Recollection: China-UK Global Health Collaboration Project on Strengthening Public Health Capacity in Sierra Leone

The Ebola epidemic across West African countries severely compromised Sierra Leone’s health system (1), exposing critical vulnerabilities in its public health infrastructure, particularly in surveillance capabilities, laboratory testing capacity, and the availability of skilled public health professionals (2). The Sierra Leone-China Friendship Bio-safety Level 3 Laboratory (hereinafter referred to as “the BSL-3 Laboratory”), constructed with Chinese government assistance, commenced operations in March 2015. This facility was designed to conduct surveillance and detection of Ebola, malaria, and other infectious disease pathogens, while simultaneously serving as a training center for developing highly qualified laboratory personnel in Sierra Leone (3). Given the prevalence of emerging infectious diseases and the insufficient viral and bacterial testing capabilities of existing facilities, there was an urgent need for enhanced professional training of local technical staff. Building upon the existing laboratory infrastructure, our objective was to assist Sierra Leone by establishing comprehensive viral, bacterial, and parasitic testing facilities, strengthening the existing laboratory surveillance system and data management network, and fostering new partnerships for cooperation and resource exchange to improve the country’s epidemic and pandemic preparedness (3).

Building on successful exchange programs with Public Health England (PHE) and the robust foundation of China-Sierra Leone cooperation (4), China CDC initiated an exploratory project in 2016 under the China-UK Global Health Support Programme to enhance Sierra Leone’s public health capacity (5). Through this initiative, PHE provided ongoing support to China CDC for laboratory testing and capacity building at the BSL-3 Laboratory, leveraging UK expertise and resources. The project’s management office (PMO), housed within the Centre for Project Supervision and Management, National Health Commission of the People’s Republic of China, oversees daily operations and project management.

China provided comprehensive support to Sierra Leone in developing surveillance and detection capabilities for emerging and re-emerging infectious diseases, training essential health management and technical experts, and establishing technical communication mechanisms with key international partners, including the Ministry of Health of Sierra Leone and the UK.

Expert teams conducted comprehensive field research visits to Sierra Leone to assess the country’s infectious disease epidemiological profile, evaluate existing public health infrastructure, and examine the BSL-3 laboratory’s operational status. This systematic assessment aimed to identify priority diseases for laboratory testing, evaluate technical and staffing gaps, and determine optimal strategies for integrating the new laboratory within the local public health system.

Malaria remains Sierra Leone’s predominant vector-borne disease. According to the World Malaria Report 2023, the country documented 2,651,760 malaria cases and 8,212 malaria-related deaths in 2022, yielding a case fatality rate of 0.3% (6). Additionally, cholera, typhoid, and other enteric diseases constitute significant infectious disease burdens in the nation.

Chinese experts participated in weekly emergency response meetings coordinated by the Ministry of Health and Sanitation (MoHS), Sierra Leone and conducted field assessments in Makeni. Through these investigations, the experts gained comprehensive insights into Sierra Leone’s public health system infrastructure and healthcare operational frameworks. Several critical challenges were identified within the health system, including inadequate epidemic preparedness and response capabilities, insufficient national epidemic surveillance data systems, and unsustainable parasitic disease control programs (7).

The BSL-3 Laboratory, established by the Ministry of Commerce, People’s Republic of China, operated under Chinese expert management with local Sierra Leonean staff participating in daily operations. While the facility conducted passive surveillance for Ebola pathogens, it lacked comprehensive bacterial and parasitological testing capabilities. Additionally, a limited number of Sierra Leonean personnel possessed only basic testing skills and were unable to work independently or participate in project management activities.

Chinese experts facilitated collaborative site visits with PHE representatives Dr. Marcus and Dr. Bausch to the BSL-3 Laboratory and Makeni Regional Hospital Molecular Laboratory. These visits enabled comprehensive knowledge exchange regarding laboratory scale, operational scope, biosafety protocols, staffing structures, and training programs.

The Sierra Leone-China Friendship Hospital provided space for establishing bacteriology and parasitology testing laboratories. Chinese experts led the comprehensive laboratory development, implementing a design that incorporated distinct zones with clear signage and separated pathways for personnel, specimens, and laboratory waste to ensure compliance with infection control and prevention protocols. The experts assessed existing bacterial testing reagent inventory, equipped the laboratory with testing apparatus scaled to anticipated specimen volumes, and established robust systems for laboratory storage and waste management. These systems supported the cultivation, storage, and safe disposal of bacterial strains, enabling comprehensive bacterial and parasitic testing capabilities.

