Introduction

Global health security is one of the current public health approaches that is revolutionizing public health and global health [1]. Public health is currently facing enormous challenges, such as emerging and re-emerging diseases, access to quality and equitable care, internally displaced populations, food and nutritional security [1-6]. Today, one of the promising public health interventions that contributes to global health security is the establishment of national public health institutes [7,8]. More and more international organizations are promoting these public health operators to respond to the public health call to urgently address emerging and re-emerging epidemics in different countries around the world. We can also cite, on a global scale, WHO, International association of national public health institutes (IANPHI) and since 2015 at the African level, Africa CDC. The intensive promotion of these new public health organizations come from lessons learned from the management of health disasters experienced by certain countries on the Africa continent such as Ebola, covid-19, Dengue [2, 9-11]. Great efforts are currently being made to show the results of countries’ interventions face of epidemics and major public health problems [8, 11-15]. However, there is a lack of knowledges sharing in the African region on the creation and operationalization of public health institute. Such knowledges would be useful for political advocacy to decision-makers, to integrate NPHI into their public health security development.

Africa Control of disease center (CDC) published a report at the end of 2022 on the development of African NPHIs and their degree of maturation [16]. According to this report, only 30% of NPHI at the African level were established to contribute to national, sub-regional and continental health security. The objective of this study was to advocate for the implementation of NPHI as crucial elements of public health systems improvement. The specifics objectives were to provide data about NPHI implementation and to share knowledges for decision-makers (high-level leadership of countries such as ministers of health), public health managers, international public health networks and.

Materials and Methods

Study Design

This study used cross-sectional qualitative design. Study has been conducted in the technical directorates of the NPHI, the technical directorates of the Ministry of Health in Burkina Faso, and other ministries and stakeholders involved in the NPHI development.

Study Setting and Population

Study has been implemented from January to July 2023. The period of the study was 2018-2023. The study was exclusively based on a literature review added by interviews with key informants who participated or who lived the experience (NPHI operationalization). NPHI of Burkina Faso is a public health operator that is mainly in charge of four missions which are: health monitoring, research, expertise/training, and reference central laboratory. This study concerned the development phase of the NPHI. NPHI of Burkina Faso was created in July 2018 by decree taken by the council of ministers.

Staff who was involved in this operationalization phase was asked to participate to this study. NPHI Burkina Faso is a public organization of the Ministry of Health which has legal personality. It receives annual funding from the government. It employs permanent staff (around 250 agents), contractual staff, teacherresearchers, and expatriates (around 120 agents). All this staff participate in the management of essential public health functions leaded by NPHI. NPHI is composed of 6 technical directorates (MURAZ center, the Nouna health research center, the national training and research center on malaria, the central reference laboratory, the center of operations and responses to health emergencies, the national population health observatory). It also involves a scientific department which coordinates all of the scientific activities, and a general secretariat which coordinates all administrative and financial activities. These six (n=6) technical directorates produce scientific evidences that health programs of the MoH use to improve the health of the population.

Study population consisted of all the documents (reports, normative documents, travel reports, etc.). Documents that were collected and introduced into the analysis were i) all the documents that were written during the preliminary setup, ii) all the documents that were written during the operationalization phase of the NPHI. Participants included in the interviews were part of the NPHI, ministry of health, others sectors ministries, and others stakeholders involved in the development of NPHI.

Sample Size

We included 15 keys people who participated or who experienced each the two phases of the study. The selection criteria were: knowledges of NPHI, involvement in working groups during the development of its strategic plan, in the drafting of documents and normative texts and in the development of the missions of the NPHI. Four documents were included in the study: NPHI Strategic plan 2020-2024, roadmap, Decree of creation of NPHI, particularly status of NPHI.

Variables

Variables included NPHI creation and development, functions of the NPHI and the roadmap of development. We also included leadership of the ministry in charge of health, partnership, strategic plan and institutional communication.

Data Resource

Data collection tool

We used literature review and interviews to collect data. Data extraction grids for the document review and semi-structured questionnaires were used for data collection.

