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Introduction: Learning is a key attribute of a resilient health system and, therefore, is central to health system strengthening. The main objective of this study was to analyse how Guinea's health system has learnt from the response to outbreaks between 2014 and 2021., Methods: We used a retrospective longitudinal single embedded case study design, applying the framework conceptualised by Sheikh and Abimbola for analysing learning health systems. Data were collected employing a mixed methods systematic review carried out in March 2022 and an online survey conducted in April 2022., Results: The 70 reports included in the evidence synthesis were about the 2014-2016 Ebola virus disease (EVD), Measles, Lassa Fever, COVID-19, 2021 EVD and Marburg virus disease. The main lessons were from 2014 to 2016 EVD and included: early community engagement in the response, social mobilisation, prioritising investment in health personnel, early involvement of anthropologists, developing health infrastructure and equipment and ensuring crisis communication. They were learnt through information (research and experts' opinions), action/practice and double-loop and were progressively incorporated in the response to future outbreaks through deliberation, single-loop, double-loop and triple-loop learning. However, advanced learning aspects (learning through action, double-loop and triple-loop) were limited within the health system. Nevertheless, the health system successfully controlled COVID-19, the 2021 EVD and Marburg virus disease. Survey respondents' commonly reported that enablers were the creation of the national agency for health security and support from development partners. Barriers included cultural and political issues and lack of funding. Common recommendations included establishing a knowledge management unit within the Ministry of Health with representatives at regional and district levels, investing in human capacities and improving the governance and management system., Conclusion: Our study highlights the importance of learning. The health system performed well and achieved encouraging and better outbreak response outcomes over time with learning that occurred., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Guinea is a country with a critical deficit and maldistribution of healthcare workers along with a high risk of epidemics' occurrence. However, actors in the health sector have missed opportunities for more than a decade to attract political attention. This article aims to explain why this situation exists and what were the roles of actors in the agenda-setting process of the post-Ebola health system strengthening programme. It also assesses threats and opportunities for this programme's sustainability., Methods: We used Kingdon's agenda-setting methodological framework to explain why actors promptly focused on the health sector reform after the Ebola outbreak. We conducted a qualitative explanatory study using a literature review and key informant interviews., Results: We found that, in the problem stream, the Ebola epidemic caused considerable fear among national as well as international actors, a social crisis and an economic system failure. This social crisis was entertained by communities' suspicion of an 'Ebola-business'. In response to these problems, policy actors identified three sets of solutions: the temporary external funds generated by the Ebola response; the availability of experienced health workers in the Ebola control team; and the overproduction of health graduates in the labour market. We also found that the politics agenda was dominated by two major factors: the global health security agenda and the political and financial interests of national policy actors. Although the opening of the policy window has improved human resources, finance and logistics, and infrastructures pillars of the health system, it, however, disproportionally focuses on epidemic preparedness and response. and neglects patients' financial affordability of essential health services., Conclusion: Domestic policy entrepreneurs must realise that agenda-setting of health issues in the Guinean context strongly depends on the construction of the problem definition and how this is influenced by international actors., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.