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Sierra Leone has one of the highest maternal mortality ratios in the world. Efforts to reduce maternal mortality have included initiatives to encourage more women to deliver at health facilities. Despite the introduction of the free health care initiative for pregnant women, many women still continue to deliver at home, with few having access to a skilled birth attendant. In addition, inequalities between rural and urban areas in accessing and utilising health facilities persist. Further insight into how and why women make decisions around childbirth will help guide future plans and initiatives in improving maternal health in Sierra Leone. The objective of this study was to explore the perceptions and decision-making processes of women and their communities during childbirth in rural Sierra Leone. Data were collected through seven focus group discussions and 22 in-depth interviews with recently pregnant women and their community members in two rural villages. Data were analysed using systematic text condensation. Findings revealed that decision-making processes during childbirth are dynamic, intricate and need to be understood within the broader social context that they take place. Factors such as distance and lack of transport, perceived negative behaviour of hospital staff, direct and indirect financial obstacles, as well as the position of women in society all interact and influence how and what decisions are made. Pregnant women face multiple interacting vulnerabilities that influence their healthcare-seeking decisions during pregnancy and childbirth. Future initiatives to improve access and utilisation of safe healthcare services for pregnant women need to be based on adequate knowledge of structural constraints and health inequities that affect women in rural Sierra Leone.

The paper examines the health system’s response to COVID-19 in Sierra Leone. It aims to explore how the pandemic affected service delivery, health workers, patient access to services, leadership, and governance. It also examines to what extent the legacy of the 2013–16 Ebola outbreak influenced the COVID-19 response and public perception. Using the WHO Health System Building Blocks Framework, we conducted a qualitative study in Sierra Leone where semi-structured interviews were conducted with health workers, policymakers, and patients between Oct-Dec 2020. We applied thematic analysis using both deductive and inductive approaches. Twelve themes emerged from the analysis: nine on the WHO building blocks, two on patients’ experiences, and one on Ebola. We found that routine services were impacted by enhanced infection prevention control measures. Health workers faced additional responsibilities and training needs. Communication and decision-making within facilities were reported to be coordinated and effective, although updates cascading from the national level to facilities were lacking. In contrast with previous health emergencies which were heavily influenced by international organisations, we found that the COVID-19 response was led by the national leadership. Experiences of Ebola resulted in less fear of COVID-19 and a greater understanding of public health measures. However, these measures also negatively affected patients’ livelihoods and their willingness to visit facilities. We conclude, it is important to address existing challenges in the health system such as resources that affect the capacity of health systems to respond to emergencies. Prioritising the well-being of health workers and the continued provision of essential routine health services is important. The socio-economic impact of public health measures on the population needs to be considered before measures are implemented.

Utilizing surgical services, including caesarean sections, can result in catastrophic expenditure and impoverishment. In 2010, Sierra Leone introduced the Free Health Care Initiative (FHCI), a national financial risk protection program for the most vulnerable groups. Aim of this study was to investigate catastrophic expenditure and impoverishment related to caesarean section in Sierra Leone and evaluate the impact of the FHCI. Women who delivered by caesarean section in nine hospitals were followed up with home visits one month after surgery, and data on medical and non-medical expenditures were collected. Individual income was estimated based on household characteristics and used to determine catastrophic expenditure and impoverishment for each patient. The impact of the FHCI was assessed by comparing actual expenditure with counterfactual expenditures had the initiative not existed. For the 1146 patients in the study, the median expenditure was 23 (IQR 4; 56) international dollars (Int$). Patients in the poorest quintile spent a median Int$ 59 (IQR 28; 76), which was significantly more than patients in the richest quintile, who spent a median Int$ 17 (IQR 2; 38, p<0.001). Travel (32.9%) and food (28.7%) were the two largest expenses. Catastrophic expenditure was encountered by 12.0% and 4.0% (10% and 25% threshold, respectively) of the women. Without the FHCI, 66.1% and 28.8% of the women would have encountered catastrophic expenditure. Many women in Sierra Leone face catastrophic expenditure related to caesarean section, mainly through food and travel expenses, and the poor are disproportionally affected. The FHCI is effective in reducing the risk of catastrophic expenditure related to caesarean section, but many patients are still exposed to financial hardship, suggesting that additional support is needed for Sierra Leone's poorest patients.

