Gender-based violence response and health system readiness during emergencies in Sierra Leone: a qualitative study of survivor experience, facility preparedness, and referral pathways

BACKGROUND: Gender-based violence (GBV) intensifies during emergencies, yet health and protection systems in Sierra Leone remain inadequately prepared to respond. Survivors face barriers including stigma, breaches of confidentiality, and weak referral pathways. OBJECTIVE: This study explored how health and protection systems in three districts of Sierra Leone respond to GBV during emergencies. METHODS: A qualitative descriptive study was conducted across three districts, integrating semi-structured interviews with referral pathway mapping. Purposive sampling recruited 54 participants: 48 key informants across eight stakeholder groups and 6 survivors identified through referral organisations. Data were analysed using the framework method. Data collection took place outside an active emergency; emergency-specific findings therefore reflect participant recollection rather than direct observation. RESULTS: Four themes emerged: fragmented and under-resourced clinical readiness; confidentiality failures and stigma as structural barriers; dysfunctional referral pathways and coordination gaps; and limited, inconsistent survivor-centred psychosocial care. Participants reported that emergency contraception was frequently unavailable and, in some accounts, withheld on moral grounds. Referrals to police and social welfare were described as ad hoc, reliant on personal relationships, and severely disrupted when GBV was excluded from emergency coordination structures. Counsellors were largely absent from peripheral facilities. A minority of participants reported functioning one-stop centre care. CONCLUSIONS: Participants described GBV response arrangements that were fragile in stable periods and, in their recollection of previous emergencies, substantially weakened, alongside a smaller set of components that functioned. Emergency preparedness planning would benefit from explicit attention to survivor-centred GBV care; the applicability of these district-level findings elsewhere requires further study.