Strengthening Global Health Security in West Africa: Insights from Joint External Evaluations and After-Action Reviews

Abstract

Purpose

West Africa faces recurring public health outbreaks, including Ebola, COVID-19, and Mpox, underscoring the need for strong Global Health Security (GHS) core capacities. This study uses Joint External Evaluation (JEE) scores and After-Action Review (AAR) findings to assess public health emergency preparedness across 15 West African countries and identify gaps between theoretical assessments and operational response capacity.

Methods

A mixed-methods approach compared JEE scores (2016–2023) with thematic analysis of AAR findings from major outbreaks. Consistency between JEE-predicted capacities and AAR-reported challenges was assessed using a three-level rating system (High/Moderate/Low) and the Kappa statistic.

Results

In 68 of 105 technical area comparisons (65%) of cases, JEE scores accurately predicted weaknesses in laboratory systems and workforce development. However, in 37 comparisons (35%) of cases, JEE scores overestimated preparedness, particularly in risk communication(all15 countries,100%), real-time surveillance(13 of 15 countries, 87%), and cross-border coordination, where countries with high scores faced operational failures during outbreaks. AARs revealed logistical bottlenecks, supply chain disruptions, and coordination failures not captured by JEEs. Alignment with SDG 3.d (health security), SDG 10 (inequalities), SDG 17 (partnerships), and SDG 9 (infrastructure) underscores broader development implications.

Conclusion

While JEE is valuable for baseline assessment, it incompletely predicts real-world outbreak response performance. Integrating AAR findings into national planning and refining JEE indicators to include operational metrics will enhance health security evaluations. Regionally coordinated action through WAHO is essential for addressing gaps and building resilient systems aligned with sustainable development goals.

Highlights

• •JEE scores predict only 65% of real-world outbreak response gaps.
• •Risk communication and cross-border coordination are often overestimated.
• •AARs reveal operational bottlenecks missed by JEE assessments.
• •Fragile states face disproportionate health security capacity gaps.
• •Regional solidarity mechanisms critical for SDG 3.d achievement.

1. Background

1.1. Overview and role of Joint External Evaluations (JEEs) and After-Action Reviews (AARs)

West Africa has experienced a wide range of public health emergencies (PHEs) over the past decade, beyond the well-known 2014–2016 Ebola outbreak. These include recurrent epidemics of Lassa fever, cholera, meningitis, yellow fever, measles, COVID-19, and, more recently, Mpox [1]. Countries in the region have developed various national response structures such as Public Health Emergency Operations Centres, multisectoral coordination platforms, and rapid response teams; at the regional level, institutions such as the West African Health Organization (WAHO) and Africa Centres for Disease Control(Africa CDC) play critical roles in coordinating cross-border efforts and surge support. In this context, Joint External Evaluations (JEEs) and After-Action Reviews (AARs) have become important cornerstones of Global Health Security (GHS), providing key information to inform Public Health Emergency Preparedness (PHEP) at both national and regional levels. For this manuscript, GHS core capacities refer to the core capacities outlined in the International Health Regulations (IHR, 2005), including surveillance, laboratory, risk communication, and emergency response systems [2]. The JEE is a voluntary, transparent and collaborative assessment conducted approximately every 4–5 years that evaluates a country's capacities in 19 technical areas defined under the IHR (2005), including national legislation and policy, IHR coordination, antimicrobial resistance, biosafety and biosecurity, zoonotic diseases, immunization, real-time surveillance, laboratory systems, workforce development, risk communication, emergency preparedness and response operations, points of entry, and response to chemical/radiation events [3]. They are coordinated by the Ministry of Health and involve a wide range of national stakeholders (public health institutes, animal health, points of entry, laboratories, civil defence, customs, etc.) as well as external experts from the World Health Organization(WHO) and partner institutions. The process includes a self-assessment by the country, followed by an in-country evaluation mission by an international team, which validates the findings. The results and recommendations are published in the JEE mission report, which is posted on the WHO website and serves as a basis for developing or updating the national action plan for health security (NAPHS) [2], [3]. Through structured reviews of these areas, JEEs highlight existing gaps and provide countries with a clear road map for strengthening health security and emergency preparedness.

The After-Action Review (AAR) is a structured qualitative assessment conducted after a real public health event, such as an outbreak or simulation exercise, to evaluate what went well and what could be improved. AARs are typically organized within three months of the event and are led by the national public health authority in collaboration with partners (e.g., WHO, Africa CDC, NGOs, academic institutions) [4]. They gather key responders such as surveillance officers, clinicians, laboratory staff, emergency operations center personnel, communication specialists, and representatives from other relevant sectors to review response actions in a participatory manner. The review is usually carried out through workshops, interviews, or field visits and results in an AAR report, which is shared with national and regional stakeholders and used to update preparedness plans and SOPs. The reports are also shared with WHO, and summaries of lessons learned are sometimes published through regional platforms.

Overall, JEEs and AARs serve as mutually reinforcing mechanisms that have helped West African countries strengthen preparedness and response capacities, though levels of readiness still vary across the region.

1.2. IHR monitoring and evaluation framework and how JEEs and AARs fit in

The International Health Regulations (IHR, 2005) Monitoring and Evaluation Framework (MEF) is a structured system developed by WHO to assist countries in regularly assessing and improving their core capacities for preventing, detecting, and responding to public health threats. The framework combines both mandatory and voluntary tools and follows a continuous cycle of assessment, planning, implementation, and improvement [3].

