Sierra Leone is one of the least developed low-income countries (LICs), slowly recovering from the effects of a devastating civil war and an Ebola outbreak. The health care system is characterized by chronic shortage of skilled human resources, equipment, and essential medicines. The referral system is weak and vulnerable, with 75% of the country having insufficient access to essential health care. Consequently, Sierra Leone has the highest maternal and child mortality rates in the world. This manuscript describes the implementation of a National Emergency Medical Service (NEMS), a project aiming to create the first prehospital emergency medical system in the country. In 2017, a joint venture of Doctors with Africa (CUAMM), Veneto Region, and Research Center in Emergency and Disaster Medicine (CRIMEDIM) was developed to support the Ministry of Health and Sanitation (MOHS) in designing and managing the NEMS system, one of the very few structured, fully equipped, and free-of-charge prehospital service in the African continent. The NEMS design was the result of an in-depth research phase that included a preliminary assessment, literature review, and consultations with key stakeholders and managers of similar systems in other African countries. From May 27, 2019, after a timeframe of six months in which all the districts have been progressively trained and made operational, the NEMS became operative at national level. By the end of March 2020, the NEMS operation center (OC) and the 81 ambulances dispatched on the ground handled a total number of 36,814 emergency calls, 35,493 missions, and 31,036 referrals.

IntroductionSierra Leone, one of the countries with the highest maternal and perinatal mortality in the world, launched its first National Emergency Medical Service (NEMS) in 2018. We carried out a countrywide assessment to analyse NEMS operational times for obstetric emergencies in respect the access to timely essential surgery within 2 hours. Moreover, we evaluated the relationship between operational times and maternal and perinatal mortality.MethodsWe collected prehospital data of 6387 obstetric emergencies referrals from primary health units to hospital facilities between June 2019 and May 2020 and we estimated the proportion of referrals with a prehospital time (PT) within 2 hours. The association between PT and mortality was investigated using Poisson regression models for binary data.ResultsAt the national level, the proportion of emergency obstetric referrals with a PT within 2 hours was 58.5% (95% CI 56.9% to 60.1%) during the rainy season and 61.4% (95% CI 59.5% to 63.2%) during the dry season. Results were substantially different between districts, with the capital city of Freetown reporting more than 90% of referrals within the benchmark and some rural districts less than 40%. Risk of maternal death at 60, 120 and 180 min of PT was 1.8%, 3.8% and 4.3%, respectively. Corresponding figures for perinatal mortality were 16%, 18% and 25%.ConclusionNEMS operational times for obstetric emergencies in Sierra Leone vary greatly and referral transports in rural areas struggle to reach essential surgery within 2 hours. Maternal and perinatal risk of death increased concurrently with operational times, even beyond the 2-hour target, therefore, any reduction of the time to reach the hospital, may translate into improved patient outcomes.

This report describes the main adaptive and transformative changes adopted by the brand-new National Emergency Medical Service (NEMS) to face the novel coronavirus disease 2019 (COVID-19) in Sierra Leone, including ambulance re-distribution, improvements in communication flow, implementation of ad-hoc procedures and trainings, and budget re-allocation. In a time-span of four months, 1,170 COVID-19 cases have been handled by the NEMS through a parallel referral system, while efforts have been made to manage the routine emergencies of the country, causing a substantial intensification of daily activities.

We aim to evaluate whether the first National Emergency Medical Service (NEMS) improved access to hospital care for the people of Sierra Leone. We performed an interrupted time-series analysis to assess the effects of NEMS implementation on hospital admissions in 25 facilities. The analysis was also replicated separately for the area of Freetown and the rest of the country. The study population was stratified by the main Free Health Care Initiative (FHCI) categories of pregnant women, children under 5 years of age, and populations excluded from the FHCI. Finally, we calculated direct costs of the service. We report a 43% overall increase in hospital admissions immediately after NEMS inception (RR 1.43; 95% CI 1.2–1.61). Analyses stratified by FHCI categories showed a significant increase among pregnant women (RR 1.54; 95% CI 1.33–1.77) and among individuals excluded from the FHCI (RR 2.95; 95% CI 2.47–3.53). The observed effect was mainly due to the impact of NEMS on the rural districts. The estimated recurrent cost per ambulance ride and NEMS yearly cost per inhabitant were 124 and 0.45 USD, respectively. To our knowledge, this is the first nationwide study documenting the increase in access to healthcare services following the implementation of an ambulance-based medical service in a low-income country. Based on our results, NEMS was able to overcome the existing barriers of geographical accessibility and transport availability, especially in the rural areas of Sierra Leone.

Minors account for 20 percent of the world’s migrants, reaching 33 million in 2019. The prevalence of malnutrition has been reported between 17 and 21% among refugees. However, data about Sub-Saharan African refugees is lacking. The study evaluates the nutritional status of refugees in the Nguenyyiel camp in Gambella (Ethiopia). The retrospective cohort study included all children under five attending the first visit to the refugee camp’s health post between 01/06/2021 and 31/08/2021. Sociodemographic data, body weight, and upper arm circumference (MUAC) were recorded. The z-score of weight for age (WFA) and MUAC for age (MUACZ) were estimated using the R ‘anthro’ package developed by the World Health Organization (WHO). Children with WFA <-2 standard deviations (SD) were considered underweight, those >2SD overweight. A MUACZ <-2SD defined acute malnutrition. Among the 782 patients admitted, 415 (53%) were under five. Females were 195 (47%). The mean age was 2.1 years (SD 1.6). The mean body weight was 11kg (SD 5). Considering the WFA, 200 (48%) children were within +2 SD. Children with WFA <-2SD were 92 (29%), those > 2SD were 28 (9%). The frequency of children with WFA <-2SD was higher in boys (p = 0.049). There were no differences in the frequency of children with WFA >2SD based on sex (p = 0.998). WFA decreased as age increased (p = 0.048). MUAC was recorded for 273 (66%) children. The mean MUAC was 14.2mm (SD 2.4). Children with MUAC z-scores within +2SD were 245 (77%). Children <-2SD were 92 (8%). The frequency of children with MUACZ <-2SD was not significantly different based on sex or age (p = 0.125, p = 0.324). The prevalence of malnutrition was moderate in the Nguenyyiel camp. At the same time, the frequency of underweight children was high, particularly among boys (34%) and with increasing age. Key messages • Nutrition remains a problem in refugee camp settings, especially in children. • Ensuring the health of refugees, as vulnerable population, should be a priority for both governments and international organizations.