A Medical Superintendent reflects on Ghana’s referral challenges, the realities behind “No Bed Syndrome,” and why strengthening coordination, not declaring system failure, holds the key to improving patient outcomes.
The Night That Explains Everything
It was exactly 1:30 a.m. in a district hospital in Ghana when my phone rang. On the other end was a distressed doctor on duty. The maternity ward was in turmoil, a young woman had developed severe postpartum haemorrhage following a vaginal delivery.
The team was doing everything right. Protocols were being followed meticulously. Staff members were donating blood themselves to keep her alive. Yet the bleeding would not stop. A referral centre had agreed to receive her, but there was one problem: we had no ambulance.
Repeated calls to the national ambulance central line went unanswered. Attempts again and again yielded only silence. We contacted the local ambulance service, which responded but refused to move unless clearance first came through the central call centre, clearance we could not obtain despite desperate efforts.
Faced with a race against time, I made a decision no clinician wishes to make. I left the ongoing resuscitation in the hands of a colleague and the midwives, drove personally to the local ambulance bay in the middle of the night, and pleaded, eventually threatened, before the vehicle was finally released to transport the patient to the referral centre.
On other days, the ambulance does arrive. Yet even then, another struggle begins. The referring facility must convince the ambulance team that the receiving hospital is truly ready to accept the patient; otherwise, they will not move. The ambulance crews cannot entirely be faulted. Too often, they arrive at referral centres only to wait for hours because there is “no bed.” Patients remain in ambulances parked outside emergency units while staff search desperately for space.
Sometimes, tragically, patients deteriorate and die before care can be handed over, as has happened in recent memory. Calls are placed to one referral centre after another, and the response is painfully familiar: “No bed.”
Moments like these are emotionally exhausting and morally distressing. To the public, such stories are often reduced to a simple conclusion: Ghana’s health system is broken. Yet what unfolds behind these words is far more complex: a referral system under strain, fragmented coordination, and healthcare workers navigating impossible choices in real time.
When “No Bed” Does Not Mean No Bed
One enduring misconception is that a hospital bed is simply a mattress waiting for the next patient. In reality, a hospital bed represents a unit of care, trained personnel, monitoring equipment, oxygen supply, medications, supervision, and a clinical team prepared to assume responsibility for another life.
A hospital may officially have one hundred beds yet still lack the capacity to admit another critically ill patient. Bed availability is not merely numerical; it is managerial. Poor patient flow, delayed discharges, weak coordination between departments, and the absence of real-time bed tracking can render a facility functionally full even when physical spaces exist. Without deliberate bed management systems, hospitals gradually choke under their own inefficiencies.
Emergency units consequently become holding areas rather than transition points for care. Patients who should move to wards remain for prolonged periods, not always because beds are unavailable, but because ownership becomes blurred among multiple clinical teams. Multi-team management, though intended to improve specialist input, can delay decisions when responsibility is unclear. Each team waits for another review, and the patient remains in limbo.
Human factors also play a role. At times, the reluctance by some ward staff to receive critically ill patients creates the impression that beds do not exist. Managing unstable patients is demanding and resource-intensive, and where staffing or confidence is limited, resistance may emerge. The result is a dangerous illusion, a hospital declared full not solely because of capacity limits but because responsibility is deferred.
Within every system are individuals whose conduct undermines teamwork, professionals who resist collaboration, dismiss alternative opinions, or insist on unilateral decision-making. Such dynamics fragment care and delay patient movement. Though largely invisible to the public, they significantly contribute to congestion within emergency units.
Compounding these challenges is the reality of limited logistics. Many wards lack adequate monitoring equipment, oxygen points, infusion pumps, or trained personnel required to safely manage critically ill patients. Even where beds exist, admission may be unsafe. In such circumstances, saying “no bed” becomes less a refusal and more an acknowledgement of operational limits.
“No Bed Syndrome,” therefore, is rarely about furniture. It is about systems, culture, coordination, accountability, and resources interacting imperfectly under pressure.
A System Under Strain — Yet Still Delivering
Amid these challenges, an overlooked truth remains: Ghana’s health sector continues to function and often performs remarkably well under constraint.
In my own district hospital, serving a catchment population of just over 165,000 people, 172,551 outpatient visits were recorded within a single year, approximately 1.05 visits per person annually. Such utilisation reflects a system that remains accessible and trusted by the population it serves.
The same facility recorded 15,586 inpatient admissions, 5,116 deliveries, and 2,591 major surgeries, all within an infrastructure that has seen no significant expansion in more than three decades. These figures represent thousands of lives stabilised, mothers safely delivered, and emergencies managed daily by healthcare workers operating within fixed physical capacity but rising demand.
Much of Ghana’s healthcare success lies in everyday resilience, clinicians improvising solutions, nurses extending shifts, laboratory staff working beyond capacity, and administrators continually reorganising scarce resources to maintain service delivery. These successes occur quietly, rarely making headlines.
A broken system does not deliver millions of outpatient encounters and thousands of safe births year after year. What we are witnessing instead is a system under pressure, evolving, adapting, and sometimes struggling, but far from collapse.
Fixing the Referral Gap: Practical Steps Forward
If “No Bed Syndrome” is not merely about beds, solutions must extend beyond constructing new wards.
Bed management must become a professional function supported by empowered bed managers with institutional authority. Tertiary facilities must establish clear operating procedures defining patient ownership and conflict-resolution pathways for multi-team care.
Communication between referring facilities and the National Ambulance Service must be standardised so referrals no longer depend on repeated phone calls during emergencies.
District hospitals must be empowered through training, specialist outreach, and teleconsultation support to safely manage more cases locally, reducing unnecessary referrals.
Investment in ward infrastructure, monitoring equipment, oxygen systems, and essential emergency tools, will convert physical beds into usable clinical capacity.
Ghana must also expand supervised home-based care. Many patients remain admitted despite being stable enough for continued treatment at home. Structured home-care programmes supervised by family physicians and general practitioners would enable earlier discharge, free hospital beds, create employment opportunities for healthcare professionals, and encourage private-sector participation in regulated home-care and ambulance services.
Finally, ambulance availability must match population needs. Every district hospital should have reliable ambulance access, complemented by regulated private ambulance services to strengthen emergency response capacity.
These reforms do not require reinventing the health system. They require coordination, leadership, and commitment to strengthening what already exists.
A System Worth Fixing — and Voices Worth Hearing
On nights like the one that began at 1:30 am and the words “no bed” carry a meaning far deeper than the public often perceives. Behind them are healthcare workers searching for solutions within imperfect circumstances.
At the centre of this daily balancing act are Medical Superintendents, clinicians tasked with navigating the intersection of care delivery, administration, logistics, and community expectation. They live the referral system daily, negotiating admissions, resolving conflicts, coordinating emergencies, and managing scarcity in real time.
Yet these voices are often absent from national conversations about healthcare reform. While policy debates unfold and crises dominate headlines, those responsible for operationalising healthcare realities at the facility level remain largely unheard.
Meaningful reform will not arise solely from declarations or infrastructure expansion. It will come from listening to frontline leadership, empowering facility managers, and aligning policy with operational realities.
Ghana’s health system is not perfect. It is stretched, sometimes overwhelmed, but sustained by professionals who continue to adapt and care despite limitations. The task before us is not to condemn the system, but to understand it and strengthen it.
Perhaps then, fewer families will hear the words “no bed.” And when they do, it will reflect not systemic failure, but the honest limits of a system continually striving to do better.
By: Dr Richard Nii Darku Dodoo, A Family Physician