It consists of four main components: States Parties' self-assessment annual reporting (SPAR), Joint External Evaluation (JEE), After-Action Review (AAR), and the Simulation Exercises (SimEx). Within this framework, the JEE is a forward-looking assessment that helps countries determine where their capacities stand and what needs to be improved, while the AAR provides a backward-looking review that helps translate lessons from real events into improved systems and capacities. Together with SPAR and SimEx, they form a continuous cycle of monitoring, testing, and improving national IHR implementation and overall readiness for public health emergencies. Fig. 1 below shows how JEEs and AARs fit in the IHR monitoring and evaluation framework.

Fig. 1.

IHR monitoring and evaluation framework, AAR and JEE.

1.3. Public health threats in West Africa and lessons from past outbreaks

Public health challenges have been numerous in the West African region throughout history and these events underscore the timely need for robust strengthening of health security capacity for Public health emergencies such as the recurrent epidemics of Lassa fever, cholera, meningitis, yellow fever, measles, COVID-19, and, more recently, Mpox, all of which have tested national and regional health security systems. Many countries in the Sahel (e.g., Niger, Burkina Faso, Mali) also face health emergencies linked to complex humanitarian crises, insecurity, and population displacement, which further complicate emergency response efforts [1], [5].

To address these threats, countries in the region have put in place a range of national response structures (Public Health Emergency Operations Centres, national rapid response teams, multisectoral coordination committees) and adopted Incident Management Systems (IMS) to coordinate emergency response. At the regional level, WAHO and Africa CDC play a key role in supporting coordination among countries, developing regional guidance, and mobilizing surge support [6].

Importantly, the JEEs and AARs conducted in several West African countries have helped to identify gaps and inform national preparedness plans. For example, recommendations from JEEs on strengthening laboratory capacity and surveillance have led to targeted investments in many countries, while AARs conducted after outbreaks (e.g., Ebola in Guinea; COVID-19 in Nigeria; meningitis in Niger) have helped update contingency plans and improve cross-border information sharing [4], [7], [8].

Overall, preparedness levels vary across the region. Countries like Nigeria, Ghana, and Senegal tend to be relatively better prepared, reflecting more mature public health institutes, stronger laboratory and surveillance systems, and experience in responding to previous outbreaks. Other countries, particularly those affected by prolonged conflict or weaker health systems (e.g., Guinea-Bissau, Sierra Leone, Liberia, Burkina Faso), still face significant gaps in terms of emergency preparedness and response capacities [7], [9], [10].

This review directly aligns with Sustainable Development Goal (SDG) 3.d, which specifically calls for strengthening the capacity of all countries, particularly developing nations, for early warning, risk reduction, and management of national and global health risks. The findings also intersect with SDG 10 (Reduced Inequalities) by highlighting disparities in health security capacities across West African countries and the need for equitable resource allocation. SDG 17 (Partnerships for the Goals) is inherently relevant given the emphasis on regional coordination through WAHO and cross-border collaboration mechanisms. Furthermore, SDG 9 (Industry, Innovation, and Infrastructure) connects to the repeated calls for strengthening laboratory infrastructure, surveillance systems, and sustainable health security capacities identified throughout this review.

1.4. Purpose and objectives of the review

This review used JEE scores and findings from AARs in 15 countries from 2016 to 2023 to provide an overall assessment of the GHS landscape in West Africa. The ultimate objective of this study is to support West Africa in establishing a proactive response mechanism that strengthens GHS and reducing vulnerabilities to future health threats. Furthermore, the study provides actionable recommendations with a roadmap for regional organizations such as WAHO to develop a strategic plan focused on building resilient and sustainable health systems across the region.

2. Methods

2.1. Review design and hypothesis

This review employs a mixed-methods approach to assess the alignment between JEE scores and real-world challenges identified in After-Action Reviews (AARs) across 15 West African countries from 2016 to 2023. The fifteen West African countries of interest are Benin, Burkina Faso, Cabo Verde, Côte d'Ivoire, The Gambia, Ghana, Guinea, Guinea-Bissau, Liberia, Mali, Niger, Nigeria, Senegal, Sierra Leone, and Togo, and the PHEIC of interest in this paper are COVID-19, Ebola, and Mpox because of their high morbidity and mortality with severe economic impact on the societies.

The 2014–2016 Ebola virus disease (EVD) epidemic was the most devastating, with over 28,600 cases and 11,325 deaths reported across Guinea, Liberia, and Sierra Leone, and additional cases in Nigeria, Mali, and Senegal. Beyond its high case fatality rate (40–60%), Ebola collapsed fragile health systems, disrupted routine services such as immunization and maternal care, and caused severe social stigma and economic losses estimated at US$2.8 billion [11], [12].

COVID-19 further tested the region, with more than 1.1 million confirmed cases and over 15,000 deaths officially reported by ECOWAS countries as of 2023. Although mortality was lower compared to other regions, the pandemic's indirect effects—lockdowns, reduced trade, unemployment, and education disruption—were profound, exacerbating poverty and inequalities [13], [14].

Mpox, historically endemic in Nigeria and parts of West Africa, re-emerged as a regional concern during the 2017–2019 outbreak in Nigeria with over 500 suspected cases and 8 deaths, and again during the 2022 global outbreak. While less lethal than Ebola, Mpox exposed persistent gaps in surveillance, risk communication, and equitable access to vaccines and therapeutics [15], [16]. Collectively, these fifteen countries face common threats but exhibit different levels of preparedness and response capacity, which underscores the importance of regional cooperation, harmonized approaches, and mutual support across the ECOWAS region. Our analysis focused on the 48 indicators common across all versions to ensure consistency in comparisons.

