An unprecedented outbreak of a novel coronavirus (SARS-CoV-2) that emerged in China in December 2019 and rapidly spread to 114 countries across the globe by 11 March 2020 resulted in the World Health Organization's (WHO's) declaration of a pandemic (1). In Africa, the spread of SARS-CoV-2 was initially centered in the northern (Algeria, Egypt, Morocco) and southern (South Africa) regions, where significant increases in the number of cases and deaths were reported from March 2020 onwards (2). In late April 2020, however, the virus had almost spread throughout the continent, and most African countries were experiencing community transmission (2). Meanwhile, the capacity of the region's health systems to effectively implement pandemic containment measures—travel restrictions, increased testing, contact tracing, isolation of cases and quarantine of contacts—was apparently sparse (3–5). Moreover, the ability of African economic systems to resist and recover from these containment measures represented another tricky situation (3, 4). These challenges led to the international prediction of a drastic effect of the pandemic in Africa (6).

In Guinea, the first case of the novel coronavirus disease (COVID-19), imported from Europe, was reported on 12 March 2020 and the first death on 14 April 2020. At the time the pandemic hit Guinea, the country was undergoing a constitutional reform, with a background of socio-political crises. Moreover, no formal national framework for epidemic-preparedness and response existed at the pandemic onset, although the National Agency for Health Security (ANSS)—the former national Ebola response committee—had gained more power and influence in epidemic management in the past years, since its establishment in June 2016 (7). Therefore, the pandemic declaration resulted in a power struggle among several actors of the health system in Guinea (8, 9). These contextual factors certainly contributed to hindering the gains of the post-Ebola health system strengthening reforms for the initial COVID-19 preparedness and response (10, 11). From mid-April 2020 onwards, for example, a steep increase in cases was observed in Guinea, compared with Sierra Leone and Liberia, which had also been confronted with the 2014/2016 Ebola epidemic (8, 12). Nevertheless, in the same period, the number of reported deaths was much lower in Guinea compared with Sierra Leone, Liberia and many other west African countries (12).

Some authors have documented Guinea's response to the COVID-19 pandemic (8, 9, 12–15). However, these studies focused on the country's early response while the pandemic was unfolding. At the time of writing this paper (November 2021), Guinea has experienced three epidemiological waves of the COVID-19 pandemic; the first wave being the longest (from March 2020 to January 2021) and the last the deadliest (43 deaths per month on average compared to 7 and 18 respectively during the first and second wave). It is, therefore, necessary to establish a broader picture of the country's experience during the first and subsequent waves of the pandemic.

The national healthcare system is essentially based on the public service with three distinct levels of health services provision: primary, secondary and tertiary. The primary level includes 410 health centers; the secondary level comprises 33 districts hospitals, and 7 regional; and the tertiary level is composed of 3 national hospitals. Households constitute the primary source of health financing through direct payment, with 62% of expenditure, followed by the external funding from multilateral cooperation (27%). The share of the Ministry of Health's budget in the national budget remained below 3% between 2010 and 2014, before rising to 8% in 2016, after the Ebola epidemic.

In terms of clinical management of epidemic and pandemic prone diseases, the country has 33 epidemic management centers, distributed among the health districts. At national level, several institutions have been capacitated in the post-Ebola context to improve epidemics preparedness and response in the country. These institutions include the national directorate for epidemiology and disease control (DNELM), the national institute of Public Health (INSP), and the national health security agency (ANSS), with overlapping functions in the epidemics surveillance and control. However, from 2017 onwards, the ANSS has gained more Leadership in epidemics surveillance and control, including sporadic cases of human anthrax, measles, varicella, and yellow fever (7). The ANSS has deconcentrated structured integrated to regional (regional alert and response team) and district (district team of alert and response) health systems. The ANSS is technically and financially supported by the Ministry of Health and development partners including the world health organization (WHO), the center for disease control and prevention of Atlanta (CDC), and the World Bank (7).

Therefore, this study aimed to describe policy decisions to the preparation and response to the COVID-19 pandemic from January 2020 to November 2021, community responses to these decisions. Such findings would provide lessons for management of future epidemics and pandemics in Guinea, and countries with similar context.

The chronology of events pertaining to the COVID-19 response can be divided into five major phases or periods (described below) according to the national dynamics of the response: policy action or inaction, extensive nature of decisions or not, and the epidemiological context (increased in cases notification or not) (Figure 2).

This study analyses Guinea's preparedness and response to the COVID-19 pandemic during the first 22 months. This study provides five key learning points for future epidemics and pandemic preparedness and response in Guinea, and beyond. These include, in the pre-epidemic period, the necessity of setting up an epidemic governance framework that is articulated with the country's health system and epidemiological contexts; and the importance of mobilizing emergency funds to support a rapid health system response whenever epidemics or pandemics hit. This study also teaches that each epidemic is unique, and previous exposure to similar ones does not necessarily guarantee population and health system resilience. Moreover, the study analyses that epidemics generate social distress because of the restrictive measures they require for their control, but the excessive securitization of epidemics response is counterproductive. Finally, from a political point of view, decision-making for epidemic control is not always disinterested; it is sometimes rooted in political computations, and health system actors should learn to cope with it while at the same time, safeguard trusted and efficient health system responses.

