Factors influencing primary care access, utilisation and quality of management for patients living with hypertension in West Africa: a scoping review protocol.

INTRODUCTION: Hypertension, one of the most prevalent non-communicable diseases in West Africa, can be well managed with good primary care. This scoping review will explore what is documented in the literature about factors that influence primary care access, utilisation and quality of management for patients living with hypertension in West Africa. METHODS AND ANALYSIS: The scoping review will employ the approach described by Arksey and O'Malley (2005) . The approach has five stages: (1) formulating the research questions, (2) identifying relevant studies, (3) selecting eligible studies, (4) charting the data and (5) collating, summarising and reporting the results. This review will employ the Preferred Reporting Items for Systematic review and Meta-Analysis extension for scoping reviews to report the results. PubMed, Embase, Scopus, Cairn Info and Google Scholar will be searched for publications from 1 January 2000 to 31 December 2023. Studies reported in English, French or Portuguese will be considered for inclusion. Research articles, systematic reviews, observational studies and reports that include information on the relevant factors that influence primary care management of hypertension in West Africa will be eligible for inclusion. Study participants should be adults (aged 18 years or older). Clinical case series/case reports, short communications, books, grey literature and conference proceedings will be excluded. Papers on gestational hypertension and pre-eclampsia will be excluded. ETHICS AND DISSEMINATION: This review does not require ethics approval. Our dissemination strategy includes peer-reviewed publications, policy briefs, presentations at conferences, dissemination to stakeholders and intervention co-production forums.

"We have nice policies but ": implementation gaps in the Ghana adolescent health service policy and strategy (2016-2020).

Introduction: Although policies for adolescent health exist in Ghana, their implementation is challenging. Availability of services for adolescent sexual and reproductive health and adolescent mental health remains less than desired, with adolescent mental health being particularly neglected despite being an important contributor to poor health outcomes. This study presents an analysis of gaps in the implementation of the Ghana Adolescent Health Service Policy and Strategy (2016-2020), including how and why the context influenced the observed implementation gaps. Methods: Data for this study is drawn from 17 in-depth interviews with purposefully identified key stakeholders in adolescent mental, sexual, and reproductive health across the national and subnational levels; four focus group discussions (FGDs) with district health management teams; and 11 FGDs with adolescents in and out of schools in four selected districts in the Greater Accra region. Data were analyzed using both inductive and deductive approaches. The deductive analysis drew on Leichter's conceptualization of context as structural, cultural, situational, and environmental factors. Results: Of the 23 planned strategies and programs for implementing the policy, 13 (57%) were partially implemented, 6 (26%) were not implemented at all, and only 4 (17%) were fully implemented. Multiple contextual factors constrained the policy implementation and contributed to the majority of strategies not being implemented or partially implemented. These factors included a lack of financial resources for implementation at all levels of the health system and the related high dependence on external funding for policy implementation. Service delivery for adolescent mental health, and adolescent sexual and reproductive health, appeared to be disconnected from the delivery of other health services, which resulted in weak or low cohesion with other interventions within the health system. Discussion: Bottom-up approaches that engage closely with adolescent perspectives and consider structural and cultural contexts are essential for effective policy implementation. It is also important to apply systemic and multi-sectoral approaches that avoid fragmentation and synergistically integrate policy interventions.

Why district assemblies disburse resources to district health systems for service delivery at district level in the context of decentralization: a comparative study of two districts in the Volta Region of Ghana.