The hypothesis guiding this review is that AAR-identified challenges in public health emergency response are consistent with weaknesses flagged by JEE scores, thus validating JEE as a predictive tool for preparedness gaps.

To test this hypothesis, the review first summarizes major conclusions from AARs regarding outbreak responses and operational challenges. It then compares these conclusions with corresponding JEE scores in relevant technical areas such as laboratory systems, real-time surveillance, workforce capacity, emergency response operations, and risk communication.

2.2. Data collection and sources

Data for this review were obtained from two primary sources:

JEE Reports (2016–2023): Publicly available JEE scores from 15 West African countries, covering 48 indicators across 19 technical areas. The most recent report was used for countries with multiple JEEs.

JEE Version Harmonization: JEE reports covered two versions of the assessment tool: JEE Version 1 (2016–2018) and JEE Version 2 (2018-present). To ensure comparability across countries and time periods, we harmonized all reports to a common set of 48 indicators. Version reconciliation was performed as follows:

• •Version 1 (19 technical areas, 48 indicators): Used as the baseline framework.
• •Version 2 (19 technical areas, 54 indicators): Mapped to Version 1 by:
• ○Consolidating split indicators (e.g., Version 2's P.4.1-P.4.3 on antimicrobial stewardship were merged to match Version 1's AMR indicator)
• ○Aligning newly introduced indicators with existing thematic areas
• ○Excluding Version 2-specific indicators without Version 1 equivalents (n = 6)

A detailed mapping table showing the reconciliation of all 54 Version 2 indicators to the 48 common indicators is provided in Supplementary Material Appendix B.

For countries with multiple JEEs (e.g., Nigeria, Ghana), the most recent report was used to reflect current capacity, but earlier reports were consulted to assess capacity evolution where relevant.

After-Action Reviews (AARs): Reports from WHO, CDC, and national health authorities documenting post-outbreak evaluations of COVID-19, Ebola, and Mpox responses.

For each country, JEE data included quantitative scores (1–5 scale) and qualitative observations providing context to each indicator. AARs provided qualitative insights into operational challenges and successes in outbreak management.

AAR Selection Criteria and Search Strategy: A systematic search for After-Action Review reports was conducted across multiple sources, including the WHO website, Africa CDC repository, West African Health Organization (WAHO) database, and national Ministry of Health websites for all 15 ECOWAS member states. The search covered the period January 2016 to December 2023.

Inclusion criteria:

• (1)Official AAR reports or intra-action reviews conducted following real public health events;
• (2)Reports focusing on outbreaks of COVID-19, Ebola, Mpox, Lassa Fever, or other major public health emergencies;
• (3)Documents available in English, French, or Portuguese (official languages of the region);
• (4)Reports containing qualitative or quantitative findings on response challenges and successes;
• (5)Documents published by WHO, Africa CDC, WAHO, or national health authorities.

Exclusion criteria:

• (1)Simulation exercise reports (SimEx) without real-event application;
• (2)News articles or media summaries without official endorsement;
• (3)Duplicate reports;
• (4)Reports with insufficient detail on response challenges.

Completeness was assessed by cross-referencing WHO's IHR monitoring database, contacting WHO country offices where reports were missing, and verifying against national publication lists. For countries with multiple AARs, all eligible reports were included and synthesized, with priority given to the most comprehensive recent reports where thematic saturation was achieved.

3. Analytical framework

3.1. Thematic codes derived from AARs and corresponding JEE indicators

3.1.1. Thematic coding process

Coding team: Two independent coders (AB and ML) with expertise in public health emergency management conducted the thematic analysis. A third senior reviewer (VK) served as an arbitrator.

Training and calibration: Coders underwent a two-day training session on the codebook, including practice coding of three sample AAR reports (one from each outbreak type: COVID-19, Ebola, Lassa Fever). Inter-coder reliability was assessed during training, achieving 85% agreement before independent coding commenced.

Codebook development: An initial codebook was developed deductively based on JEE technical areas and IHR core capacities. This was refined inductively through preliminary review of five AAR reports, adding emergent themes (e.g., supply chain disruptions, cross-border coordination). The final codebook contained 7 main themes with 23 sub-codes (see Supplementary Material Appendix C).

Coding process: Both coders independently reviewed all AAR reports, applying codes to relevant text segments using NVivo 14. Coding was conducted at the paragraph level, with each paragraph potentially receiving multiple codes.

Resolution of disagreements: After independent coding, coders met weekly to compare coding. Disagreements were discussed and, if unresolved, referred to the senior reviewer for final decision. A consensus rate of 92% was achieved after reconciliation.

Saturation assessment: Thematic saturation was assessed after coding 75% of reports, with no new themes emerging in subsequent reports, confirming comprehensiveness of the coding framework.

3.1.2. Summarizing Key AAR conclusions

• •Thematic analysis was conducted on AARs to identify common challenges in outbreak response.
• •Key themes included workforce shortages, inadequate laboratory capacity, poor risk communication, and delays in emergency response.

3.1.2.1. Synthesis of multiple AARs per country

For countries with multiple AAR reports (e.g., Nigeria: COVID-19 IAR 2020, Lassa Fever AAR 2019, Mpox AAR 2022), a hierarchical synthesis approach was used:

• i.Primary analysis: Findings from the most recent AAR for each event type were given priority, as they reflect the most current capacities.
• ii.Recency weighting: AARs conducted within 12 months of an event received a higher weight than delayed reviews.
• iii.Event-type aggregation: For countries with AARs on multiple outbreak types, themes were aggregated across events, with persistent challenges (reported in ≥2 different outbreak AARs) considered more significant than event-specific issues.
• iv.Conflict resolution: When AARs presented conflicting findings (e.g., one reporting strong laboratory performance and another reporting weaknesses), the more conservative assessment (identifying gaps) was retained, and the conflict was noted in qualitative analysis.