Chinese experts developed standardized testing procedures for Vibrio cholerae and Salmonella typhi pathogens, focusing on stool sample analysis from diarrheal patients. They completed procedural documentation and laboratory operation manuals for parasitic disease testing, with particular emphasis on the Plasmodium parasite responsible for malaria, incorporating the World Health Organization (WHO) SOPs for Plasmodium microscopy detection. These measures ensured consistent laboratory operations and project continuity.

Laboratory personnel training was strategically organized by work specialization, with customized theoretical and practical training programs developed for each area. The curriculum encompassed pathogen monitoring and detection in bacteriological laboratories, standardized laboratory operations, sentinel hospital sample collection methodologies, and data collection and statistical analysis. In response to public health emergencies in Sierra Leone, additional practical training sessions focused on environmental sample collection in affected areas, disease surveillance protocols, and environmental decontamination procedures.

Through rigorous quantification of project outcomes and comprehensive feedback from both UK and Sierra Leone stakeholders, this initiative has achieved its intended impacts. The project successfully trained laboratory professionals to operate BSL-3 facilities, establishing sustainable and efficient operations that exemplify the mutual benefits of China and UK’s collaborative health assistance to Sierra Leone.

From China’s perspective, the multi-stakeholder collaboration enhanced the nation’s capacity to coordinate international health cooperation resources. The China-UK partnership optimized resource sharing and joint laboratory capacity building, maximizing the advantages of their collaborative program. Additionally, the diversification of China’s foreign aid activities in Sierra Leone accelerated the development of China’s global health workforce, strengthening the country’s capacity for international engagement.

From Sierra Leone’s perspective, the establishment of bacteriological and parasitological testing laboratories markedly enhanced the nation’s diagnostic capabilities. The successful training of 19 local laboratory technicians has been instrumental in building sustainable operations (8). This comprehensive capacity-building initiative improved Sierra Leone’s ability to design testing protocols, manage biosafety programs, and maintain a skilled surveillance and testing workforce. The trained laboratory personnel are now central to strengthening the country’s emerging infectious disease surveillance systems.

The United Kingdom’s involvement optimized resource allocation by preventing redundant laboratory investments, thereby enhancing funding efficiency. This tripartite cooperation model improved the effectiveness of UK aid programs while strengthening their capacity to deliver health assistance. Furthermore, the project enabled the UK to leverage its healthcare expertise by transforming technical knowledge, resources, and governmental influence into tangible improvements in socioeconomic outcomes and health security, ultimately advancing their strategic objectives.

The laboratory has achieved significant recognition, being designated as Sierra Leone’s “National Reference Laboratory for Viral Hemorrhagic Fever” and “National Training Centre for Virus Detection and Biosafety.” During the COVID-19 pandemic, it served as the primary testing facility not only for Sierra Leone but also for the entire West African region.

The United Kingdom’s financial support served as the primary catalyst for the project’s success. Their comprehensive involvement extended beyond funding to include laboratory capacity-building initiatives and collaborative exchanges. The UK’s extensive experience in international project management significantly enhanced the implementation strategy. Their established global health network provided crucial support in developing technical communication mechanisms between China CDC and key stakeholders, including Sierra Leone MoHS, PHE, and other international partners (9).

The laboratory capacity training led by Chinese experts constituted another critical success factor. This foundation enabled China and the UK to jointly develop and share laboratory capacity-building resources, leading to optimized resource utilization through mutual exchange of outcomes and experiences.

Sierra Leone’s receptive approach toward public health cooperation with China and the UK proved instrumental to the project’s success.

The establishment of an effective communication and coordination mechanism provided a robust foundation for project implementation. Throughout both the application and execution phases, the Center for Global Public Health, China CDC, maintained consistent communication with the Project Management Office through regular progress reports, prompt problem identification, and collaborative solution development guided by the PMO-designated project manual, ensuring smooth project progression.

A strategic focus on innovation and collaboration enabled project expansion beyond its initial scope. Building upon previously established international partnerships, China CDC effectively engaged with PHE, CDC, WHO, UN, and other international organizations to develop new collaborative opportunities (10).

Complex logistical challenges and force majeure events, including a devastating mudslide in Freetown in August 2017, impacted expert secondments to international organization offices in third countries. Based on these experiences, researchers recommend earlier planning for secondments to accommodate administrative procedures and enhanced communication with international organization offices in host countries to secure necessary approvals and support.

The China-UK Global Health Programme should expand its multilateral health technical cooperation initiatives in global health, with particular emphasis on tailoring interventions for African nations and other developing countries. By combining China’s extensive expertise in infectious disease prevention with the UK’s established global health network, this collaboration has the potential to achieve significant innovations and breakthroughs in international public health capacity building.