Objectives: To explore why the District Assembly disburses financial and other resources to the District Health System. Design: Multiple case study with a single unit of analysis (holistic) using quantitative and qualitative methods of data collection involving a desk review, analysis of routine health management information system data and key informant interviews. Setting: Two districts in the Volta Region of Ghana. Participants: Twelve key officials of each district assembly and the district health system (24 total) who had worked in the district at least a year or more. Interventions: None. Results: Both District Assemblies had moderate decision space which was influenced by their capacity, power and contextual factors like politics, economics, legal and situational factors. Disbursement of financial and other resources to the District Health Systems was influenced by financial capacity, use of power by stakeholders, context and the decision space of the District Assembly. Political actors appeared to have more power in resource disbursement decision making than community members and technocrats in a context of resource constraints and inadequate funding. The funding available was used predominantly for capital investments, mainly construction of Community Based Health Planning and Services (CHPS) compounds. Conclusion: It is important to make policies that will regulate the relative power among the political appointees like the District Chief Executives (DCEs), public and civil servants in decentralized departments and agencies and Community members to make resource disbursement more sensitive to communities and decentralized departments.

Implementation of the Community-based Health Planning and Services (CHPS) in rural and urban Ghana: a history and systematic review of what works, for whom and why.

Background: Despite renewed emphasis on strengthening primary health care globally, the sector remains under-resourced across sub-Saharan Africa. Community-based Health Planning and Services (CHPS) has been the foundation of Ghana's primary care system for over two decades using a combination of community-based health nurses, volunteers and community engagement to deliver universal access to basic curative care, health promotion and prevention. This review aimed to understand the impacts and implementation lessons of the CHPS programme. Methods: We conducted a mixed-methods review in line with PRISMA guidance using a results-based convergent design where quantitative and qualitative findings are synthesized separately, then brought together in a final synthesis. Embase, Medline, PsycINFO, Scopus, and Web of Science were searched using pre-defined search terms. We included all primary studies of any design and used the RE-AIM framework to organize and present the findings to understand the different impacts and implementation lessons of the CHPS programme. Results: N = 58 out of n = 117 full text studies retrieved met the inclusion criteria, of which n = 28 were quantitative, n = 27 were qualitative studies and n = 3 were mixed methods. The geographical spread of studies highlighted uneven distribution, with the majority conducted in the Upper East Region. The CHPS programme is built on a significant body of evidence and has been found effective in reducing under-5 mortality, particularly for the poorest and least educated, increasing use and acceptance of family planning and reduction in fertility. The presence of a CHPS zone in addition to a health facility resulted in increased odds of skilled birth attendant care by 56%. Factors influencing effective implementation included trust, community engagement and motivation of community nurses through salaries, career progression, training and respect. Particular challenges to implementation were found in remote rural and urban contexts. Conclusions: The clear specification of CHPS combined with a conducive national policy environment has aided scale-up. Strengthened health financing strategies, review of service provision to prepare and respond to pandemics, prevalence of non-communicable diseases and adaptation to changing community contexts, particularly urbanization, are required for successful delivery and future scale-up of CHPS. Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=214006, identifier: CRD42020214006.

Burden of mental health problems among pregnant and postpartum women in sub-Saharan Africa: systematic review and meta-analysis protocol.

INTRODUCTION: Pregnancy and postpartum-related mental health problems pose serious public health threat to the society, but worryingly, neglected in sub-Saharan Africa (SSA). This review will assess the burden and distribution of maternal mental health (MMH) problems in SSA, with the aim to inform the implementation of context sensitive interventions and policies. METHODS AND ANALYSIS: All relevant databases, grey literature and non-database sources will be searched. PubMed, LILAC, CINAHL, SCOPUS and PsycINFO, Google Scholar, African Index Medicus, HINARI, African Journals Online and IMSEAR will be searched from inception to 31 May 2023, without language restriction. The reference lists of articles will be reviewed, and experts contacted for additional studies missed by our searches. Study selection, data extraction and risk of bias assessment will be done independently by at least two reviewers and any discrepancies will be resolved through discussion between the reviewers. Binary outcomes (prevalence and incidence) of MMH problems will be assessed using pooled proportions, OR or risk ratio and mean difference for continuous outcomes; all will be presented with their 95% CIs. Heterogeneity will be investigated graphically for overlapping CIs and statistically using the I2 statistic and where necessary subgroup analyses will be performed. Random-effects model meta-analysis will be conducted when heterogeneity is appreciable, otherwise fixed-effect model will be used. The overall level of evidence will be assessed using Grading of Recommendations Assessment, Development and Evaluation. ETHICS AND DISSEMINATION: Although no ethical clearance or exemption is needed for a systematic review, this review is part of a larger study on maternal mental health which has received ethical clearance from the Ethics Review Committee of the Ghana Health Service (GHS-ERC 012/03/20). Findings of this study will be disseminated through stakeholder forums, conferences and peer review publications. PROSPERO REGISTRATION NUMBER: CRD42021269528.

