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

The study explores the "no bed syndrome" in Ghana, a phenomenon where patients are turned away from hospitals due to a lack of beds. This lack of responsiveness in the healthcare system is particularly concerning given the importance of timely emergency care, especially for maternal and neonatal health, in achieving the Sustainable Development Goals (SDGs). Ghana's 2012 referral policy and guidelines aimed to improve the referral system, but shortcomings persist, affecting the delivery of quality emergency services. The "no bed syndrome" highlights inadequacies in Ghana's emergency healthcare system, contributing to high maternal and neonatal mortality rates, especially in the Greater Accra Region. The study aims to understand the phenomenon, its causes, and potential solutions through a multidisciplinary desk review.

The review examined published and grey literature, including dissertations, presentations, policies, legislation, administrative reports, and press statements, along with electronic and print media reports from January 2014 to February 2021. Keywords included "no bed syndrome," "no bed," "emergency care," "access," "Ghana," "Sub-Saharan Africa," and "low-and middle-income countries." Sources included Google, Google Scholar, PubMed, university websites, and the Ghana Health Service and Ministry of Health websites. The electronic and print media search utilized Dow Jones Factiva software, focusing on six major media outlets in Ghana. The international peer-reviewed literature lacked publications on the specific term "no bed syndrome."

A qualitative desk review employing a thematic synthesis approach was used. Text was coded line by line to identify themes and sub-themes related to the research questions: What does "no bed syndrome" refer to? How and why does it occur? What interventions are in place or have been tried? The analysis involved manual coding and sorting of themes using Microsoft Excel. The ENTREQ guidelines informed the reporting of results. The study included scholarly articles, grey literature, and media articles containing the search words within the Ghanaian context. Documents not addressing "no bed syndrome," bed availability, emergency referral access, or emergency obstetric referral and care in Ghana were excluded. A total of 99 articles (70 media reports and 29 other sources) were reviewed.

The "no bed syndrome" describes the refusal of emergency care to patients in Ghanaian hospitals and clinics due to a stated lack of beds. This often leads to patients being transferred between multiple facilities without receiving initial treatment, sometimes resulting in death. The problem is most prevalent in Greater Accra. Underlying factors include: Contextual factors: rapid population growth, urbanization, increasing disease burden, slow economic growth, and inconsistent infrastructure projects. Health system priorities and values: underfunding and neglect of emergency health services, unequal distribution of facilities, and limited investment beyond the establishment of a national ambulance service. Health system functions: insufficient funding, ineffective regulation, poor information systems, inadequate human resources (number, skills, distribution, motivation), insufficient equipment, tools, and supplies, and unreliable emergency transport. Existing interventions have been fragmented, focusing on supply-side solutions like administrative directives, health worker training, call center interventions, and donations of resources. Demand-side interventions are lacking.

The "no bed syndrome" reflects a broader systemic failure within Ghana's emergency healthcare system. Similar challenges exist in other Sub-Saharan African countries and low-to-middle-income countries. The multiple interconnected factors driving the syndrome demand a holistic, integrated systems approach to reform. Piecemeal interventions are insufficient. Addressing this requires simultaneous action across various levels: contextual factors, health system priorities, values, and core health system functions. This includes improving infrastructure, providing sufficient equipment and supplies, ensuring adequate numbers of skilled healthcare professionals, and enhancing information systems and communication. Legislative measures, such as sanctions for refusing first aid, could be considered but must be coupled with sufficient resource provision.

The "no bed syndrome" represents a critical gap in access to emergency healthcare in Ghana and beyond. A systems approach is necessary to address this, involving simultaneous attention to contextual factors, health system priorities, values, and functional deficiencies. This includes improving infrastructure, training, staffing, and resource allocation. Further research and evaluation of interventions are needed to ensure effective and sustainable solutions. The problem's global relevance underscores the urgent need for prioritization of emergency care within universal health coverage initiatives.

The review's reliance on grey literature and a limited number of media sources may restrict the findings' generalizability. The focus on readily available sources may have resulted in missing some relevant information. The lack of research and peer-reviewed publications on the specific term "no bed syndrome" also presents a limitation; however, sufficient information from other sources was used to comprehensively address the research questions.