First, the analysis of pandemic preparedness reveals an early response, almost 47 days before the virus was introduced into Guinea. This early response was coordinated by the ANSS, the former Ebola coordination body, which has strengthened its leadership in the response to recurrent epidemics including anthrax, measles and yellow fever from 2017 onwards. This recent role of ANSS in the response to epidemics in Guinea had implicitly played its value, particularly in obtaining support from several actors, including decision-makers and development partners, for the coordination of preparedness and response to COVID-19. Despite this, however, we noted tensions between several health system actors when it came to formally assigning, through a presidential decree, the coordination of the response to the ANSS. These tensions were likely entertained by the absence, before COVID-19, of a formal framework for epidemic governance, with a clear distinction between the roles and responsibilities of the actors. The difficulties in coordinating the COVID-19 response mechanisms at the beginning of the pandemic might explain the increase in incidence cases of disease during this period in Guinea, compared with west African countries like Liberia, Sierra Leone, Mali, and Burkina Faso (8, 12). This is why we argue that national stakeholders should formalize epidemic governance framework, in pre-epidemic period, in order to ensure effective coordination of epidemic or pandemic response. Such a governance framework should take into account local specificities.

In Guinea, for example, two options can be envisaged with their pros and cons. A first option would be to establish the ANSS as the leading organization for the coordination and implementation of epidemics and pandemics preparedness and response interventions. Such a measure, because of its centralized nature, would facilitate decision making and operationalisation of health interventions in the face of epidemics or pandemics. However, as noted during this study, the concurrent emergence of epidemics would substantially reduce the response capacity of such an arrangement (7, 44). Also, such a vertical response mechanism would raise questions about the sustainable strengthening of the health system, including routine immunization services and interventions since the latter has not yet been integrated with COVID-19 immunization in Guinea. Also, in a context of political instability—with its implication for change in leadership positions in national institutions—the risk that institutional memory for epidemics preparedness and response is altered could be high. Specially, because with the recurrence of epidemics and pandemics in Africa, the mobility of such experienced health workers in managing epidemics could also be high.

A second option in Guinea would be to decentralize epidemics and pandemics response functions. For example, in the pre-epidemic period, the DNELM could be responsible for routine surveillance of diseases with epidemic potential. In the event of an epidemic or pandemic, this surveillance role could be devolved to the ANSS while the INSP would be responsible for their diagnosis. The EPI/DNELM would be responsible for the vaccination pillar in the response to epidemics. Such a mechanism therefore implies setting up the ANSS as an “agence de veille sanitaire” in the pre-epidemic period. However, such a scheme would give the advantage to several national institutions to test their capacities during epidemics and draw lessons for their continuous strengthening.

Second, this study highlights the unpredictability of epidemics including their occurrence in a difficult socio-political and economical context. In Guinea, the pandemic occurred in Guinea in a period when donor countries were confronted with an acute phase of the disease. Importantly, the COVID-19 pandemic also occurred in the middle of an electoral process for the renewal of legislative and presidential institutions. In this context, despite the anticipation of the response by health system actors, the implementation of the pandemic preparedness and response interventions was difficult, due to among others the low mobilization of financial resources to support the COVID-19 response strategies. This finding raises the question on the need of putting in place sustainable funding mechanisms for improving national health system readiness toward epidemic-prone diseases. One way of doing this may be creating, in pre-epidemic situations, an emergency fund that can be used by health system actors as soon as an epidemic-prone disease occurs on the national territory. Such funding mechanisms could avoid unnecessary delays in responding to emergencies.

Third, this study also analyses that each epidemic is unique, and previous exposure to similar ones does not necessarily guarantee population and health system resilience. In 2014, Guinea was the epicenter of the largest and deadliest Ebola outbreak in human history. This outbreak triggered several health system reforms to improve the national health system resilience. These efforts yielded positive results in the rapid response to the recurrent epidemics in Guinea, including the 2016 Ebola outbreak (7). However, our findings showed that the country was not well-prepared to deal with the COVID-19 pandemic. First, Ebola treatment centers were proven inappropriate to manage COVID-19 cases due to lack of adequate equipment—for example, lack of oxygen tanks—for COVID-19 treatment. Second, the testing capacity of national reference laboratories were very limited, given the high infectivity of COVID-19 compared to Ebola. Similarly, the bed capacities of Ebola treatment centers were very limited during the early phases the COVID-19 pandemic. Third, the health services utilization was compromised during the first wave of the pandemic due to a lack of personal protective equipment for health workers, and people's fear of visiting health facilities. All of these point to the fact that the Ebola experience did not guarantee effective preparedness and response to the COVID-19 pandemic. Delamou et al. in their rapid assessment of health system preparedness and response to the COVID-19 pandemic undertaken in 13 health districts in Guinea, reported that most of healthcare facilities visited did not have intensive care units (95%), oxygenators (98%), and respirators (94.4%) (50).