The "No bed syndrome" in Ghana - what, how and why? A literature, electronic and print media review.

Objectives: "No bed syndrome" has become a familiar phrase in Ghana. Yet, there is very little in medical texts or the peer reviewed literature about it. This review aimed to document what the phrase means in the Ghanaian context, how and why it occurs, and potential solutions. Design: A qualitative desk review using a thematic synthesis of grey and published literature, print and electronic media content covering the period January 2014 to February 2021. Text was coded line by line to identify themes and sub-themes related to the research questions. Analysis was manual and with Microsoft Excel to sort themes. Setting: Ghana. Participants and Intervention: Not applicable. Results: "No bed syndrome" describes the turning away by hospitals and clinics of people seeking walk in or referral emergency care with the stated reasons "no bed available" or "all beds are full". There are reported cases of people dying while going round multiple hospitals seeking help and being repeatedly turned away because there is "no bed". The situation appears to be most acute in the highly urbanized and densely populated Greater Accra region. It is driven by a complex of factors related to context, health system functions, values, and priorities. The solutions that have been tried are fragmented rather than well-coordinated whole system reform. Discussions and recommendations: The "no bed syndrome" describes the challenge of a poorly functioning emergency health care system rather than just the absence of a bed on which to place an emergency case. Many low and middle income countries have similar challenges with their emergency health care systems and this analysis from Ghana is potentially valuable in attracting global attention and thinking about emergency health systems capacity and reform in low and middle income countries. The solution to the "no bed syndrome" in Ghana requires reform of Ghana's emergency healthcare system that takes a whole system and integrated approach. All the components of the health system such as human resource, information systems, financing, equipment tools and supplies, management and leadership need to be examined and addressed together alongside health system values such as accountability, equity or fairness in the formulation, implementation, continuous monitoring and evaluation of policies and programs for system reform to expand and strengthen emergency healthcare system capacity and responsiveness. Despite the temptation to fall back on them as low hanging fruit, piecemeal and ad-hoc solutions cannot solve the problem.

Multilevel Governance and Control of the COVID-19 Pandemic in the Democratic Republic of Congo: Learning from the Four First Waves.

The COVID-19 pandemic continues to impose a heavy burden on people around the world. The Democratic Republic of the Congo (DRC) has also been affected. The objective of this study was to explore national policy responses to the COVID-19 pandemic in the DRC and drivers of the response, and to generate lessons for strengthening health systems' resilience and public health capacity to respond to health security threats. This was a case study with data collected through a literature review and in-depth interviews with key informants. Data analysis was carried out manually using thematic content analysis translated into a logical and descriptive summary of the results. The management of the response to the COVID-19 pandemic reflected multilevel governance. It implied a centralized command and a decentralized implementation. The centralized command at the national level mostly involved state actors organized into ad hoc structures. The decentralized implementation involved state actors at the provincial and peripheral level including two other ad hoc structures. Non-state actors were involved at both levels. These ad hoc structures had problems coordinating the transmission of information to the public as they were operating outside the normative framework of the health system. Conclusions: Lessons that can be learned from this study include the strategic organisation of the response inspired by previous experiences with epidemics; the need to decentralize decision-making power to anticipate or respond quickly and adequately to a threat such as the COVID-19 pandemic; and measures decided, taken, or adapted according to the epidemiological evolution (cases and deaths) of the epidemic and its effects on the socio-economic situation of the population. Other countries can benefit from the DRC experience by adapting it to their own context.

Change in glycaemic control with structured diabetes self-management education in urban low-resource settings: multicentre randomised trial of effectiveness.

