This was an observational, qualitative descriptive study aimed at documenting the process, best practices, lessons learned, and challenges encountered during the development of the second NAPHS 2025–2029 for Sierra Leone. The NAPHS development process was guided by the 2024 WHO NAPHS implementation toolkit (18) and was conducted and documented from June 2024 to April 2025.

Data were collected through direct observation and documentation of key activities undertaken during the NAPHS development process. These activities included multiple workshops to develop, prioritize, and cost planned activities. The tools and templates used for the NAPHS development process were derived from the 2024 WHO NAPHS implementation toolkit (18). In addition, the updated WHO IHR Benchmarks digital tool (19) was used to autogenerate a draft NAPHS, while an Excel costing tool template was provided by the WHO Regional Office for Africa.

To document each activity conducted, trained rapporteurs completed a standardized reporting template within 1 week of activity completion. The template captured the activity name, dates, justification, objectives, participants, facilitators, outputs, and budget. Rapporteurs received training to ensure consistency in data capture and to minimize observer bias. These reports served as the primary data source for this study.

To complement these reports, additional information was obtained from key informants drawn from stakeholder groups that participated in the process. Data were collected using a semistructured questionnaire administered via an online Google Form (Supplementary File 1). The questionnaire was voluntary and collected information on national ownership, stakeholder engagement, best practices, lessons learned, challenges, and recommendations for future processes.

The data analyzed were predominantly qualitative, drawn from the documented activity reports and key informant responses obtained through the Google Form. A team of five members of the NAPHS planning team reviewed and synthesized the data manually to identify common themes as described by Braun and Clarke (20). The main variables of interest included activities undertaken during the NAPHS development process, dates and costs of each activity, best practices, lessons learned, challenges, and recommendations for future improvement. Data were analyzed at the aggregate level, and no personal identifiers were analyzed.

Responses collected from key informants through the Google Form were exported into Microsoft Excel for organization and then analyzed thematically. Thematic analysis involved familiarization with the data, coding of key concepts, and identification of emerging patterns across responses. Codes were grouped into broader themes that reflected participants’ perspectives on the study objectives. Representative quotations were used to illustrate key themes and ensure that findings captured the diversity of views among informants. The data analyzed were then triangulated with the activity reports and used to write this paper.

The NAPHS development process followed the One Health approach with all key sectors represented such as human health, animal health, environment, water and sanitation, security, finance, and civil society, among others. Approximately 100 participants participated in the process at various stages, and the majority (65, 65%) were from government organizations, while the rest (35, 35%) were from non-state organizations. The government participants were drawn from 14 government ministries, departments, and agencies, while the non-state organizations were from 12 organizations representing UN agencies, non-governmental organizations (NGOs), civil society, and academia. The ratio of participants from government and non-state organizations was considered fair representation based on the One Health stakeholder landscape in the country.

Approximately 40 people who participated in the NAPHS development process were invited via email to respond to the key informant questionnaire, of which 12 responded, representing a response rate of 30%. Those who responded were from the following organizations: National Public Health Agency, Ministry of Health, Ministry of Agriculture and Food Security, World Health Organization, and ICAP. The majority of those who responded said they were actively involved in all the stages of the NAPHS process. Most also reported that the overall process was well coordinated and fully owned by the government and that the majority of the stakeholders participated in the process, except the private sector.

The development of Sierra Leone’s second NAPHS (2025–2029) was conducted between June 2024 and April 2025. The process included a sequence of nine structured steps/activities as shown in Figure 1. The first step was the formation of a multisectoral eight member NAPHS planning team that conducted stakeholder mapping and developed a roadmap of all the activities that needed to be conducted. The planning team also conducted a thorough desk review of existing assessment reports, e.g., Joint External Evaluation (JEE), Universal Health and Preparedness Review (UHPR), State Party Annual Self-assessment Reports (SPAR), Simulation Exercises (SIMEX), After-Action Reviews (AARs), and Intra-Action Reviews (IARs). The subsequent steps were conducted in a series of four workshops, with each having specific outputs. The use of standardized reporting templates facilitated systematic documentation across all activities/steps, as shown in Figure 1.

The first workshop was held for 5 days and had an end-term evaluation of the first NAPHS (2018–2022) conducted (Figure 2) as well as a SWOT analysis of the health security situation in the country. During this workshop, a draft strategic NAPHS was autogenerated using the WHO benchmarks digital tool. There was a choice of updating the old NAPHS or autogenerating a draft from the benchmarks tool, which already had the country’s 2023 JEE report. Based on the NAPHS end-term evaluation and the JEE outcomes, the old NAPHS was considered too broad and non-specific, and hence, a decision to use the benchmarks tool was preferred.

Past assessments showed that the country had not made significant improvement in JEE scores: 61% of the JEE indicators had limited or no capacity in 2016, and this remained more or less the same at 62% in 2023. Using the autogenerated draft plan and the 2023 JEE recommendations as a starting point, the objectives and target scores for each of the 56 JEE indicators were agreed upon for midterm (2027) and end term (2029). In general, the country decided to increase the JEE score by two levels for those indicators that were at level 1 (no capacity), increase by two levels for those indicators that were at level 2 (limited capacity), and increase by one level for those indicators that were at level 3 (developed capacity). For those indicators that were at level 4 (demonstrated capacity), the decision was either to sustain or increase to level 5 based on the feasibility of sustainability.

