How Sierra Leone Developed its First National Hospital Strategy 2025–2030: A Policy Analysis Case Study of Process, Actors, and Procedural Legitimacy

Sierra Leone’s hospital system faces persistent challenges, including high maternal and under-five mortality, infrastructure and supply deficits, workforce shortages, fragmented governance, and high out-of-pocket health expenditure. These constraints limit the contribution of hospitals to Universal Health Coverage (UHC) and service delivery. In response, the Ministry of Health (MoH) developed the first National Hospital Strategy for Service Delivery Transformation 2025–2030. We conducted a mixed-methods policy analysis case study of the development of the hospital strategy. The analysis was guided by the Walt and Gilson Health Policy Analysis Triangle, focusing on context, content, process, and actors. Data sources included a desk review of policy documents, assessments of nine purposively selected hospitals, fifteen key informant interviews with health sector stakeholders, and three validation workshops using a modified nominal group technique, a structured consensus method in which participants generate priorities individually, present them in turn, discuss them as a group, and then rank them. The accountability for reasonableness framework was applied to assess the procedural legitimacy of the strategy development process. The strategy was shaped by Sierra Leone’s epidemiological, economic, institutional, and health system context, including high mortality rates, limited fiscal space, weak infrastructure, severe shortages of skilled health workers, irregular supply of essential medicines, and fragmented hospital governance. These contextual factors informed a strategic vision for an equitable, accessible, affordable, resilient, and transformative hospital system. The strategy includes ten interlinked strategic objectives covering legal and regulatory reform, governance, financing, infrastructure, human resources, service delivery, supply chain management, health information systems and research, human rights and community engagement, and emergency preparedness. The development process was iterative and participatory, involving MoH leadership, hospital managers, clinicians, district health teams, development partners, professional associations, civil society, and community representatives. Assessed against the accountability for reasonableness framework by the author team, the process showed features consistent with procedural legitimacy, including evidence-informed priority-setting, stakeholder deliberation, iterative revision, and political endorsement, although formal public appeals mechanisms were limited. The development of Sierra Leone’s first hospital strategy illustrates how structured policy analysis, evidence synthesis, and participatory deliberation can support the formulation of a context-sensitive hospital reform agenda in a low-income setting. The analysis covers strategy formulation only. It makes no claim about implementation or health outcomes, which remain to be evaluated. The experience offers transferable lessons for countries seeking to strengthen hospitals as part of progress toward UHC, while highlighting the importance of sustained financing, implementation capacity, accountability and monitoring.