Data collection

Three (n=3) experienced experts who were familiar with the health system, the issues of governance and management of public health institutions, were mobilized for 3 months to contribute to data collection (data extraction, interviews, analyzes and the presentation of the first results). Data was collected from notetaking, accompanied by recordings which were then encoded using qualitative data processing software.

Bias and limitations

This study had some limitations and bias. We can noted desirability bias for this qualitative study. Also, the study has carried out accordance with qualitative method. It is contextbased. So, the results concern the context of the Burkina Faso health system. No generalization or copy pass are possible in this case.

Data analysis

The operationalization phase corresponds to the stage of development of the essential’s public health functions of the NPHI. This development was achieved by procedures, normative texts, human, financial, logistical, informational, and relational resources. Data analysis from the literature review and interviews were carried out to identify the enabling factors contributing to the success of this phase. The analysis of the thematic content allowed the identification of factors favorable to the success of this phase. Verbatim language was used to illustrate some comments made by the participants.

Ethical consideration

Administrative agreements were obtained to allow experts to collect data from identified participants. Prior permissions from participants were obtained before recording the recorded interviews. All interviews were anonymized.

Results

Participants

Participants were 15 keys people who participated or who experienced the operationalization phase. We also included these documents: NPHI Strategic plan 2020-2024, roadmap, Decree of creation of NPHI, particularly status of NPHI.

Descriptive Data

The creation and development of the NPHI. After the preliminary setup phase, the NPHI was created by decree n°2018- 0621/PRES/PM/MINEFID/MS/MESRSI of 7/19/2018. Its special statutes were also adopted giving it the status of public health establishment (EPS) with legal personality, administrative and financial management autonomy. The NPHI was created to meet 3 needs in the MoH:

• Responding to problems of coordination of essential public health functions
• A new public health operator within the health system dealing with health security operations
• A decision-making tool

After the creation of the NPHI and the adoption of the statutes, it was necessary to organize the structure and operating texts, management procedure manuals, strategic plan, scientific program, annual action plans for resource mobilization to engage ministry of health and partners. The development of all these instruments was based on a roadmap to be implemented with basic human, material and financial resources. The Director General was the first person appointed by the Council of Ministers to operationalize the NPHI. He was responsible for organization, development of the NPHI functions and reach out administrative and scientific deliverables.

The functions of the NPHI and the roadmap. The methodical operationalization of the NPHI functions is part of a roadmap shared and regularly monitored by its management bodies (staff of directors and administrative council). The content of this roadmap was to:
• Develop the structures of the NPHI (texts, management bodies, procedures, manual, teams, etc.)
• Ensure the merge of all resources from different centers and their development (human, material, informational, financial resources)
• Ensure governance (leadership, participatory management, ownership, procedure manuals, etc.)
• Develop internal and external communication
• Develop the NPHI functions
• Develop partnerships: research, technical, financial, training,

Three months after the appointment of the Director General in October 2018, minimal staff was put in place for the implementation of the roadmap and functions of the NPHI. The particularity of the NPHI of Burkina Faso is that it was born from the merger of structures that already existed. Some of which had a good background in scientific and administrative management. These structures were already delivering for the Ministry of Health and with technical partners. These were the 3 research centers which merged to create the NPHI (MURAZ Center, CRSN and CNRFP). According to the organization of a State public establishment (EPE), the staff was supplemented by the appointment and empowerment of 6 technical directors for each of the NPHI centers. In addition to the 6 DT, administrative, financial, and scientific directors were appointed to support the Director General in accountability towards the two supervisory authorities of the NPHI (ministry in charge of health and in charge of the economy).

What facilitated the establishment of technical staff was the mobilization and deployment of pre-existing staff in the structures which merged to create the NPHI. This mobilization was supplemented by staff from the Ministry of Health. Thus, it was necessary to simultaneously implement the functions of the NPHI and deliver for the ministry. A good example is that of the two successive crises that the NPHI dealt with in 2019 (Yirgou community crisis) and in 2020 (COVID-19) while the NPHI was in full operationalization. Deconstruction and reconstruction approach was used by the staff. This approach comes from the fact that it was necessary to organize the devolution of all the resources of the merged structures within the same entity which became the NPHI and to work to promote positive practices, to develop common procedures, to set up common databases, a single list of human resources, single material accounting, single budget, quality.