Based on the JEE objectives and target scores, the proposed 900 generic strategic actions/activities in the draft plan were reviewed alongside the 95 specific JEE recommendations from the country report. These activities were contextualized and prioritized to only those that had an impact on the JEE target scores and addressed immediate country priorities based on other reports, such as the UHPR and other assessments. Special focus was given to technical areas that had underperformed in the past due to funding and human resource challenges, such as antimicrobial resistance, national laboratory system, food safety, biosafety and biosecurity, chemical events, and radiation events. Therefore, technical areas that had a low JEE score had more proposed activities in order to move them to the desired two-level improvement.

In total, 257 strategic actions were selected for implementation (approximately three to five activities per indicator based on the desire for change). Though the prioritized activities were more than the 167 in the previous plan, it was found necessary to have better-defined activities that were measurable and realistic based on lessons learned from the first NAPHS.

The second workshop was conducted for 4 days by a multisectoral team of 20 that was drawn from the various stakeholders. This team reviewed the first NAPHS (2018–2022) that had expired and updated it to capture the outputs and discussions of the first workshop of the second NAPHS (2025–2029). Specifically, the team developed a Word version of the draft NAPHS that captured the various chapters and sections based on discussions from the first workshop: background/context, country IHR assessments, SWOT analysis, vision, mission, objectives, core values, methodology, strategic actions agreed on, implementation/governance plans, etc.

A third costing workshop was held for 4 days and was attended by 70 participants. During this workshop, 905 detailed activities (subactivities) were generated and costed from the 257 prioritized strategic actions. The total cost of the 5-year plan was $91.6 million, with only approximately 21% of the funding available. The technical areas having the highest contribution to the cost were immunization (16.4%), infection prevention and control (14.5%), and surveillance (13%). The least cost contributors were health equity and human rights (0.2%) and linking public health and security authority (0.3%).

The fourth and final workshop was held for 4 days by 70 participants to validate the costed plan. During this workshop, the teams also developed a 2-year operational plan (2025–2026) and conducted a resource mapping for it. The total budget for the 639 detailed activities that were prioritized for the first 2 years (2025–2026) was $42,398,480, of which only $12,104,780 (29%) was available by the time of finalizing the plan. Of the 639 prioritized activities, 23% were fully funded, 10% were partially funded, while 68% had no funding, as shown in Figure 3.

Key informants highlighted several best practices that contributed to the success of the NAPHS process (Table 1). Strong government ownership was frequently emphasized, with the National Public Health Agency of the Ministry of Health providing leadership and oversight throughout. Broad stakeholder engagement, involving all the 19 technical areas of the JEE/NAPHS with participants drawn from more than 15 MDAs and 15 non-state actors (UN/NGOs/CSOs/academia, etc.) ensured a multisectoral perspective. The use of standardized templates and tools from the 2024 WHO NAPHS toolkit promoted consistency in documenting workshop outcomes. Evidence-based planning and prioritization of activities based on national priorities and JEE and other assessment recommendations ensured a focused plan with a lean budget.

To facilitate objective monitoring of the plan, midterm and end-term JEE targets were included unlike the first NAPHS. Partner coordination was cited as critical in avoiding duplication and ensuring alignment of technical support. Additionally, a 2-year operational plan was developed, and resource mapping was conducted to enable gaps to be identified for resource mobilization. Lastly, equity, gender, and human rights are very important pillars of social inclusion. Since gender was already included as an indicator in the NAPHS, an extra technical area known as “equity and human rights” was added in addition to the usual 19 technical areas in order to champion for equity, human rights, and social inclusion in the country.

The NAPHS process generated important lessons for future planning. First, early planning was identified as essential to ensuring the timely development of NAPHS. For example, there was a 2-year gap between the end of the first NAPHS (December 2022) and the start of the second NAPHS (January 2025) due to delayed planning. Although the JEE assessment was done on time (March 2023) after the expiry of the previous NAPHS, there was more than a 1-year time lag between the JEE assessment (March 2023) and the start of the second NAPHS development process (June 2024). The main reason for this delay is that the JEE report was officially published by the WHO in November 2023 (8 months after the assessment), but the country did not come to know about it until March 2024. To ensure the NAPHS planning process can start on time in the future, the WHO needs to fast-track the JEE publication process and also ensure timely communication to the countries.

Second, continuous communication with stakeholders, including regular updates, maintained momentum and fostered inclusivity during the planning process, and this should be institutionalized.

Third, the NAPHS mid- and end-term evaluations showed that activity completion was high, but this did not match the low JEE capacity improvement due to misalignment of activities. Activities selected for NAPHS should therefore be based on their potential impact on JEE. Fourth, the multisectoral NAPHS workshops were conducted in the same venue with small groups of 2–4 technical areas in close proximity. This allowed for seamless consultation and collaboration across technical areas. Fifth, capacity building, particularly training of rapporteurs, was found to improve the quality and timeliness of documentation. Lastly, the NAPHS development coincided with the United States Government funding freeze in early 2025, and alternate sources of funding had to be sought to complete the process.

The total direct cost of developing the NAPHS plan was $75,000. This was the cost of the four workshops that were conducted to develop the plan and comprised venue costs, travel allowances, and stationery.

Stakeholders proposed a range of recommendations to strengthen future planning cycles: Start the NAPHS planning process immediately after JEE is conducted, establish a dedicated budget line for NAPHS planning and monitoring to ensure a coordinated approach by all sectors, enhance district-level and private sector involvement, and institutionalize the identified best practices and lessons learned into the national planning process including the use of the WHO NAPHS implementation toolkit and costing tool which were found to be very useful.