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Objective: To explore factors influencing surgical provider productivity and identify barriers against and opportunities to increase individual surgical productivity in Sierra Leone, in order to explain the observed increase in unmet surgical need from 92.2% to 92.7% and the decrease in surgical productivity to 1.7 surgical procedures per provider per week between 2012 and 2017., Design and Methods: This explanatory qualitative study consisted of in-depth interviews about factors influencing surgical productivity in Sierra Leone. Interviews were analysed with a thematic network analysis and used to develop a conceptual framework., Participants and Setting: 21 surgical providers and hospital managers working in 12 public and private non-profit hospitals in all regions in Sierra Leone., Results: Surgical providers in Sierra Leone experience a broad range of factors within and outside the health system that influence their productivity. The main barriers involve both patient and facility financial constraints, lack of equipment and supplies, weak regulation of providers and facilities and a small surgical workforce, which experiences a lack of recognition. Initiation of a Free Health Care Initiative for obstetric and paediatric care, collaborations with partners or non-governmental organisations, and increased training opportunities for highly motivated surgical providers are identified as opportunities to increase productivity., Discussion: Broader nationwide health system strengthening is required to facilitate an increase in surgical productivity and meet surgical needs in Sierra Leone. Development of a national strategy for surgery, obstetrics and anaesthesia, including methods to reduce financial barriers for patients, improve supply-mechanisms and expand training opportunities for new and established surgical providers can increase surgical capacity. Establishment of legal frameworks and appropriate remuneration are crucial for sustainability and retention of surgical health workers., Competing Interests: Competing interests: HAB and AJvD are board members of CapaCare, a non-profit organisation that provides surgical training to physicians and associate clinicians in Sierra Leone. JB was a volunteer trainer for CapaCare in Sierra Leone, WWEN the programme coordinator, and PM and TS are graduates of the surgical training programme., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The clients' level of satisfaction is an important measure in assessing the quality of health care services provided in health facilities, and is important in enhancing the utilisation of health care services., Objectives: This study aimed to determine pregnant women's level of satisfaction on the quality of care in the Reproductive and Child Health (RCH) clinic at Huruma Designated District Hospital, Rombo Kilimanjaro., Methodology: A cross-sectional study was conducted from May to June 2018 using the Donabediean model. Using systematic sampling, 270 pregnant women were selected to participate in the study. Data was collected using a pre-tested Service Quality(SERVQUAL) questionnaire. Descriptive statistics were performed using univariate and bivariate analysis, and one sample t-test to compare mean gap scores. The principal component analysis was employed to identify key items that measure the quality of care. A p-value of <.05 was considered statistically significant., Results: Overall, pregnant women's level of satisfaction on the quality of care in the Reproductive and Child Health clinic at Huruma DDH was 48.5%. The overall mean gap score (±SD) for the level of satisfaction was -0.53 (±1.69) signifying dissatisfaction with the quality of care. The overall level of satisfaction was associated with level of education (p<.001), occupation (p=.003), residence (p=.035). The levels of dissatisfaction in the 5 service dimensions were: empathy (-0.05), responsiveness (-0.09), assurance (-0.10), tangible (-0.13), and reliability (-0.17)., Conclusion: Overall, pregnant women were dissatisfied with the quality of care provided. Pregnant women who are educated, being employed, and residing in Rombo were more likely to report dissatisfied with the quality of care. To improve the quality of care, lack of adequate staff and inadequate knowledge of the staff at RCH, and improvement in staff-clients interactions, and keeping scheduled appointments need to be improved., Competing Interests: Competing interests: The author(s) declare that they have no competing interests. Competing Interests: None declared., (© The East African Health Research Commission 2020.)

In 2012, Sierra Leone experienced its worst cholera outbreak in over 15 years affecting 12 of the country's 13 districts. With limited diagnostic capability, particularly in bacterial culture, the cholera outbreak was initially confirmed by microbiological testing of clinical specimens outside of Sierra Leone. During 2012 - 2013, in direct response to the lack of diagnostic microbiology facilities, and to assist in investigating and monitoring the cholera outbreak, diagnostic and reference services were established in Sierra Leone at the Central Public Health Reference Laboratory focusing specifically on isolating and identifying Vibrio cholerae and other enteric bacterial pathogens. Sierra Leone is now capable of confirming cholera cases by reference laboratory testing.