BACKGROUND: In high-resource settings, structured diabetes self-management education is associated with improved outcomes but the evidence from low-resource settings is limited and inconclusive. AIM: To compare, structured diabetes self-management education to usual care, in adults with type 2 diabetes, in low-resource settings. DESIGN: Single-blind randomised parallel comparator controlled multi-centre trial. Adults (> 18 years) with type 2 diabetes from two hospitals in urban Ghana were randomised 1:1 to usual care only, or usual care plus a structured diabetes self-management education program. Randomisation codes were computer-generated, and allotment concealed in opaque numbered envelopes. The intervention effect was assessed with linear mixed models. MAIN OUTCOME: Change in HbA1c after 3-month follow-up. Primary analysis involved all participants. CLINICALTRIAL: gov identifier:NCT04780425, retrospectively registered on 03/03/2021. RESULTS: Recruitment: 22nd until 29th January 2021. We randomised 206 participants (69% female, median age 58 years [IQR: 49-64], baseline HbA1c median 64 mmol/mol [IQR: 45-88 mmol/mol],7.9%[IQR: 6.4-10.2]). Primary outcome data was available for 79 and 80 participants in the intervention and control groups, respectively. Reasons for loss to follow-up were death (n = 1), stroke(n = 1) and unreachable or unavailable (n = 47). A reduction in HbA1c was found in both groups; -9 mmol/mol [95% CI: -13 to -5 mmol/mol], -0·9% [95% CI: -1·2% to -0·51%] in the intervention group and -3 mmol/mol [95% CI -6 to 1 mmol/mol], -0·3% [95% CI: -0·6% to 0.0%] in the control group. The intervention effect was 1 mmol/mol [95%CI:-5 TO 8 p = 0.726]; 0.1% [95% CI: -0.5, 0.7], p = 0·724], adjusted for site, age, and duration of diabetes. No significant harms were observed. CONCLUSION: In low-resource settings, diabetes self-management education might not be associated with glycaemic control. Clinician's expectations from diabetes self-management education must therefore be guarded.

Implementation of Medicines Pricing Policies in Ghana: The Interplay of Policy Content, Actors' Participation, and Context.

BACKGROUND: Implementing medicines pricing policy effectively is important for ensuring equitable access to essential medicines and ultimately achieving universal health coverage. However, published analyses of policy implementations are scarce from low- and middleincome countries. This paper contributes to bridging this knowledge gap by reporting analysis of implementation of two medicines pricing policies in Ghana: value-added tax (VAT) exemptions and framework contracting (FC) for selected medicines. We analysed implications of actor involvements, contexts, and contents on the implementation of these policies, and the interplay between these. This paper should be of interest, and relevance, to policy designers, implementers, the private sector and policy analysts. METHODS: Data were collected through document reviews (n=18), in-depth interviews (n=30), focus groups (n=2) and consultative meetings (n=6) with purposefully identified policy actors. Data were analysed thematically, guided by the four components of the health policy triangle framework. RESULTS: The nature and complexity of policy contents determined duration and degree of formality of implementation processes. For instance, in the FC policy, negotiating medicines prices and standardizing the tendering processes lengthened implementation. Highly varied stakeholder participation created avenues for decision-making and promoted inclusiveness, but also raised the need to manage different agendas and interests. Key contextual enablers and constraints to implementation included high political support and currency depreciation, respectively. The interrelatedness of policy content, actors, and context influenced the timeliness of policy implementations and achievement of intended outcomes, and suggest five attributes of effective policy implementation: (1) policy nature and complexity, (2) inclusiveness, (3) organizational feasibility, (4) economic feasibility, and (5) political will and leadership. CONCLUSION: Varied contextual factors, active participation of stakeholders, nature, and complexity of policy content, and structures have all influenced the implementation of medicines pricing policies in Ghana.

Implementation of medicines pricing policies in sub-Saharan Africa: systematic review.