No quantitative weighting by event type was applied, but qualitative attention was given to higher-mortality events (Ebola) and more recent events (COVID-19) as these provided more robust tests of health security capacity.

3.1.2.2. Statistical analysis

• •Inter-rater reliability for the correspondence ratings was assessed using Cohen's Kappa statistic with 95% confidence intervals. The unit of analysis was the country-technical area pairing (15 countries × 7 technical areas = 105 pairings). Two independent raters (AB and ML) classified each pairing into one of three correspondence levels.
• •Correspondence rating thresholds:
• -High correspondence: JEE score ≤ 3 AND AAR confirms significant challenges; OR JEE score ≥ 4 AND AAR confirms strong performance; OR clear alignment between predicted and observed capacity (≥80% agreement in qualitative findings).
• -Moderate correspondence: Partial alignment where JEE scores (3–4) show some predictive value, but AAR identifies unanticipated challenges or successes (50–79% agreement).
• -Low correspondence: JEE score ≥ 4 but AAR reports major failures; OR JEE score ≤ 3 But AAR reports a successful response; OR a clear contradiction between predicted and observed capacity (<50% agreement).
• •Sensitivity analysis: To test robustness, alternative thresholds were applied: (a) stricter criteria requiring ≥90% agreement for High correspondence; (b) binary classification (High+Moderate vs. Low). Results remained consistent across sensitivity analyses (see Supplementary Material Appendix D).

3.1.3. Comparing AAR findings with JEE scores

• •Each AAR theme was matched with corresponding JEE indicators (e.g., workforce challenges →JEE workforce development score).
• •Consistency was evaluated using a three-level rating system (High, Moderate, Low) based on how well JEE scores aligned with AAR-reported weaknesses.
• •A Kappa statistic was used to measure inter-rater reliability in scoring agreement.

3.1.4. Identifying discrepancies

• •If a country had a high JEE score but poor AAR findings, this suggested an overestimation of preparedness.

If both JEE and AAR findings are aligned, it validates the predictive value of JEE scores.

3.2. Ethics approval

This review used only secondary, anonymized data from publicly available JEE, AAR reports published by WHO and national health authorities. No identifiable individual-level data was used in this analysis. All sources are publicly accessible through the WHO website and the national ministry of health portals. As this study involved no human subjects, private data, or interventions, formal ethical approval was not required.

4. Results

4.1. Inter-rater reliability

Cohen's Kappa statistic demonstrated substantial agreement between raters for the correspondence classifications (κ = 0.78, 95% CI: 0.69–0.87, p < 0.001), indicating reliable rating of the 105 country-technical area pairings.

4.2. Thematic codes derived from AARs and corresponding JEE indicators

The final coding framework produced four dominant themes, each mapped to specific JEE indicators. Where additional cross-cutting issues emerged (e.g., supply chain/logistics, cross-border coordination), new sub-codes were created and mapped to JEE Technical Area 8 (Emergency Preparedness), Technical Area 9 (Response Operations), and Technical Area 14 (Points of Entry). This coding ensured that operational challenges described in AARs could be systematically aligned with the corresponding JEE indicators for consistency analysis, as shown in Table 1.

Table 1.

Thematic codes derived from AARs and corresponding JEE indicators.

Code / Theme	Definition	Corresponding JEE Technical Areas & Indicators
Workforce Shortages	Limited numbers of trained epidemiologists, laboratory technicians, and public health responders; overreliance on surge staff during outbreaks.	Workforce Development (TA 7) – 7.1 Human resources for IHR implementation; 7.2 Field Epidemiology Training Program (FETP) coverage.
Inadequate Laboratory Capacity	Gaps in diagnostic facilities, delays in sample transport/processing, limited biosafety systems, and poor-quality management.	National Laboratory System (TA 5) – 5.1 Laboratory testing capacity; 5.2 Laboratory quality management systems; 5.3 Biosafety and biosecurity.
Poor Risk Communication	Ineffective messaging, low community engagement, misinformation, and cultural/linguistic barriers in crisis communication.	Risk Communication (TA 10) – 10.1 Risk communication systems; 10.2 Community engagement; 10.3 Public communication.
Delays in Emergency Response	Slow activation of EOCs, weak coordination across sectors, and dependence on donor support delaying response.	Emergency Response Operations (TA 9) – 9.1 EOC capacity; 9.2 Emergency response operations; 9.3 Linking public health with security authorities.
Cross-border Surveillance and Points of Entry	Weak coordination and information-sharing at points of entry; lack of joint outbreak investigations.	Points of Entry (TA 14) – 14.1 Core capacity requirements at PoE; Zoonotic Disease (TA 4) – 4.1 One Health coordination mechanisms.
Medical Countermeasures & logistics	Shortages in stockpiles, supply chain disruptions, delays in mobilizing essential medicines, PPE, and vaccines.	Medical Countermeasures & Personnel Deployment (TA 12) – 12.1 Systems for medical countermeasures; 12.2 Deployment of personnel.

4.3. Summary of Key AAR conclusions: thematic analysis of outbreak response challenges

A thematic analysis of AAR findings across 15 West African countries identified recurring challenges in outbreak preparedness and response. The major themes that emerged include workforce shortages, inadequate laboratory capacity, poor risk communication, and delays in emergency response(See Table 2).

Table 2.

Key themes and common challenges identified in AARs.

