Effect of the COVID-19 pandemic on the post-Ebola referral system in Sierra Leone: A descriptive analysis

BackgroundThe COVID-19 pandemic severely impacted health systems in several countries, including Sierra Leone, which was recovering from the 2014-2016 Ebola Virus Disease epidemic. The National Referral Service was established in 2017 followed by launching of the National Emergency Medical Services (NEMS) in 2018 to strengthen the countrys referral system as part of the post-Ebola recovery strategy. This study examined the impact of COVID-19 on the referral system and hospital bed occupancy in Sierra Leone. MethodsWe conducted a retrospective study using individual-level referral and daily hospital bed occupancy data from 16 public hospitals in Sierra Leone, covering the period October 2017 to February 2022. Data were categorized into four periods: post-Ebola/pre-NEMS (12 months), post-NEMS/pre-COVID (12 months), during COVID-19 (12 months), and post-COVID (12 months). Descriptive statistics was used to analyze the trends in referral and bed occupancy. ResultsA total of 78,406 referrals were recorded. Referrals increased from 14,870 in the post-Ebola/pre-NEMS period to 27,299 to post-NEMS launch. The number of referrals dropped to 22,948 (during COVID-19) and 13,289 (post-COVID-19). The mean number of referrals per facility initially increased from 1,359 in the post-Ebola and pre-NEMS periods but declined to 1,863 during and after the pandemic. The number of referrals at the provincial level was consistently higher than in Freetown. Bed occupancy rates also declined significantly during the COVID-19 pandemic, with a more pronounced decline in Freetown. ConclusionOur results show a continued decline in patient referrals and bed occupancy even after the peak of the COVID-19 pandemic, with greater impact in the capital Freetown than the provincial regions. The initial increase in referrals and bed occupancy post-Ebola reflects health system strengthening interventions following the Ebola outbreak. However, the COVID-19 pandemic disruptions led to significant declines in both metrics, underscoring the need for sustainable investment in resilient health systems.