Health-system barriers and missed opportunities in cardiovascular care in Sierra Leone: a scoping review

Cardiovascular disease (CVD) mortality is rising in Sierra Leone, but the health-system drivers of this trend are not well characterised. We mapped health-system barriers and facilitators for CVD care in Sierra Leone using a systems lens tied to universal health coverage (UHC). We conducted a scoping review following PRISMA-ScR guidelines. We searched MEDLINE, Embase, Scopus, Global Health, and African Journals Online (1 Jan 2000 – 10 May 2025), Of 498 unique records, we included 40 sources reporting CVD-relevant data. Findings were mapped to WHO health-system building blocks, and synthesised narratively. Our findings show a health system shaped by path dependence: investments in infectious disease programmes have strengthened vertical delivery platforms with limited integration of non-communicable disease services. Facility readiness averaged 41% for HIV services versus 16.8% for cardiovascular care. An urban risk paradox was identified: urbanisation increased the odds of hypertension (OR 1.46) and diabetes (OR 1.84), while primary care infrastructure remained more oriented toward rural maternal health. Service delivery was undermined by diagnostic gaps; limited access to neuroimaging for stroke was associated with a threefold increase in mortality. High out-of-pocket costs narrowed effective coverage toward wealthier groups, and recurrent medicine stockouts reinforced distrust and disengagement from formal care. Scalable enablers included task-sharing, digital tools, pooled procurement, and community engagement. Strengthening task-shared primary care, ring-fenced CVD budgets, pooling drug procurement, and improving digital infrastructure could accelerate UHC-effective coverage in Sierra Leone. Evidence on cost-effectiveness and socio-cultural determinants remains limited and should guide implementation research. Heart diseases are a major cause of death in Sierra Leone. However, the health system is still mainly designed to respond to infectious diseases including malaria and HIV, rather than long-term conditions like heart disease. In this review, we analysed 40 studies to understand why people often struggle to get proper heart disease care. We found that health facilities were much better prepared to deliver HIV services (41% readiness) than heart disease services (17% readiness). High blood pressure and other heart disease risks are increasing, especially with urbanisation. However, services for heart disease are not always available where people need them most. Many people still face long travel distances, limited services at nearby clinics, and poor availability of medicines, equipment, and trained staff. Unlike HIV care, heart disease care often requires out-of-pocket payments, which delays treatment until emergencies such as stroke happen. Solutions include adapting HIV infrastructure for heart disease care and lowering costs. Jalloh et al. map health-system barriers and facilitators for cardiovascular disease care in Sierra Leone using a systems lens tied to universal health coverage. This scoping review concludes that service delivery and high patient negatively impacted diagnostics and care and impacted mortality.