The "No bed syndrome" in Ghana - what, how and why? A literature, electronic and print media review

The study addresses the phenomenon termed "no bed syndrome" in Ghana, a manifestation of poor responsiveness in emergency healthcare. Responsiveness is a core health system outcome, encompassing prompt, safe, and adequate care. Ghana introduced a comprehensive referral policy and guidelines in 2012 to improve emergency referrals across all facility levels and sectors, emphasizing avoidance of delays and the rights of referred patients. Despite this, Ghana’s emergency referral system faces significant shortcomings that hinder quality emergency services, including for obstetric emergencies. Media and public discourse frequently reference the "no bed syndrome"—patients, including pregnant women, turned away with the reason of no bed availability—implicated in maternal and neonatal mortality, especially in Greater Accra. A high-profile 2018 case of a 70-year-old man who died after multiple hospital refusals intensified public and parliamentary scrutiny. This review seeks to clarify what "no bed syndrome" means in Ghana, how and why it occurs, and what interventions exist or have been tried, to inform policy discussions and solutions. A multidisciplinary team conducted the review to reflect the multi-faceted nature of the issue.

The review situates Ghana’s "no bed syndrome" within broader evidence on emergency care access challenges in sub-Saharan Africa (SSA) and other low- and middle-income countries (LMICs). Studies from Ghana, Kenya, Rwanda, Tanzania, and Uganda report hospitals often lacking infrastructure to meet WHO minimum standards for emergency and surgical care. Systematic reviews in SSA identify barriers to Emergency Obstetric Care (EmOC) including shortages of trained staff, inadequate supplies and services, poor management and coordination, cost barriers, long waits, and weak referral practices; EmOC facilities are inequitably distributed, concentrated in capitals and urban centers, with many women unable to reach care within two hours. Sierra Leone’s national referral system is described as weak with insufficient access for much of the population. Beyond SSA, similar though often less severe constraints are reported, including overstretched and demotivated staff, information and communication gaps, and inadequate equipment and infrastructure. Comparative policy references include the U.S. EMTALA legislation mandating emergency stabilization, highlighting the potential role of legal frameworks when resourced. Within Ghana, existing literature details the evolution and current state of emergency care, limited specialty training capacity, overcrowding in emergency departments, and resource gaps in second-level hospitals, aligning with the drivers identified for "no bed syndrome."

Design: Qualitative desk review using thematic synthesis. Sources: Grey and published literature (dissertations, presentations, policies, legislation, administrative reports, press statements) and electronic/print media from January 2014 to February 2021. Search strategy: Searched Google, Google Scholar, PubMed; university repositories (University of Ghana; Kwame Nkrumah University of Science and Technology); Ghana Health Service and Ministry of Health websites. Media search via Dow Jones Factiva (March 2021) across six major Ghanaian outlets (Graphic Online, Ghanaian Times, Ghana News Agency, Daily Guide Network, The Ghanaian Chronicle, MyJoyonline) and GhanaWeb. Keywords: "no bed syndrome", "no bed", "emergency care", "access", "Ghana", "Sub-Saharan Africa", "Low- and middle-income countries." Inclusion: Ghana-context documents addressing no bed syndrome, hospital bed availability challenges, emergency referral access/care, emergency obstetric referral/care. Exclusion: Documents not addressing these topics. Screening: Abstracts reviewed when available; otherwise full texts. Yield: Factiva identified 70 media records for "no bed syndrome". Google initially returned 16,400 hits; refined search ("no bed syndrome" AND "emergency care access" AND "Ghana") yielded 37 records; 8 excluded; 29 retained. Total reviewed: 29 articles plus 70 media reports. Analysis: Text read thoroughly; line-by-line coding to identify themes/sub-themes related to definitions, causes, and solutions of no bed syndrome; manual coding supplemented by Excel-based sorting. Reporting followed ENTREQ guidelines. Quality appraisal of studies was not undertaken due to the predominance of journalistic and descriptive sources and the conceptual focus of the questions.

