still a gap in effectively utilizing the OH framework to coordinate activities at the country level. International stakeholders have recommended that the current regional framework incorporate components of the IHR framework as they complement each other. Most stakeholders emphasized that in considering OH as a country’s approach to global health security, it is crucial to align it with the IHR, as it supports its implementation.

“The lack of clear guidelines on the existing [One Health] framework is slowing the progress a bit, especially from the animal and environmental sector.” Stakeholder 5

“The institutional structures of the One Health initiatives should have a system that brings on board all relevant sectors from the planning stages to have an idea of the fiscal year, and this helps to know the timeline of activities.” Stakeholder 7

Management and coordination capacity

Six of the interviewed stakeholders reported that the ECOWAS region had robust regional management and coordination capacity, citing examples such as national bridging workshops and regional meetings that have bought stakeholders together. Nevertheless, all stakeholders agreed that while OH initiatives are strong at the national level, there is a lack of coordination at the sub-national level. All regional stakeholders indicated that national bridging workshops aim to involve all relevant sectors to support IHR implementation.

“To answer the question, I must say as a region we are progressing quite well with management and coordination considering the Dakar and Nigeria meetings bringing all relevant stakeholders on board." Stakeholder 1

“I have to say this is not going as planned; we have several meetings, but in reality, we do not have a strong system at the sub-national level.” Stakeholder 8

Joint planning and implementation

The collaborative planning aspect of the OH initiative is considered a strength by many interviewed stakeholders, and progress has been made in involving all stakeholders in several countries. However, some participants mentioned that joint planning was challenging because of the lack of interest and power struggles among stakeholders. Nonetheless, the majority of participants agreed that implementing the core capacities of IHR requires joint efforts from all relevant stakeholders, and the OH approach is perceived to play a crucial role in ensuring the implementation of IHR.

“The technical working group for One Health is done in multisectoral lens where all relevant stakeholders are bought on board for joint activities.” Stakeholder 4

“More coordination of activities at planning and implementation is required, often human health takes the lead, and others are invited as spectators.” Stakeholder 2

Technical and financial resources

Numerous participants highlighted the availability of financial and human resources, especially in the animal and environmental sectors, as one of the most challenging aspects of the OH approach. According to stakeholders, there is a shortage of funds in the national budget earmarked for OH platforms, and there is a need for concrete evidence of economic benefits to secure long-term government support and resources This approach recognizes that while conceptual buy-in is important, financial considerations often drive decision-making at the governmental level.

“Other sectors find it difficult to commit to the [One Health] agenda because they have insufficient staff and frequently face more issues in their sectors.” Stakeholder 17

“Lack of domestic resources to finance the sustainability of the [One Health] approach is a major challenge.” Stakeholder 12

“The government must recognize that a dedicated finance system for this approach improves global health security in the country. Still, we need convincing evidence to evaluate and inform the government of the economic savings if the One Health platforms effectively function with the necessary resources.” Stakeholder 9

Discussion

Selected Global Health Security Frameworks and OH

Our findings indicate a notable disconnect between the scores from the Joint External Evaluation (JEE), and electronic State Parties Self-Assessment Annual Reporting Tool (e-SPAR) and the actual implementation status of OH initiatives across ECOWAS countries. These results underscore the varied levels of readiness and sustainability in implementing OH platforms across the region, reflecting a mixed capacity and implementation success for these critical indicators. This suggests that the existing global health security indicators may be inadequate for capturing the nuanced and interdisciplinary capabilities essential for OH implementation. These results corroborate a previous study that highlighted that frameworks such as the IHRME may not encompass all critical dimensions of a country’s health system and its readiness to address complex health challenges [15]. Despite the synergies and potential crosscutting benefits inherent in the OH approach, the indicators used in our study have a limited capacity to accurately inform health system capabilities. Although present at the sub-national level, many national stakeholders have reported that OH activities are generally less effective than those at the national level. Consequently, global health security indicators may fail to adequately capture subnational capabilities. This finding is consistent with previous observations that IHR implementation data may not accurately reflect subnational capacities [16]. Given that these indicators were not designed to assess subnational capabilities, their scores did not show a significant association with OH platform implementation. This highlights the critical need to enhance the design and deployment of indicators to effectively measure the implementation of OH strategies at the sub-national level.

Furthermore, whether the IHR tools can precisely measure OH emphasizes a tailored operational plan for monitoring and evaluating the indicators that consider the variation in countries and perform a centralized method of reporting. Careful planning and application of the OH approach at all government levels, including the sub-national level, are crucial for accurately measuring OH implementation. However, success in building capacity requires leadership, resource investment, prioritization, and commitment from the specific countries themselves. Moreover, creating an unprecedented opportunity to build multisectoral partnerships at the national and global levels can be viewed as an opportunity to advance global health security. The OH approach paves the way for developing other tools to strengthen countries’ capacities to manage issues at the human-animal-environment interface [17]. As a result, multidisciplinary evaluation and monitoring frameworks should be emphasized to produce optimal results for global health security, taking advantage of OH’s current momentum and existing initiatives that promote regulation and implementation.