BACKGROUND: High medicine prices contribute to increasing cost of healthcare worldwide. Many patients with limited resources in sub-Saharan Africa (SSA) are confronted with out-of-pocket charges, constraining their access to medicines. Different medicine pricing policies are implemented to improve affordability and availability; however, evidence on the experiences of implementations of these policies in SSA settings appears limited. Therefore, to bridge this knowledge gap, we reviewed published evidence and answered the question: what are the key determinants of implementation of medicines pricing policies in SSA countries? METHODS: We identified policies and examined implementation processes, key actors involved, contextual influences on and impact of these policies. We searched five databases and grey literature; screening was done in two stages following clear inclusion criteria. A structured template guided the data extraction, and data analysis followed thematic narrative synthesis. The review followed best practices and reported using PRISMA guidelines. RESULTS: Of the 5595 studies identified, 31 met the inclusion criteria. The results showed thirteen pricing policies were implemented across SSA between 2003 and 2020. These were in four domains: targeted public subsides, regulatory frameworks and direct price control, generic medicine policies and purchasing policies. Main actors involved were government, wholesalers, manufacturers, retailers, professional bodies, community members and private and public health facilities. Key contextual barriers to implementation were limited awareness about policies, lack of regulatory capacity and lack of price transparency in external reference pricing process. Key facilitators were favourable policy environment on essential medicines, strong political will and international support. Evidence on effectiveness of these policies on reducing prices of, and improving access to, medicines was mixed. Reductions in prices were reported occasionally, and implementation of medicine pricing policy sometimes led to improved availability and affordability to essential medicines. CONCLUSIONS: Implementation of medicine pricing policies in SSA shows some mixed evidence of improved availability and affordability to essential medicines. It is important to understand country-specific experiences, diversity of policy actors and contextual barriers and facilitators to policy implementation. Our study suggests three policy implications, for SSA and potentially other low-resource settings: avoiding a 'one-size-fits-all' approach, engaging both private and public sector policy actors in policy implementation and continuously monitoring implementation and effects of policies. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020178166.

Learning from the COVID-19 pandemic for future epidemics and pandemics preparedness and response in Guinea: Findings from a scoping review.

The outbreak of the novel coronavirus (SARS-CoV-2) in December 2019 prompted a response from health systems of countries across the globe. The first case of COVID-19 in Guinea was notified on 12 March 2020; however, from January 2020 preparations at policy and implementation preparedness levels had already begun. This study aimed to assess the response triggered in Guinea between 27th January 2020 and 1st November 2021 and lessons for future pandemic preparedness and response. We conducted a scoping review using three main data sources: policy documents, research papers and media content. For each of these data sources, a specific search strategy was applied, respectively national websites, PubMed and the Factiva media database. A content analysis was conducted to assess the information found. We found that between January 2020 and November 2021, the response to the COVID-19 pandemic can be divided into five phases: (1) anticipation of the response, (2) a sudden boost of political actions with the implementation of strict restrictive measures, (3) alleviation of restrictive measures, (4) multiple epidemics period and (5) the COVID-19 variants phase, including the strengthening of vaccination activities. This study provides several learning points for countries with similar contexts including: (1) 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; (2) the importance of mobilizing, during pre-epidemic period, emergency funds for a rapid health system response whenever epidemics hit; (3) each epidemic is a new experience as previous exposure to similar ones does not necessarily guarantee population and health system resilience; (4) epidemics generate social distress because of the restrictive measures they require for their control, but their excessive securitization 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, safeguarding trusted and efficient health system responses. We conclude that health system actors anticipated the response to the COVID-19 pandemic and (re-) adapted response strategies as the pandemic evolved in the country. There is a need to rethink epidemics governance and funding mechanisms in Guinea to improve the health system response to epidemics.

The Role of the Private Sector in the COVID-19 Pandemic: Experiences From Four Health Systems.