Factors favoring the implementation of NPHI functions were summarized by the sustained leadership of the authorities of the ministry in charge of health, the commitment to a beneficial partnership, the development of an institutional strategic plan and permanent communication for visibility.

The sustained leadership of the authorities of the ministry in charge of health: This support was a trigger for the good and quick implementation of the NPHI and its functions into the health system. This leadership made it possible to reduce resistance to change and to develop trust beyond the Ministry of Health. The first example is the case of January 2019, where at the very beginning of the operationalization of the NPHI, the Minister of Health activated the CORUS to contribute significantly to the management of the Yirgou crisis. This is the social crisis in the north of the country which was the basis of community violence and the start of displacement of internal populations in the country. The first head of the health department believed in his NPHI and his CORUS and gave him the means through his activation to express himself. Thus, partners and stakeholders of the ministry of health engagement allowed the first uses of NPHI. This exercise was repeated one year later due to the appearance of COVID-19 where enormous efforts were developed such as human efforts through the establishment of CORUS response operations, intensive mobilization of financial and technical resources. From this moment, the organizational capacities of the NPHI were established and internal and external trust built to recognize the usefulness of an NPHI for a health system.

The commitment to a beneficial partnership. The process of establishing and operationalizing the NPHI in Burkina Faso benefited from strong stakeholders’ engagement. Several consultation frameworks and collective production workshops have been organized by the NPHI for this purpose. We can cite: The first meeting was the stakeholder’s engagement workshop on the operationalization of the NPHI held on February 26, 27 and 28, 2019 in Ouagadougou. This workshop aimed to:
• Harmonize the points of view of national stakeholders on the SWOTT report carried out by a consultant appointed by CDC-IANPHI;
• Collect contributions and guidance on the NPHI functions with a view to develop the strategic plan;
• Obtain consensus on the NPHI roadmap for this year.

The second partner engagement meeting was the round table discussion with development partners held in Ouagadougou on June 11, 2019. It was attended by the following partners: USAID, CDC-Atlanta, IANPHI, World Bank, UNICEF, WHO, UNFPA, European Union, WAHO, Expertise France, French Embassy, Pathfinder, ASMADE, AMP and others. Stakeholders from the Ministry of Health participated strongly in this round table. This meeting was an opportunity for the NPHI to present the main orientations and its priorities which will enable it to ensure effective implementation of its public health essentials functions. This meeting also allowed partners to ask questions about the NPHI and most importantly to present their area of interest with a view to supporting the development of the institution.

The third meeting focused on commitments and the mobilization of resources for the implementation of the strategic plan. The objective was to bring partners together around the same table so that they could express their commitments in a harmonized way to support the implementation of this strategic plan. During this session, the partners all expressed the types of support they intended to provide and designated focal points of contact within their institutions.

The fourth meeting organized on July 19, 2022 provided an opportunity to discuss with development partners the progress of the NPHI and the effects of collaboration and partnership on its progress. This meeting essentially aimed to engage the stakeholders of the NPHI of Burkina Faso in a win-win partnership, to share the achievements and institutional skills which will allow them to develop a partnership of trust, to expose the resilience mechanisms of the NPHI facing the dual insecurity and health crisis. This meeting saw the participation of non-traditional partners such as mining companies, insurance companies and banks and others.