COVID-19 performance index (recovery and severity) and OH platforms

There was no correlation between OH and the COVID-19 pandemic recovery and severity index. The COVID-19 response has revealed serious gaps in global health systems [18]. Following the initial spillover event, the vast majority of transmissions were between humans only, so there was a limited role for the animal and environmental sectors, although some high-profile instances of reverse spillover into animal populations underscored the importance of maintaining OH vigilance [19]. According to the national stakeholders interviewed, the human sector primarily led the COVID-19 response in West Africa, with only minor contributions from the animal and environmental sectors. Overall, the country representatives claimed that the OH platform had little effect on the pandemic response. They emphasized that other sectors supported the response, but not under the umbrella of OH platforms. Given that OH emphasizes coordination and strategic planning across sectors, OH platforms may play a crucial role in addressing the governance shortcomings exposed by the COVID-19 pandemic.

Stakeholders’ view on OH and Global Health Security

The study revealed that stakeholders’ views on the position of OH in the ECOWAS region align with the premises and objectives of regional coordination for OH implementation [20]. It is interesting to note that the region’s stakeholders were optimistic about the OH approach. Most participants emphasized that implementing the OH strategy has been observed from a global health perspective to address antimicrobial resistance (AMR) and zoonotic outbreaks. According to Lokossou et al., the region’s ability to address AMR and other epidemic-prone diseases through OH is highly motivating, contributing to its success [21]. The challenges associated with OH surveillance may persist during the design stage through execution, monitoring, and evaluation [22]. Without a unified approach across sectors, it may be challenging to develop necessary collaboration and information sharing to address global health security threats.

Therefore, OH supporters must recognize that their vision is highly political, and plan accordingly. On a global level, increasing attention has been paid to the potential inclusion of OH in the proposed Pandemic Treaty, although the intended final round of negotiations in May 2024 failed to reach an agreement on this and a number of other critical topics, forcing the WHO to extend discussions for a further 12 months. Parallel efforts to renegotiate the IHR have been more successful; however, they do not explicitly address OH and only implicitly evoke the importance of multisectoral coordination [23]. To this end, OH governance continues to rely on a patchwork of non-binding guidance documents and initiatives, which, although globally recognized, fail to provide robust indicators for measuring implementation progress. Although many successes have been achieved using the OH approach to improve health outcomes, questions remain about what kind of information decision-makers require and how the impact of this approach, including cost savings, can be measured [23]. Most importantly, as with any approach involving resource allocation decisions, the OH call to action must provide clear, concrete, and measurable justifications to persuade governments and decision-makers at the national and regional levels to allocate the necessary resources to all relevant sectors.

Study strengths and limitations

This study offers a comprehensive and detailed overview of OH initiatives and challenges in the ECOWAS region. It achieves this by engaging with a diverse group of stakeholders actively involved in implementing the OH approach, thereby providing rich contextualization of the issues. The participants were drawn from a wide range of national, regional, and international backgrounds, contributing to a more inclusive and varied perspective. Although the country-level sample size was relatively small, the diverse backgrounds of participants enriched the findings. However, we acknowledge that gathering insights from multiple experts in each country rather than relying on a single information rich representative could have provided even deeper insights.

This study has limitations. Firstly, securing a commitment from stakeholders for scheduled qualitative interviews was challenging due to logistical constraints. Additionally, conducting interviews with participants from French and Portuguese-speaking countries presented language barriers; only two participants from French-speaking countries were interviewed, while others could not be interviewed. Connectivity issues also led to occasional interruptions during interviews. Furthermore, while the selected quantitative indicator scores were validated by the ECOWAS regional OH Coordinator and national experts, they may not fully capture the current situation due to potential underreporting and inherent flaws. We invite future research to determine the most effective indicators for measuring the implementation of OH on global health security. This could involve comparative studies of existing indicators and the development of new, more comprehensive metrics. 

Conclusion

OH has significantly enhanced global health security, yet uncertainties remain among implementers regarding the most effective indicators for measuring its impact. To fully integrate the OH approach into health security, enhancements are necessary, but progress to date has been slow, as evidenced by the challenges faced during recent Pandemic Treaty negotiations. Global frameworks, if supported by appropriate monitoring and evaluation indicators, can guide regional and national implementation, which in turn relies on factors such as securing adequate funding, ensuring national ownership, and robust advocacy from dedicated interest groups in disease control to shape health policies and drive effective implementation.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Abbreviations

OH

One Health

ECOWAS

Economic Community of West African States IHR, International Health Regulation

GHSF

Global Health Security Frameworks

JEE

Joint External Evaluation

e-SPAR

Electronic State Part Annual Reporting, WAHO, West African Health Organization

WHO

World Health Organization

OIE

World Organization for Animal Health

FAO

United Nation Food and Agricultural Organization

R-OHCM

Regional One Health Coordination Mechanism

Author contributions

DC designed the project, conducted fieldwork, analyzed data and wrote results. DC, AB, RSR and CS wrote the original manuscript and approved its intellectual content. DC had the final responsibility to submit for publication.

Funding

No specific funding was received to support this study.

Data availability

The datasets are available upon request from the corresponding author.

Declarations

Ethics approval and consent to participate

The study protocol was approved by the Ethics Committee of the Ruprecht Karls University (NoS-310/2022). All methods were performed according to the relevant guidelines and regulations. Written informed consent was obtained from each participant before participation in the study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.