Fourth, the finding shows that epidemics generate social distress because of the restrictive measures they require for their control, but their excessive securitization is counterproductive. The securization of the COVID-19 pandemic response has been documented to negatively impact populations health with implication on injuries and deaths as results of policy interventions, but also an increase in their resistance to government response measures (7).

Fifth, the analysis of the COVID-19 pandemic response process in Guinea reveals that decision-making was sometimes underpinned by political considerations. At times, COVID-19 was used by politicians as a springboard to push through decisions that were favorable to them. For example, bans on mass gatherings or movements on the eve and aftermath of elections were surely taking as a dissuading measure for political protests. Such situations have also been reported in other countries such as France (51). However, health system actors should learn to cope with it while at the same time, safeguard trusted and efficient health system responses. In Guinea, health system actors adapted to this situation by emphasizing the importance of facemask wearing and compliance with barrier measures during political campaigns, appealing to political leaders for their responsibility to enforce health guidelines related to COVID-19, but also by undertaking active case finding and systemic testing among high-risk groups following periods of intensified mass movements.

Furthermore, referring to Kruk definition of resilient health system, this study analyzed that the Guinean health system resilience capacities have been improved (52). First, the Guinean health system actors adopted an earlier response, about 47 days, in face of the SARS-CoV-2 introduction on the national territory, notably through the planning of epidemiological surveillance, and case management. This result could be explained by the experience heath system actors have acquired in managing the 2014–16 Ebola epidemic, the gains of the post-Ebola health system reforms that led to the establishment of a central public health emergency operation department networked with 38 health districts and the training of biosecurity workforce (45). Authors have reported that exposure to major epidemics in the past is associated with earlier responses, especially in implementing epidemiological surveillance strategies (53). In Liberia and Sierra Leone, the two other West-African countries severely affected by Ebola in 2014–16, rapid readiness of health systems have also been reported (54, 55). Second, the declaration of the COVID-19 pandemic triggered the undertaking and implementation of several innovative approaches in Guinea. These initiatives include a phytomedicine therapeutic trial; manufacturing of hydroalcoholic solutions and traditional facemasks; and COVID-19-patient monitoring and spraying machines. These initiatives have certainly helped the country to overcome the global challenges of health resources (e.g., masks, hydroalcoholic solutions), especially observed in developing countries, for the control of the acute phase of the pandemic (56, 57). Some authors define attitudes that help societies to resist shocks as an indication of improved collective resilience (58, 59). Third, the COVID-19 pandemic response in Guinea acknowledge the rise of new players in the health system, compared with Ebola in 2014/2016. Despite the positives discussed, some challenges have been noted in the COVID-19 pandemic response processes in Guinea. This include the indirect effects of the COVID-19 pandemic control measures on populations socio-economic and psychological wellbeing. For instance, increases in transportation fare and loss of income for many private institutions in Guinea such as restaurants, bars and hotels were noted as results of, unnecessarily prolonged restrictive measures. Authors in South Africa have reported that the prolonged effects of restrictive measures such as lockdowns have resulted in acute panic, depression, anxiety and social unrest (60).

The present review has some limitations. First, the methodological design of this study—scoping review—did not allow any quality (or risk of bias) assessment of included studies. This could limit the internal validity of the findings reported in the present study. Second, this review covers the period between January 2020 and November 2021. Given the highly dynamic and changing prospects of the COVID-19 pandemic, and the high political instability in Guinea, conclusion of the study may not be applicable to next phases of COVID-19 response. However, this study utilizes diverse data sources to allow a better understanding of the responses from the government and other civil actors in the country, during the 22 first months of the pandemic. It therefore provides insights on challenges health system actors have been confronted with, and proposed solutions for an improved preparedness and response strategies of future epidemics and pandemics in Guinea.

This scoping review aimed to assess the response triggered in Guinea between January 2020 and November 2021. It provides several learning points for future epidemics and pandemics preparedness and response in Guinea, and beyond. These learning points include the necessity of setting up, in the pre-epidemic period, an epidemic governance framework that is articulated with the country's health system and epidemiological contexts; the importance of mobilizing, during pre-epidemic period, emergency funds for a rapid health system response whenever epidemics hit; each epidemic is a new experience as previous exposure to similar ones does not necessarily guarantee population and health system resilience; epidemics generate social distress because of the restrictive measures they require for their control, but their excessive securitization is counterproductive; and that decision-making for epidemic control is not always disinterested, from a political perspective, and that health system actors should learn to cope with it while safeguarding trusted and efficient health system responses. Health system actors anticipated the response to the COVID-19 pandemic and (re-) adapted response strategies as the pandemic evolved. There is a need to work toward rethinking the epidemics governance framework and funding mechanisms in Guinea for improved health system efficacy toward their management.

The study protocol was developed by DK, FK, and AD and reviewed by WV and IA. DK and FK did the data analysis, performed the literature search, screening, and selection of articles. The first draft of the manuscript was written by DK. The manuscript was critically reviewed by WV, J-PD, and IA. All authors were involved with interpretation, read, and agreed to the final version of this manuscript.

This study was funded by the International Development Research Centre (IDRC), Canada through the Grant number (CATALYSE PROJECT 109479-001). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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