Beyond the development of the classic partnership (technical, financial, research) in an increasingly complex global environment where countries and continents are developing instruments for global health security, the NPHI has chosen to quickly focus on international organizations that support and advocate for NPHIs such as IANPHI, CDC-US, Africa CDC, WHO, and WAHO. With these organizations, the NPHI regularly participates in high-level meetings, international meetings for the development of continental and sub-regional strategies, and in the design of instruments and manuals for health security. These meetings were opportunities to make the NPHI known, to present its deliverables and to benefit from the experiences of others to progress. It is in this sense that the NPHI holds the position of vice-chair of the IANPHI Africa network. For several years, it has regularly benefited of visits from other NPHI under construction. Among these visits, we can cite: the immersion visit of the NPHI of the Democratic republic of Congo, Mali, Tchad, Cameroon (website of NPHI of Burkina Faso). All of this constitutes enabling factors to establish a culture of trust in the health system, to attract partners, to facilitate the accession of new quality public health personnel to work for health security in the NPHI.

The development of an institutional strategic plan. From the creation of the NPHI, the challenge was to very quickly have a strategic plan in which the vision and values of the structure were expressed and known. This plan made it possible to bring together development partners, stakeholders from the ministry of health and other sectors to organize health security missions. This plan constituted the reference framework of the NPHI which allowed it to be introduced into the planning of the Minister of Health and into more strategic programs such as national health development programs. This strategic plan was developed and aligned for the most national health strategic plans and guidelines. This strategic plan in its drafting methodology made it possible to understand the challenges, the expectations of NPHI staff and its partners and to gradually work to meet them.

A factor favoring the development of strategic plan was the model of technical support through the provision by CDC/IANPHI of a consultant and technical advisor for the NPHI. During this phase, the technical support has been an innovation for the NPHI. This mission consists of developing links with other structures, other partners capable of sustainably supporting certain operations of the institution. Also, while managers work, they lack resources to develop the mobilization of other resources other than those made available by the State. This is why this support was significant for the NPHI. It made it possible to establish direct annual subsidies with IANPHI in the form of support for the activities of its action plan. Over the first years of regular support, the NPHI has benefited from more than $300,000 to support certain activities linked to investments in its unsupported action plan by the state budget. This governance mechanism set up within the structure allowed the advisor to exchange with privileged partners, to develop other areas of interest for the NPHI for win-win contracts.

The permanent communication for visibility. This institutional communication plan was a key opportunity in raising collective awareness regarding the increasingly role of the NPHI in the health system. It began with the creation and management of a website, coverage of most institutional events by the written press and national public and private television radio (RTB, faso.net, etc.). Strategic information from the NPHI was relayed by social networks and the communication networks of public health organizations which promote the NPHI (IANPHI insider). Institutional communication used national and international webinar channels to raise awareness of the structure’s achievements and its national and international expertise. The contribution of the NPHI’s expertise in leading national and sub-regional public health has been a great contribution to the visibility of the operationalization of its functions. As examples, we can cite its publicized participation in national webinars on the management of internally displaced populations, sub regional webinars with WAHO in covid-19, international webinars in the IANPHI African networks on COVID-1 (IANPHI insider): Role of West African NPHI. July 14, 2021, the IANPHI African Network hosted a webinar on the operationalization of National Public Health Institutes in the region and the lessons learned from stakeholder involvement. February 7, 2023 (IANPHI insider)

Mains Results

The enabling factors which allowed the functions of the NPHI were: the sustained leadership of the authorities of the Ministry of Health, the commitment of the structure in a beneficial partnership, the development of an institutional strategic plan, permanent communication for visibility.

Discussion

This paper presents the process of operationalization of the NPHI in Burkina Faso. Operationalization phase was participatory internally and with the interests of stakeholders within the ministries taken into account. This phase was supported by a roadmap and led by a committed, motivated management team with a good background in public health management. According to a recent report published by Africa CDC on NPHI in Africa 12/40 (30%) of NPHI reported being fully established, 17/40 (42,5%) were at an advanced stage, 6/40 (15%) had started the process and 5/40 (12%). A total of 5% said they did not have a plan to develop their NPHI. According to this report, NPHI of Burkina Faso was fully established. These results show the gaps that African countries present in restoring their health systems in the pathway towards health security. Some of recent emerging infectious diseases are still prevalent (monkey pox, Ebola, Crimea - Congo, etc.). There must attract more attention from the health authorities of these countries and their managers [17-19].