Theme	Summary of Challenges Identified in AARs	Examples from Outbreaks
Workforce Shortages	- Limited trained epidemiologists and laboratory technicians. - Overreliance on international surge staff during outbreaks. - High attrition rates due to poor retention policies.	- COVID-19: Several countries struggled with scaling up response teams. - Ebola (2014–2016): Some countries had severe gaps in public health workforce capacity. - Lassa Fever: In certain states, response was hindered by a shortage of infectious disease specialists.
Inadequate Laboratory Capacity	- Limited diagnostic facilities, especially in rural areas. - Delays in processing samples due to reagent shortages. - Lack of biosafety protocols for handling infectious specimens.	- Mpox: Multiple countries lacked PCR testing capabilities, delaying confirmation. - Lassa Fever: Several countries experienced delays in sample transportation and testing.
Poor Risk Communication	- Ineffective messaging led to public distrust and misinformation. - Weak coordination between government agencies and media. - Cultural and language barriers affecting community engagement.	- Ebola: Misinformation fueled resistance to public health measures. - COVID-19: Vaccine hesitancy due to poor engagement. - Mpox: Stigmatization and unclear messaging hampered containment.
Delays in Emergency Response	- Slow activation of Emergency Operations Centers (EOCs). - Weak intersectoral coordination among ministries. - Dependence on donor funding caused delays in mobilization.	- Ebola: Initial responses were fragmented. - COVID-19: Slow policy decisions hindered containment. - Lassa Fever: Absence of rapid response teams in endemic areas increased mortality.

4.4. Consistency between JEE scores and AAR findings

Using a three-level rating system (High, Moderate, Low), the review assessed the degree to which AAR-identified weaknesses aligned with JEE scores across 105 country-technical area pairings (15 countries × 7 technical areas). The results were as follows:

• 1.High Correspondence (68 of 105 comparisons, 65%)

• ○Areas where JEE scores accurately predicted AAR-reported challenges included:
• •Laboratory Systems: 10 of 15 countries(67%) with JEE scores below 3 had significant AAR-reported delays in diagnostic capacity, especially in Guinea-Bissau and Mali.
• •Workforce Development: 13 of 15 countries (87%) with low JEE workforce scores faced critical personnel shortages during outbreaks. (e.g., Liberia, Sierra Leone).
• •Risk Communication: 15 of 15 countries (100%) with weak JEE risk communication scores matched AAR-reported public distrust and misinformation issues during COVID-19 and Ebola outbreaks.

• 2.Moderate Correspondence (26 of 105 comparisons, 25%)

• ○Some technical areas showed partial alignment between JEE scores and AAR findings:
• •Real-time Surveillance: 13 of 15 countries (87%) with high JEE surveillance scores (e.g., Ghana, Senegal) still experienced delays in case detection.
• •Emergency Response Operations: 12 of 15 countries (80%) with moderate JEE scores (2–3), AARs highlighted inconsistent activation of emergency operations centers (EOCs) during outbreaks in countries like Côte d'Ivoire and Burkina Faso.

• 3.Low Correspondence (11 of 105 comparisons, 10%)

• ○Notable discrepancies were found in:
• •Cross-border Surveillance:: 9 of 15 countries (60%) received relatively high JEE scores, but AARs identified persistent gaps in coordination and data-sharing at points of entry.
• •Medical Countermeasures and logistics: 14 of 15 countries (93%) with moderate JEE scores struggled with supply chain disruptions during outbreaks, indicating an overestimated preparedness. Table 3 summarizes the Consistency Between JEE Scores and AAR Findings in West African Countries.

Table 3.

Consistency between JEE scores and AAR findings in West African countries.

Technical Area	JEE Score Range	AAR Findings	Consistency Level
Laboratory Systems	1.5–3	Delays in diagnostics, inadequate infrastructure (reported in multiple countries)	High
Workforce Development	2–3	Severe shortages of trained personnel, reliance on external support (reported in several countries)	High
Risk Communication	2–3	Public distrust, misinformation, weak community engagement (observed across different outbreaks)	High
Real-Time Surveillance	3–4	Delays in case detection despite good JEE scores (noted in multiple countries)	Moderate
Emergency Response Operations	2–3	Inconsistent activation of EOCs, delayed mobilization (reported in more than one country)	Moderate
Cross-Border Surveillance	3–4	Weak coordination, poor data sharing at points of entry	Low
Medical Countermeasures & Logistics	2–3	Supply chain disruptions, difficulty mobilizing resources	Low

4.5. Discrepancies between JEE scores and AAR findings in West African countries

Evaluations of national health security capacities in West African countries have revealed inconsistencies between Joint External Evaluation (JEE) scores and findings from After Action Reviews (AARs), highlighting potential gaps in preparedness and response effectiveness. Table 4 summarizes the findings of this review in seven technical areas.

Table 4.

Discrepancies between JEE scores and AAR findings in West African countries.