As societies urbanize, their populations have become increasingly dependent on the private sector for essential services. The way the private sector responds to health emergencies such as the COVID-19 pandemic can determine the health and economic wellbeing of urban populations, an effect amplified for poorer communities. Here we present a qualitative document analysis of media reports and policy documents in four low resource settings-Bangladesh, Ghana, Nepal, Nigeria-between January and September 2020. The review focuses on two questions: (i) Who are the private sector actors who have engaged in the COVID-19 first wave response and what was their role?; and (ii) How have national and sub-national governments engaged in, and with, the private sector response and what have been the effects of these engagements? Three main roles of the private sector were identified in the review. (1) Providing resources to support the public health response. (2) Mitigating the financial impact of the pandemic on individuals and businesses. (3) Adjustment of services delivered by the private sector, within and beyond the health sector, to respond to pandemic-related business challenges and opportunities. The findings suggest that a combination of public-private partnerships, contracting, and regulation have been used by governments to influence private sector involvement. Government strategies to engage the private sector developed quickly, reflecting the importance of private services to populations. However, implementation of regulatory responses, especially in the health sector, has often been weak reflecting the difficulty governments have in ensuring affordable, quality private services. Lessons for future pandemics and other health emergencies include the need to ensure that essential non-pandemic health services in the government and non-government sector can continue despite elevated risks, surge capacity to minimize shortages of vital public health supplies is available, and plans are in place to ensure private workplaces remain safe and livelihoods protected.

Powers, engagements and resultant influences over the design and implementation of medicine pricing policies in Ghana.

INTRODUCTION: Universal availability and affordability of essential medicines are determined by effective design and implementation of relevant policies, typically involving multiple stakeholders. This paper examined stakeholder engagements, powers and resultant influences over design and implementation of four medicines pricing policies in Ghana: Health Commodity Supply Chain Master Plan, framework contracting for high demand medicines, Value Added Tax (VAT) exemptions for selected essential medicines, and ring-fencing medicines for local manufacturing. METHODS: Data were collected using reviews of policy documentation (n=16), consultative meetings with key policy actors (n=5) and in-depth interviews (n=29) with purposefully identified national-level policymakers, public and private health professionals including members of the National Medicine Pricing Committee, pharmaceutical wholesalers and importers. Data were analysed using thematic framework. RESULTS: A total of 46 stakeholders were identified, including representatives from the Ministry of Health, other government agencies, development partners, pharmaceutical industry and professional bodies. The Ministry of Health coordinated policy processes, utilising its bureaucratic mandate and exerted high influences over each policy. Most stakeholders were highly engaged in policy processes. Whereas some led or coproduced the policies in the design stage and participated in policy implementation, others were consulted for their inputs, views and opinions. Stakeholder powers reflected their expertise, bureaucratic mandates and through participation in national level consultation meetings, influences policy contents and implementation. A wider range of stakeholders were involved in the VAT exemption policies, reflecting their multisectoral nature. A minority of stakeholders, such as service providers were not engaged despite their interest in medicines pricing, and consequently did not influence policies. CONCLUSIONS: Stakeholder powers were central to their engagements in, and resultant influences over medicine pricing policy processes. Effective leadership is important for inclusive and participatory policymaking, and one should be cognisant of the nature of policy issues and approaches to policy design and implementation.

Power sources among district health managers in Ghana: a qualitative study.

BACKGROUND: In Ghana district directors of health services and district hospital medical superintendents provide leadership and management within district health systems. A healthy relationship among these managers is dependent on the clarity of formal and informal rules governing their routine duties. These rules translate into the power structures within which district health managers operate. However, detailed nuanced studies of power sources among district health managers are scarce. This paper explores how, why and from where district health directors and medical superintendents derive power in their routine functions. METHODS: A multiple case study was conducted in three districts; Bongo, Kintampo North and Juaboso. In each case study site, a cross-sectional design was used to explore the research question. Purposive sampling technique was used to select study sites and 61 participants for interview and focus group discussion. A total of 11 interviews (3 in each district and 2 with deputy regional directors), and 9 focus group discussions (3 in each district) were conducted. Transcriptions of the voice-recordings were done verbatim, cleaned and imported into the Nvivo version 11 software for analysis using the inductive content analysis approach. RESULTS: The findings revealed that legitimacy provides formal power source for district health managers since they are formally appointed by the Director General of the Ghana Health Service after going through the appointment processes. These appointments serve as the primary power source for district health managers based on the existing legal and policy framework of the Ghana Health Service. Additionally, resource control especially finances and medical dominance are major informal sources of power that district health managers often employ for the management and administration of their functional areas in the health districts. CONCLUSIONS: The study concludes that district health managers derive powers primarily from their positions within the hierarchical structure (legitimacy) of the district health system. Secondary sources of power stems from resource control (medical dominance and financial dominance), and these power sources inform the way district health managers relate to each other. This paper recommends that district health managers are oriented to understand the power dynamics in the district health system.