The place of these NPHI in the health system and their role in the response to epidemics no longer needs to be demonstrated [2, 3, 7]. They make it possible to establish more proactive alert and response systems for mobilizing stakeholders and more pronounced community engagement. These institutions have made it possible to rebuild effective laboratory diagnostic platforms and strengthen national and sub-regional biological and genomic surveillance, thus strengthening overall health. These NPHI have allowed African countries to rely on effective public health instruments to capitalize on their national and subregional efforts in the management of health security.

All these arguments are in favor of the establishment and acceleration of the development of NPHI in Africa. To reassure and engage decision-makers and health system managers that the process is possible and that they can successfully establish their NPHI, these evidences provided in this paper can serve as guidance. These two phases presented in this paper do not constitute a standard, nor lessons to be applied stricto- census. These are the results of an experience of the NPHI of Burkina Faso which has its socio-political and economic health context. These are variables to take into account in the use of these evidences. This paper has chosen not to address questions related to the challenges, difficulties and resistance that the actors encountered during these two phases. These questions were not lacking during the development of the NPHI of Burkina Faso. They are certainly important to take into account but too exposed, they sometimes become counterproductive and discourage certain decisionmakers and managers involved in the process. Each system must face its reality and develop its experience.

These few evidences of guidance presented in this paper for the implementation of an NPHI, are for some known in the management of public administrations. But we noted that the NPHI are specific and are based on scientific values and results. The development of NPHIs needs to be based on strong administrative and scientific values to help save lives in our populations. Also, these institutions are being set up in health systems where in certain countries departments of ministries of public health are already developing similar missions which must be known how to negotiate, where public health specialties need to understand these new concepts of preparation, alert, response, useful sectoral research, rapid collective expertise, genomic surveillance.

Conclusion

NPHIs are structures that could benefit countries facing epidemics. To success in the implementation of the NPHIs, efforts have to be made in order to integrate these keys factors identified. The decision-makers and managers of NPHI involved in the implementation of their NPHI could consider these lessons learned from Burkina Faso to succeed their missions.

What is already know

• Implementation of NPHI in the Africa context
• Documentation of epidemic quantitative research
• Availability of knowledges of the impact of epidemic on the population

What this study adds

• Framework for NPHI development
• Essentials functions of public health to address at the NPHI
• Factors favoring the development of the NPHI for decision-making

Acknowledgement

Thanks are addressed to all the authorities of the Ministry of Health who have facilitated, created, operationalized and used the NPHI for the health security. Thanks, are also addressed to the experts who facilitated the primary report of the NPHI (Dr Bocar Kouyaté, Dr Corneille Traoré,) and all technical directors, stakeholders who contributed to the development of the NPHI.

Competing interests

The authors declare no competing interests.

Authors’ contributions

HH wrote the first draft of the manuscript. PS contributed to the data collection and readed the first draft of the manuscript. AS contributed to the data collection and road the first draft of the manuscript. IB contributed to the data collection and road the first draft of the manuscript. HB contributed to data collection and data analysis. ASO contributed to the data collection and readed the first draft of the manuscript. BB contributed to the data collection. MD contributed to the proofreading of the manuscript. BI contributed to the proofreading of the manuscript., EW contributed to the proofreading of the manuscript. SO contributed to the production of the data. AZ contributed to the finalization of the manuscript. CL contributed to the production of the data. MN contributed to the finalization of the manuscript.