Technical Area	Number of Countries (%)	JEE Score	AAR Findings	Interpretation
National Laboratory Systems	10(66.7%)	High (≥3)	Significant delays in diagnostics, inadequate infrastructure	Overestimation of preparedness
Workforce Development	13(86.7)	Low (≤3)	Severe personnel shortages, reliance on surge teams	JEE validated
Risk Communication	15(100)	High (≥3)	Public distrust, misinformation issues, and weak engagement	Overestimation of preparedness
Real-Time Surveillance	13(86.7)	High (≥3)	Delays in case detection despite strong systems	Overestimation of preparedness
Emergency Response Operations	12(80.0)	Moderate (2–3)	Inconsistent EOC activation, weak coordination	Partial validation
Points of entry	9(60.0)	High (≥3)	Poor coordination, weak data sharing at entry points	Overestimation of preparedness
Medical Countermeasures and personnel deployment	14(93.3)	Moderate (2–3)	Supply chain disruptions, inadequate stockpiles	Overestimation of preparedness

4.6. Validation of JEE as a predictive tool

Overall, JEE scores were validated as a useful but imperfect predictor of emergency response capacity. In cases where JEE and AAR findings aligned, the JEE proved to be a reliable assessment tool. However, discrepancies suggest that:

• •JEE assessments may overestimate operational readiness, particularly in logistics and surveillance.
• •AARs provide critical post-outbreak insights that should complement JEE evaluations for a more accurate picture of health security gaps.

5. Discussion

The findings of this review underscore the critical role of Joint External Evaluations (JEEs) and After-Action Reviews (AARs) in assessing and improving Global Health Security (GHS) in the West Africa region. While JEEs provide a structured framework for evaluating national preparedness capacities, AARs offer invaluable insights into the operational realities of outbreak responses. The results revealed that while JEE scores provided a useful baseline for identifying health security gaps, discrepancies between JEE scores and AAR findings suggest that JEE assessments alone may overestimate preparedness in certain technical areas. The integration of these two tools can significantly enhance the region's ability to predict, prepare for, and respond to public health emergencies, as corroborated by a study in South Africa, which concluded that AAR demonstrated the importance of coordinated epidemiological, laboratory, and communication response that requires significant public health reserve capacity in peacetime for rapid expansion in an emergency [17].

The alignment between our findings and SDG targets reinforces the importance of integrating health security strengthening within broader sustainable development frameworks. The persistent inequalities in preparedness capacities across the region (SDG 10) underscore the need for targeted investments in the most vulnerable countries. Similarly, the cross-border coordination challenges identified in our analysis highlight the critical role of regional partnerships (SDG 17) in achieving collective health security. Sustainable infrastructure development (SDG 9) remains fundamental to translating JEE recommendations into lasting operational capacity.

5.1. Alignment between JEE scores and AAR findings

Our findings show a moderate to high correlation between JEE scores and challenges documented in AAR related to workforce development, laboratory systems, and emergency response operations. In 65% of cases, AAR findings confirmed JEE scores, especially regarding workforce shortages and weak laboratory capacity. For instance, countries like Liberia and Sierra Leone, which had low JEE workforce development scores, also experienced significant shortages of trained personnel during outbreak responses, confirming that JEE effectively identified existing gaps [18]. Likewise, laboratory system weaknesses indicated by JEE in Guinea-Bissau and Mali matched with AAR-reported delays in diagnostics and inadequate infrastructure during Mpox and Lassa Fever outbreaks.

However, in 35% of cases, JEE scores overestimated preparedness, particularly in risk communication, real-time surveillance, and cross-border coordination. Countries like Ghana and Senegal received high JEE scores for surveillance but struggled with delays in case detection during outbreaks. Similarly, despite moderate-to-high JEE scores for risk communication in some countries, AARs reported significant public distrust and misinformation challenges, especially during the COVID-19 and Ebola outbreaks. This is in line with the findings from.

5.2. Overestimation of preparedness and key discrepancies

A major discrepancy emerged in cross-border surveillance and medical countermeasures. Several countries, including Niger and Benin, had high JEE scores for cross-border coordination, yet AARs identified weak data-sharing mechanisms and poor coordination at points of entry. This misalignment suggests that JEE assessments may not fully capture the operational effectiveness of response mechanisms in real-time settings. Additionally, medical countermeasures and logistics critical for outbreak containment were overestimated in JEE assessments, as AARs reported supply chain disruptions and inadequate stockpiles in multiple countries, including Nigeria and Sierra Leone.

These findings are consistent with previous studies that have questioned the predictive validity of JEE scores in real-world outbreak responses. For example, Garfield et al. found that while JEE provided valuable baseline assessments, actual outbreak performance was often weaker than indicated by JEE scores, particularly in emergency response functions [19].

While our analysis suggests that JEE scores may overestimate actual response capacity, another possibility is that the scores are accurate. Still, the level of capacity required to achieve a score of 3 or 4 is insufficient for an effective public health response. This distinction is critical as it highlights a potential misalignment between the JEE scoring thresholds and the real-world demands of outbreak response. Future revisions to the JEE framework should consider refining the benchmarks for higher scores to ensure they reflect the functional capacity needed to mount a timely and effective response to public health emergencies.

5.3. The role of AARs in enhancing preparedness

AARs are crucial in bridging the gap between theoretical assessments and practical response capabilities [20]. By systematically analyzing what worked and what did not during past outbreaks, AARs provide actionable insights that can inform future preparedness efforts. For instance, the thematic analysis of AARs in this review highlighted recurring challenges, such as workforce shortages, inadequate laboratory capacity, and poor risk communication. These findings align with previous studies emphasizing the importance of workforce training, laboratory infrastructure, and community engagement in strengthening health systems [21], [22].

Moreover, AARs have been instrumental in identifying systemic issues such as weak intersectoral coordination and dependence on donor funding, which JEEs do not always capture. These findings align with conclusions from a study in the Republic of Moldova, Montenegro [23]. These insights are critical for developing targeted interventions that address the root causes of preparedness gaps. For example, the slow activation of Emergency Operations Centers (EOCs) in Côte d'Ivoire and Burkina Faso, as reported in AARs, underscores the need for stronger institutional frameworks and sustainable funding mechanisms to ensure timely mobilization of responses.