ObjectiveTo assess challenges and enablers in accessing paediatric inguinal hernia surgical care at governmental hospitals in Sierra Leone.MethodologyA qualitative exploratory interview study was conducted using semistructured interviews with 16 healthcare providers and 19 guardians of 17 children at four governmental secondary-level and tertiary-level hospitals in Sierra Leone. All interviews were analysed using thematic analysis within a constructivist paradigm, with subsequent framework-based interpretation using the WHO health system building blocks.ResultsThe study identified five interrelated themes describing barriers to accessing surgical care across household and health system levels: (1) access to equipment, consumables and medicines; (2) health-seeking behaviour; (3) financial considerations; (4) workforce; and (5) management and hospital structure. These themes illustrate how health system constraints and household-level barriers interact to delay or impede access to surgery. Key enablers included task-sharing within the surgical workforce, community trust and financial protection through the Free Healthcare Initiative or non-governmental organisations.ConclusionAccess to paediatric inguinal hernia surgery in Sierra Leone is hindered by economic barriers, limited awareness and shortages of staff, equipment and medicines. Targeted community outreach, expansion of the Free Healthcare Initiative beyond age 5 and securing dedicated paediatric surgical instrument sets emerged as feasible strategies to reduce delays and improve equity of care.

Background Access to safe, timely and affordable surgical care is lacking globally. Less than 6% of all surgical operations are carried out in low- and middle-income countries, where over a third of the world’s population lives. CapaCare, an NGO operating in Sierra Leone, have developed a surgical training programme (STP) for Associate Clinicians based on principles of task-shifting to improve access. Interventions to increase healthcare access have the same value evidence requirements as new technologies but their evaluation presents methodological challenges as access is not routinely incorporated explicitly in economic evaluations. Objective To evaluate the cost-effectiveness of surgical task-shifting in Sierra Leone, implemented through the CapaCare STP, to increase provision of caesarean section (C-section). Methods We evaluated the impact of the STP on the provision of C-section and subsequent maternal and child outcomes, measured in disability-adjusted life-years (DALYs), relative to the costs using a healthcare system perspective and decision-tree model parameterised using data from surgical logbooks, national data, and the literature. Results Results indicate that the surgical task-shifting programme in Sierra Leone would be considered cost-effective in increasing provision for C-section. It is cost saving (USD − 16.77) and results in 2.14 DALYs averted, per women with an indication for C-section, due to avoidance of maternal and child deaths as well as reduced complications. Conclusion Investment in surgical task-shifting initiatives should be considered by policymakers as a potentially cost-effective way to increase access to quality surgical services. Future evaluations of access-increasing interventions should seek to capture the distributional impact of this strategy and system benefits.

Chronic wounds pose a significant healthcare burden in low- and middle-income countries. Buruli ulcer (BU), caused by Mycobacterium ulcerans infection, causes wounds with high morbidity and financial burden. Although highly endemic in West and Central Africa, the presence of BU in Sierra Leone is not well described. This study aimed to confirm or exclude BU in suspected cases of chronic wounds presenting to Masanga Hospital, Sierra Leone. Demographics, baseline clinical data, and quality of life scores were collected from patients with wounds suspected to be BU. Wound tissue samples were acquired and transported to the Swiss Tropical and Public Health Institute, Switzerland, for analysis to detect Mycobacterium ulcerans using qPCR, microscopic smear examination, and histopathology, as per World Health Organization (WHO) recommendations. Twenty-one participants with wounds suspected to be BU were enrolled over 4-weeks (Feb-March 2019). Participants were predominantly young working males (62% male, 38% female, mean 35yrs, 90% employed in an occupation or as a student) with large, single, ulcerating wounds (mean diameter 9.4cm, 86% single wound) exclusively of the lower limbs (60% foot, 40% lower leg) present for a mean 15 months. The majority reported frequent exposure to water outdoors (76%). Self-reports of over-the-counter antibiotic use prior to presentation was high (81%), as was history of trauma (38%) and surgical interventions prior to enrolment (48%). Regarding laboratory investigation, all samples were negative for BU by microscopy, histopathology, and qPCR. Histopathology analysis revealed heavy bacterial load in many of the samples. The study had excellent participant recruitment, however follow-up proved difficult. BU was not confirmed as a cause of chronic ulceration in our cohort of suspected cases, as judged by laboratory analysis according to WHO standards. This does not exclude the presence of BU in the region, and the definitive cause of these treatment-resistance chronic wounds is uncertain.

ObjectivesThis study explores potential barriers and enabling factors that may influence the acceptance of implementation of a surgical task-sharing initiative targeting physician assistants (PAs) in Liberia.DesignA qualitative, pre-implementation study using semistructured interviews. Data was analysed in NVivo V.12 using deductive coding and the consolidated framework for implementation research as a guide.SettingLiberia has few surgical providers and a poor surgical infrastructure resulting in a very low surgical volume. The research was conducted in the context of an already running surgical task-sharing programme for midwives.ParticipantsIn 2019, a total of 30 key stakeholders in the field of surgery and the PAs training programme were interviewed.ResultsThe majority of the stakeholders supported the idea of training PAs in surgery. The high unemployment rate among PAs and the need for career advancement of this cadre were important enabling factors. Resistance against surgical task sharing for mid-level clinicians is multifaceted. The Ministry of Health (MOH) did not share a common vision. Opponents within the MOH believed budgetary constraints within the MOH and the lack of surgical infrastructure is a more pressing problem compared with the surgically trained human resources. Another important group of opponents are medical officers (MOs) and their professional bodies. Many of their negative beliefs around surgical task sharing reflect lessons to be drawn from the current surgical training programme for midwives.ConclusionPrior to deciding on implementation of a surgical training programme for PAs, wider support is needed. If surgical task sharing with PAs is to be considered, the intervention should focus on adapting the ‘adaptable’ periphery of the intervention to broaden the support of the MOH, MOs and their professional bodies. Failing to obtain such support should make the implementors consider alternative strategies to strengthen surgical human resources in rural Liberia.