References

1. Agyepong I, Spicer N, Ooms G, Jahn A, Bärnighausen T, Beiersmann C, et al. (2023) Lancet Commission on synergies between universal health coverage, health security, and health promotion. Lancet Lond Engl 401(10392): 1964‑
2. Binder S, Ario AR, Hien H, Mayet N, Jani IV, et al. (2021) African National Public Health Institutes Responses to COVID-19: Innovations, Systems Changes, and Challenges. Health Secur 19(5): 498‑
3. Hien H (2020) La résilience des systèmes de santé: enjeux de la COVID-19 en Afrique subsaharienne. Santé Publique 32(2‑3): 145‑14
4. Abbas M, Aloudat T, Bartolomei J, Carballo M, Durieux Paillard S, et al. (2018) Migrant and refugee populations: a public health and policy perspective on a continuing global crisis. Antimicrob Resist Infect Control 7: 1-11.
5. Ejeromedoghene O, Tesi JN, Uyanga VA, Adebayo AO, Nwosisi MC, et al. (2020) Food security and safety concerns in animal production and public health issues in Africa: A perspective of COVID-19 pandemic era. Ethics Med Public Health 15: 1-8.
6. Lufuke M, Bai Y, Fan S, Tian X (2022) Women’s Empowerment, Food Security, and Nutrition Transition in Africa. Int J Environ Res Public Health 20(1): 1-11.
7. Clemente J, Rhee S, Miller B, Bronner E, Whitney E, et al. (2020) Reading between the lines: A qualitative case study of national public health institute functions and attributes in the Joint External Evaluation. J Public Health Afr 11(1): 1-8.
8. Myhre S, Habtemariam MK, Heymann DL, Ottersen T, Stoltenberg C, et al. (2022) Bridging global health actors and agendas: the role of national public health institutes. J Public Health Policy 43(2): 251‑2
9. League A, Bangure D, Meyer MJ, Salyer SJ, Wanjohi D, et al. (2023) Assessing the impact of regional laboratory networks in East and West Africa on national health security capacities. PLOS Glob Public Health 3(5): 1-14.
10. Johnstone PW, Costa Eder M, Newton A, Bentley N, Rufus I (2019) The West African Ebola emergency and reconstruction; Lessons from Public Health England. Br Med Bull 129(1): 79-89.
11. Kapata N, Ihekweazu C, Ntoumi F, Raji T, Chanda Kapata P, et al. (2020) Is Africa prepared for tackling the COVID-19 (SARS-CoV-2) epidemic. Lessons from past outbreaks, ongoing pan-African public health efforts, and implications for the future. Int J Infect Dis IJID Off Publ Int Soc Infect Dis 93: 233‑23
12. Chersich MF, Gray G, Fairlie L, Eichbaum Q, Mayhew S, et al. (2020) COVID-19 in Africa: care and protection for frontline healthcare workers. Glob Health 16(1): 1-6.
13. Fekadu ST, Gebrewahid AL, Mankoula W, Eteng W, Lokossou V, et al. (2023) public health emergency operations centers in Africa: a cross-sectional study assessing the implementation status of core components and areas for improvement, December 2021. BMJ Open 13(6).
14. Heymann DL, Chen L, Takemi K, Fidler DP, Tappero JW, et al. (2015) Global health security: the wider lessons from the west African Ebola virus disease epidemic. Lancet Lond Engl 385(9980): 1884‑1
15. Greiner AL, Stehling Ariza T, Bugli D, Hoffman A, Giese C, et al. (2020) Challenges in Public Health Rapid Response Team Management. Health Secur 18(S1): 8‑
16. Taame Desta H, Mayet N, Riolexus Ario A, Tajudeen R (2022) Role of National Public Health Institutes for a Stronger Health System in Africa. Fortune J Health Sci 5(4): 603-609.
17. Excler JL, Saville M, Privor Dumm L, Gilbert S, Hotez PJ, et al. (2023) Factors, enablers and challenges for COVID-19 vaccine development. BMJ Glob Health 8(6): 1-6.
18. Schneidman M, Matu M, Nkengasong J, Githui W, Kalyesubula Kibuuka S, et al. (2018) Building Cross-Country Networks for Laboratory Capacity and Improvement. Clin Lab Med 38(1): 119‑1
19. Eteng WEO, Lilay A, Tekeste S, Mankoula W, Collard E, et al. (2023) Strengthening COVID-19 pandemic response coordination through public health emergency operations centers (PHEOC) in Africa: Review of a multi-faceted knowledge management and sharing approach, 2020-2021. PLOS Glob Public Health 3(6): 1-14.