5.4. Integration of SimEx and AAR recommendations

Simulation Exercises (SimEx) and After-Action Reviews (AARs) have increasingly been used as practical mechanisms to strengthen national preparedness planning by identifying real-world gaps and ensuring that corrective actions are incorporated into emergency plans and policies. In several countries, recommendations from AARs conducted after outbreaks such as Ebola, measles, and COVID-19 have led to updates in national emergency response plans, revisions of standard operating procedures, and establishment of permanent multisector coordination structures [21], [24]. For example, following the 2021 national SimEx in Sierra Leone, gaps in cross-sectoral coordination and information management were addressed through the integration of simulation-informed actions into the National Health Security Plan. Similarly, in Nigeria, recommendations from AARs conducted following Lassa fever and monkeypox outbreaks informed the updating of the National Incident Management System and resulted in the inclusion of scenario-based training in the national preparedness and response strategy [25]. These examples demonstrate how SimEx and AAR findings are increasingly being used as evidence to improve preparedness planning and strengthen health security at the national level.

5.5. Equity considerations and regional solidarity

Our analysis reveals stark inequities in health security capacities across West Africa that align with SDG 10 (Reduced Inequalities). Countries affected by protracted conflict and fragility, notably Burkina Faso, Mali, and Niger, consistently demonstrated lower preparedness scores and more severe AAR-reported gaps compared to more stable peers like Ghana and Senegal. This fragility-preparedness gradient was most pronounced in laboratory infrastructure (average JEE score 1.8 in conflict-affected vs. 3.4 in stable countries) and workforce retention (80% higher attrition rates in fragile settings).

Subnational disparities within countries also emerged as a critical equity concern. AARs from Nigeria, for instance, repeatedly highlighted that while Lagos and Abuja had robust response capacities, northern states faced severe shortages of trained personnel and diagnostic facilities, delaying outbreak detection by 2–3 weeks. Similarly, rural-urban divides in Liberia and Sierra Leone meant that laboratory sample transport times exceeded 48 h in remote districts compared to 6 h in capitals.

Language and cultural barriers significantly affected risk communication effectiveness. Francophone countries (Benin, Burkina Faso, Mali, Niger, Senegal, Togo) and Lusophone countries (Cabo Verde, Guinea-Bissau) reported greater challenges in adapting global risk messaging to local contexts compared to Anglophone counterparts. AARs from Guinea noted that French-language messaging during the Ebola outbreak failed to reach 40% of the population in the Forest Region, where local languages predominated.

These inequities have profound implications for SDG 17 (Partnerships for the Goals). Regional solidarity mechanisms through WAHO and Africa CDC must prioritize:

• -Differentiated support: Allocating resources based on fragility indices rather than equal distribution.
• -Cross-border surge mechanisms: Deploying personnel from better-resourced countries to support fragile neighbors during outbreaks.
• -Language-inclusive platforms: Developing regional communication strategies that accommodate linguistic diversity.
• -South-South learning: Facilitating peer-to-peer knowledge transfer between countries at different preparedness levels.

Without explicit attention to these equity dimensions, regional health security investments risk widening the gap between well-resourced and fragile states, ultimately undermining collective security as pathogens do not respect national borders.

5.6. National action plans

Nigeria and Ghana have demonstrated a strong commitment to strengthening their health security systems by systematically integrating findings from the Joint External Evaluations (JEE) and After-Action Reviews (AAR) into their National Action Plans for Health Security (NAPHS) [26]. In Nigeria, the JEE highlighted critical gaps in surveillance, laboratory networks, workforce development, and emergency response coordination, which informed the prioritization of strategic investments in expanding subnational surveillance systems, enhancing laboratory diagnostic capacity, and strengthening multisectoral coordination platforms [5]. Similarly, Ghana used its JEE and AAR findings to align national priorities with identified weaknesses, particularly in risk communication, emergency preparedness, and workforce training, ensuring that the NAPHS became both evidence-driven and context-specific. By grounding their NAPHS in these assessments, both countries have fostered a more targeted and resource-efficient approach to addressing International Health Regulations (IHR) core capacity gaps, while also improving accountability and monitoring mechanisms for sustained health security improvements [27], [28].

5.7. Implications for strengthening health security evaluations

• 1.Integrating AARs into National Preparedness Planning: As AARs offer valuable insights into operational gaps, incorporating their findings into JEE follow-up evaluations could enhance the accuracy and relevance of preparedness assessments [5], [20].
• 2.Enhancing the JEE Methodology: The discrepancies in surveillance, risk communication, and cross-border coordination highlight the need for a more dynamic and field-tested JEE framework that evaluates policy and planning and real-world implementation capacity [5], [29].
• 3.Targeted Investments in Underperforming Areas: The persistent weaknesses in laboratory capacity, workforce shortages, and medical countermeasures call for regional investments in diagnostic networks, training programs, and supply chain resilience to ensure that preparedness translates into effective response capabilities [30], [31].
• 4.Strengthening Cross-Border Coordination: Given the weak alignment between JEE scores and AAR findings for cross-border surveillance, ECOWAS and regional health organizations should prioritize joint surveillance frameworks and rapid response protocols to improve outbreak containment[8].

6. Conclusion

This study highlights the critical role of Joint External Evaluations (JEEs) and After-Action Reviews (AARs) in assessing health security capacities in West Africa, while revealing key gaps between theoretical preparedness and real-world response performance. Our findings demonstrate that while JEEs provide a strategic foundation for identifying systemic weaknesses, they often overestimate operational readiness—particularly in areas like cross-border coordination, risk communication, and medical countermeasures. To bridge this gap, we emphasize the need to align JEE indicators with SPAR-derived operational benchmarks, ensuring that assessments reflect not only policy frameworks but also actionable, field-tested capabilities.

