A study of public health emergency management capacity and capability of Sierra Leone’s national public health agency

Abstract

Abstract Purpose Emerging National Public Health Institutes (NPHIs) often receive a statutory mandate before the internal systems and district routines needed to deliver public health emergency management (PHEM) have matured. External assessments report national capacities but reveal less about whether an institute can convert mandate into reliable emergency action. This study assessed PHEM capacity and capability at Sierra Leone’s National Public Health Agency (NPHA), examined the staff and organisational factors that shape it, and derived transferable lessons for similar institutes. Methods We conducted a convergent parallel mixed-methods study from 1 February to 31 August 2025. All 214 staff were invited to a structured survey rating perceived readiness across eleven PHEM domains; 180 (84.1%) responded. In parallel, 28 key informant interviews and four focus group discussions (32 focus-group participants) were conducted, stratified by organisational role. Routine institutional and operational records were reviewed for triangulation across a 12-month window. Quantitative data were analysed using descriptive statistics and multivariable logistic regression with pre-specified interaction terms; qualitative data were analysed using a role-sensitive framework approach; and the strands were integrated through a joint display. Results Mean overall readiness was 2.8 of 5 (standard deviation 0.7). Internal human resource (HR) management was the lowest-rated domain (mean 2.1; 12.8% rating four or five), below workforce and surge capacity (mean 3.0), surveillance (mean 3.4) and coordination with partners and the Ministry of Health (mean 3.6). Technical cadre combined with prior outbreak-response experience was associated with higher readiness beyond the additive effect of either characteristic (adjusted odds ratio 3.41, 95% confidence interval 1.62–7.18). Routine records converged with staff perception: vacancy rate 25.2%, documented induction for 31.7% of new appointees, completed appraisal for 13.1% of staff, partner-supported workforce 40.7%, and documented emergency roles for 43 of 74 surge-rostered staff. Across 12 reviewed events, median emergence-to-detection was 5 days and detection-to-notification 1 day, but median notification-to-completion of early response was 18 days. Qualitative accounts across all role groups converged on weak internal HR systems, centralisation and dependence on a small experienced cohort. Conclusions NPHA’s principal constraint was not its legal mandate, its partner relationships or its outbreak experience, but the incomplete institutionalisation of the systems that convert those assets into consistent emergency action. Internal HR management, surge documentation, emergency financing, procurement and district response systems were the weakest links between mandate and capability. Similar emerging NPHIs should treat these systems as core emergency preparedness infrastructure rather than administrative functions.