From emergency relief to system strengthening: Stakeholder perspectives on official development assistance for reproductive, maternal, neonatal and child health in Guinea-Bissau

Guinea-Bissau, a politically fragile West African nation, relies heavily on official development assistance (ODA) to sustain reproductive, maternal, neonatal and child health (RMNCH) services. This study explored how national and international stakeholders perceive the role, evolution and effectiveness of RMNCH-related ODA and how these perspectives compare with donor strategies. We conducted semi-structured interviews with 10 key informants and applied an AI-assisted, systematically validated framework to analyse 50 donor documents, integrating findings through comparative coding and convergence-divergence synthesis. Stakeholders viewed ODA as 'humanitarian' or 'emergency' aid, substituting for the state rather than catalysing durable system change. Donor documents strongly emphasised coordination, alignment and ownership but tended to underplay political risk and institutional capacity limits. Triangulated analysis identified interlinked constraints: political instability and ministerial turnover, fragmented coordination despite multiple formal mechanisms, performative alignment with national plans, limited domestic financial contribution and an evolution toward vertical funding that risks further fragmentation. Findings point to the need for hybrid coordination arrangements combining national and international leadership, depoliticised and stable technical capacity within the Ministry of Public Health, longer and more flexible programme cycles with contingency mechanisms, and greater domestic financing and use of national strategic plans as a genuine framework for system strengthening.