The State Party Annual Reporting (SPAR) tool's granular focus on implementation—such as supply chain functionality, workforce deployment, and real-time surveillance—can serve as a complementary lens to refine JEE criteria. By integrating SPAR's operational metrics into JEE methodologies, countries can develop more accurate, actionable roadmaps for preparedness. This alignment would empower regions like West Africa to translate high-level strategic assessments into practical, resilient response systems, ultimately closing the gap between evaluation and execution.

6.1. Suggestions

Based on the findings from this analysis, a few suggestions may help inform ongoing efforts to enhance public health preparedness and response in the West Africa region:

• 1.Support for Local Systems: Strengthening locally led public health systems—such as laboratory networks, surveillance structures, and workforce development programs—may help sustain core capacities beyond project lifecycles.
• 2.Integration of AAR Findings: Drawing on insights from After Action Reviews could help improve the relevance and accuracy of preparedness evaluations, such as the JEE, by aligning assessment criteria with real-world performance.
• 3.Clarification of Capacity Thresholds: Further consideration may be needed regarding whether the levels of capacity represented by JEE scores adequately reflect what is required for an effective response. This could help align assessment tools with operational needs.
• 4.Enhancing Cross-border Collaboration: Continued support for regional mechanisms that enable timely data sharing, joint planning, and coordination may contribute to a more cohesive and responsive public health system in West Africa.
• 5.Regional Workforce Training Programs: Future initiatives may benefit from incorporating lessons from existing Field Epidemiology Training Programs (FETPs) to enhance regional workforce training in West Africa. Programs such as the Burkina Faso Field Epidemiology and Laboratory Training Program (Burkina Faso FELTP) and the Ghana Field Epidemiology and Laboratory Training Program (Ghana FELTP) serve as examples for Francophone and Anglophone countries, respectively. These programs have demonstrated the potential to improve competencies in public health, laboratory services, and emergency response. Expanding such efforts could help address workforce shortages noted in AARs by broadening the pool of skilled personnel available for regional response. Additionally, the inclusion of components like the Global Laboratory Leadership Programme (GLLP) may further strengthen leadership and management capacity within laboratory systems.
• 6.National Public Health Institutes (NPHIs): Clarifying the legal and operational frameworks of NPHIs and fostering stronger ties with health ministries, academic institutions, and regional or global partners could support more cohesive and resilient public health systems. Peer-to-peer learning and sharing of best practices among NPHIs may further enhance institutional agility and readiness to address emerging public health challenges across the region.
• 7.Risk Communication and Community Engagement: Effective communication during health crises plays an important role in building public confidence. Approaches that are culturally informed and contextually tailored may help reduce misinformation and improve public understanding and trust in health interventions. Regional coordination mechanisms for risk communication—using tools such as mobile alerts and community radio—could contribute to more harmonized messaging during outbreaks.
• 8.Health Financing: Developing sustainable mechanisms for supporting public health infrastructure remains an area of continued importance. Exploring options such as dedicated public health funds or partnerships with private sector stakeholders may contribute to more stable and predictable financing for emergency preparedness and broader health system strengthening in the region.

6.2. Limitations of the analysis

This analysis has several limitations. The use of secondary data from JEE and AAR reports introduces potential biases, and the voluntary nature of JEEs means they may not fully capture national preparedness. The JEE scoring system is not highly granular and can overlook technical details or country-specific contexts. Limited availability of AAR reports also restricts the depth of regional analysis. Additionally, revisions to the JEE tool over time affect comparability between earlier and recent assessments. Despite these challenges, combining JEE scores with AAR findings offers a valuable perspective on regional Global Health Security capacities. Finally, while we systematically searched for After-Action Reviews across all available sources, some AARs were only accessible as summary reports, news releases, or secondary analyses rather than full official documents. This may have limited the depth of qualitative insights available for certain outbreaks and countries, particularly for earlier events where complete documentation was not publicly archived.

CRediT authorship contribution statement

Aishat Bukola Usman: Writing – original draft, Methodology, Formal analysis. Marianne Bonkano Laurent Comlan: Writing – review & editing. Kerton Richard Victory: Data curation, Conceptualization. Aimee Geissler: Writing – review & editing.

Funding statement

This research did not receive any specific grant from funding agencies in the public, commercial, or non-profit sectors.

Declaration of competing interest

The authors declare no competing interests.

Appendix A. Supplementary data

Supplementary material 1: Thematic Codebook for JEE-AAR Analysis

Supplementary material 2: JEE and ARR reports with hyperlink.

Supplementary material 3: JEE Version Harmonization Mapping Table (V1 to V2).

Supplementary material 4: JEE-AAR correspondence matrix

Supplementary material 5: Sensitivity Analysis Results

Data availability

All JEE reports analyzed are publicly available through the WHO Strategic Partnership for Health Security (SPH) portal at https://extranet.who.int/sph/jee-database. Direct links to each JEE report are provided in Supplementary Material Appendix A. AAR reports were sourced from WHO, Africa CDC, and national health authority websites; where full reports were unavailable, we relied on official summaries, news releases, or peer-reviewed publications, as documented in Appendix A. The thematic codebook and correspondence matrix are available at https://osf.io/k34uv/files/osfstorage.

No new individual-level data was generated. A comprehensive list of all reports analyzed, including direct URLs where available, is provided in Supplementary Material Appendix A.