- Definition: In Ghana, "no bed syndrome" denotes the turning away of emergency patients (referred or walk-in) from hospitals/clinics with the stated reason "no bed available" or "all beds are full", often without preliminary examination, triage, or stabilization. Cases include reports of patients dying after being refused by multiple facilities. It is most cited in Greater Accra. - The syndrome reflects systemic failure in emergency care access and responsiveness, not merely bed scarcity. - Drivers are interlinked across: (1) Context: Rapid population growth and urbanization; dual burden of disease (communicable and NCDs) increasing bed occupancy; overcrowding in public facilities; stressed and exhausted staff; limited macroeconomic resources; political discontinuity causing abandoned infrastructure projects. - Health system priorities/values: Underprioritization and underfunding of emergency care beyond establishing the National Ambulance Service; emergency departments sometimes omitted from facility designs; maldistribution of higher-level hospitals concentrated centrally while peripheral urban areas remain underserved. - Health system functions/building blocks: • Financing: Chronic resource constraints; inadequate procurement of emergency tools/supplies; NHIS indebtedness hampers restocking, contributing to refusals masked as "no bed". • Regulation: Under-resourced regulators (HeFRA, professional councils) struggle to enforce standards; facilities may breach protocols due to resource scarcity, creating enforcement dilemmas. • Information systems/technology: Poor referral documentation and coordination; reliance on informal personal phone calls; lack of structured call centers; referrals often made without prior acceptance. • Human resources: Shortages and maldistribution of skilled emergency/critical care teams; limited training opportunities; multitasking by inadequately trained staff; poor motivation, burnout, absenteeism; upfront payment requests; weak supervision and constrained managerial authority in centralized public HR/investment systems. • Equipment, tools, supplies, infrastructure, and transport: Shortages and maintenance failures; overcrowded ERs with patients treated on floors/benches; underfunded National Ambulance Service with equipment and staffing gaps; private sector often lacks emergency capacity and is risk-averse, leading to rapid referrals to public sector. - Interventions tried (largely fragmented, supply-side): • Administrative directives: MOH/GHS instructed facilities not to turn away emergencies but to stabilize before transfer; no formal evaluation reported. • Health worker training/deployment: Basic life support/lifesaving skills CPD; temporary redeployments (e.g., KBTH doctors); no impact evaluations identified. • Call centers/teleconsultation: Greater Accra maternal/newborn referral call center pilot reduced effects of "no bed" but faced funding/staffing constraints; Amansie West teleconsultation for CHWs to manage cases and avoid unnecessary referrals; limited scale-up and outcome evaluations. • Logistics/infrastructure/transport: Periodic donations of beds, mattresses, ambulances; commissioning of new infrastructure; bed-tracking/referral software pilots (e.g., KBTH); recurrent costs (e.g., fuel) constrain ambulance operations. - Evidence base: Review synthesized 99 records (29 documents from refined Google search plus 70 media reports) covering Jan 2014–Feb 2021; term "no bed syndrome" not found in PubMed as a quoted phrase as of April 2, 2022.

The findings reveal that Ghana’s "no bed syndrome" is a symptom of broader emergency system inadequacies rather than a singular issue of bed counts. Multiple interdependent drivers spanning context, priorities/values, and core health system functions converge to produce refusals and delayed emergency care, especially in densely populated Greater Accra. Similar patterns across SSA and other LMICs underscore that Ghana’s challenges are emblematic of systemic emergency care constraints, including infrastructural deficits, workforce shortages, poor coordination, and underfunding. Addressing the syndrome requires integrated systems reform: aligning political and health system priorities with equity and responsiveness values; strengthening information systems and communication (e.g., coordinated call centers); equipping ERs to minimum international standards; expanding and distributing emergency/critical care training; improving working conditions and retention to reduce burnout; and considering legal frameworks that mandate stabilization prior to transfer, coupled with resourcing to make compliance feasible. Fragmented measures (donations, ad hoc trainings, directives) are insufficient without coordinated, well-financed, and evaluated reforms. The Ghana case can inform regional and global agendas to prioritize emergency care within UHC (SDG 3) by highlighting actionable system-level levers and the necessity of monitoring and evaluation of implemented solutions.

The review concludes that: (1) The "no bed syndrome" is essentially a synonym for inadequate emergency healthcare access and reflects neglect of emergency and critical care within the UHC agenda. (2) Solutions require integrated, system-wide reforms rather than piecemeal actions. (3) While focused on Ghana, similar underlying problems exist across SSA and other LMICs, making these insights broadly relevant. (4) Emergency medical, surgical, and obstetric care should be elevated on UHC policy, implementation, and research agendas in SSA. (5) Practical steps include: adopting a systems approach that addresses context, priorities, and equity values alongside deficiencies in health system building blocks; equipping all hospital emergency rooms to a basic minimum standard; developing and adequately funding emergency and critical care training programs and in-service updates; enacting and enforcing legislation requiring first aid/stabilization for life-threatening conditions with concomitant resourcing; and ensuring adequate numbers and equitable distribution of skilled emergency care staff across the system. Future work should include robust monitoring and evaluation of interventions (e.g., call centers, training, infrastructure upgrades) to assess impact on morbidity and mortality and guide scale-up.

The review is constrained by the scarcity of peer-reviewed publications specifically using the term "no bed syndrome"; most evidence derives from grey literature and media reports. The media review was limited to six high-circulation outlets and GhanaWeb, so some reports may have been missed. Quality appraisal of sources was not conducted due to the predominance of journalistic/descriptive material and the conceptual nature of the research questions.