ObjectivesThe economic consequences of untreated surgical disease are potentially large. The aim of this study was to estimate the economic burden associated with unmet surgical needs in Liberia.DesignA nationwide enumeration of surgical procedures and providers was conducted in Liberia in 2018. We estimated the number of disability-adjusted life years (DALYs) saved by operative activities and converted these into economic losses averted using gross national income per capita and value of a statistical life (VSL) approaches. The total, the met and the unmet needs for surgery were determined, and economic losses caused by unmet surgical needs were estimated. Finally, we valued the economic losses avoided by various surgical provider groups.ResultsA total of 55 890 DALYs were averted by surgical activities in 2018; these activities prevented an economic loss of between US$35 and US$141 million. About half of these values were generated by the non-specialist physician workforce. Furthermore, a non-specialist physician working a full-time position for 1 year prevented an economic loss of US$717 069 using the VSL approach, while a specialist resident and a certified specialist saved US$726 606 and US$698 877, respectively. The burden of unmet surgical need was associated with productivity losses of between US$388 million and US$1.6 billion; these losses equate to 11% and 46% of the annual gross domestic product for Liberia.ConclusionThe economic burden of untreated surgical disease is large in Liberia. There is a need to strengthen the surgical system to reduce ongoing economic losses; a framework where specialist and non-specialist physicians collaborate may result in better economic return than a narrower focus on training specialists alone.

Background Limited data exist on surgical providers and their scope of practice in low-income countries (LICs). The aim of this study was to assess the distribution and productivity of all surgical providers in an LIC, and to evaluate correlations between the surgical workforce availability, productivity, rates, and volume of surgery at the district and hospital levels. Methods Data on surgeries and surgical providers from 56 (93.3 %) out of 60 healthcare facilities providing surgery in Sierra Leone in 2012 were retrieved between January and May 2013 from operation theater logbooks and through interviews with key informants. Results The Sierra Leonean surgical workforce consisted of 164 full-time positions, equal to 2.7 surgical providers/100,000 inhabitants. Non-specialists performed 52.8 % of all surgeries. In rural areas, the densities of specialists and physicians were 26.8 and 6.3 times lower, respectively, compared with urban areas. The average individual productivity was 2.8 surgeries per week, and varied considerably between the cadres of surgical providers and locations. When excluding four centers that only performed ophthalmic surgery, there was a positive correlation between a facility’s volume of surgery and the productivity of its surgical providers ( r s  = 0.642, p  < 0.001). Conclusions Less than half of all of the surgery in Sierra Leone is performed by specialists. Surgical providers were significantly more productive in healthcare facilities with higher volumes of surgery. If all surgical providers were as productive as specialists in the private non-profit sector (5.1 procedures/week), the national volume of surgery would increase by 85 %.

BackgroundOpen inguinal hernia repair is the most commonly performed procedure in general surgery in sub-Saharan Africa, but data on its learning curve are lacking. This study evaluated the learning curve characteristics to improve surgical training and enable scaling up hernia surgery in low- and middle-income countries.MethodsLogbook data of associate clinicians enrolled in a surgical training program in Sierra Leone were collected and their first 55 hernia surgeries following the Bassini technique (herniorrhaphies) were analyzed in cohorts of five cases. Studied variables were gradient of decline of operating time, variation in operating time, and length of stay (LOS). Eleven subsequent cohorts of each five herniorrhaphies were investigated.ResultsSeventy-five trainees enrolled in the training program between 2011 and 2020 were eligible for inclusion. Thirty-one (41.3%) performed the minimum of 55 herniorrhaphies, and had also complete personal logbook data. Mean operating times dropped from 79.6 (95% CI 75.3–84.0) to 48.6 (95% CI 44.3–52.9) minutes between the first and last cohort, while standard deviation in operating time nearly halved to 15.4 (95% CI 11.7–20.0) minutes, and LOS was shortened by 3 days (8.5 days, 95%CI 6.1–10.8 vs. 5.4 days, 95% 3.1–7.6). Operating times flattened after 31–35 cases which corresponded with 1.5 years of training.ConclusionsThe learning curve of inguinal hernia surgery for associate clinicians flattens after 31–35 procedures. Training programs can be tailored based on this finding. The recorded learning curve may serve as a baseline for future training techniques.