Establishing communities of practice to improve health policy, systems and reproductive, maternal, newborn, child and adolescent health in West Africa.

Objectives: To explore and analyse factors that facilitate and inhibit the initiation and functioning of a national and transnational Community of Practice (CoP) for health policy and systems (HPS) and Reproductive, Maternal, New-born, Child and Adolescent Health (RMNCAH) in West Africa and to identify lessons for CoP interventions in similar multilingual low and middle-income contexts. Design: A case study, with the case defined as processes, enablers and barriers to the initiation and functioning of a national and transnational CoP for HSP and RMNCAH in West Africa and drawing on a review and analysis of secondary data from the program, workshop, country team and project reports, and training sessions. Setting: The Economic Community of West African States (ECOWAS). Participants: Professionals from two Anglophone (Ghana and Sierra Leone) and four Francophone (Burkina Faso, Cote d'Ivoire, Niger e Senegal) ECOWAS countries. Interventions: Training and mentoring of multi-disciplinary country teams supported by small research grants to undertake formative evaluation and advocacy of priority HPS and RMNCAH issues; support for CoP development within and across country teams. Results: The desire to learn from peers and mentors was a major enabler of the process. Human and financial resource availability, competing demands for time, communication in the context of a Francophone-Anglophone official language divide and the arrival of COVID-19 were all constraints. Conclusions: This study highlights the processes, achievements, and challenges of establishing country-level and transnational CoPs in West Africa. CoPs require sustained human and financial resource investments, communication and medium-to-long-term implementation support for sustainability and impact. Funding: None declared.

Historical and contemporary factors that influenced the emergence and continuity of WANEL: Lessons for sustainable HPSR network formation in LMICs.

Objectives: To explore historical and contemporary factors and processes that influenced the emergence of WANEL and analyse how the formation process has influenced the network's continued existence and sustainability and lesson for sub-regional health policy and systems research (HPSR) networking in Low -and -Middle -Income Countries (LMICs). Design: Qualitative explanatory case study which used process tracing to chart the formation and development of WANEL. Methods: Data was obtained through document reviews, semi-structured interviews, group discussions, and participant observation. Data was analysed using thematic content analysis. Results: The emergence of WANEL was made possible by several factors, including support from a network of senior HPSR champions and institutions across West Africa; sustained funding from IDRC Canada, a reputable funder with a track record in supporting research capacity development in LMICs; learning and networking opportunities provided by CHEPSAA Emerging Leaders and the Institute of Tropical Medicine Antwerp Emerging Voices for Global Health initiative. Its formation followed a mix of emergent and engineered processes. Conclusion: WANEL is the first and currently the only sub-regional network for early and mid-career health policy and systems researchers and practitioners in West Africa. To ensure its long-term sustainability, the network needs to put in place mechanisms to constantly attract and develop the next generation of early and mid-career researchers, maintain links with senior researchers, strengthen its capacity for coordination and facilitation, and develop a plan for its long-term financial sustainability. Funding: The study is funded by IDRC Canada Project 108237-001: Popularly known as the Consortium for Mothers, Newborn, Children, Adolescents and Health Policy and Systems strengthening in West and Central Africa. (COM-CAHPSS).