Building Care with Systems: The 5 S’s of the MCOE

Editor's Note: The Paul E. Farmer Maternal Center of Excellence (MCOE), a Partners In Health (PIH)-supported facility, opened to patients in February 2026 on the campus of Koidu Government Hospital (KGH) in Kono District, Sierra Leone.

Built in partnership with Build Health International and the Sierra Leone Ministry of Health, the state-of-the-art facility was designed to confront one of the most urgent challenges in Sierra Leone: preventable maternal death. It represents years of deliberate work to strengthen care where it has long been weakest, part of a two-decade effort across Sierra Leone that has reduced the country's maternal mortality rate by 78% since 2000.

This series explores the MCOE through what PIH calls the "five S's": staff, stuff, space, systems, and social support, the essential elements of a strong health care system. In this article, we focus on systems: the processes and leadership structures that link facilities, teams, and resources so that care can be delivered without delay.

Since opening its doors to patients on Feb. 14, 2026, the MCOE has supported over 2,800 women with care. They came from every district in Sierra Leone and from neighboring Guinea through multiple pathways: referrals from rural clinics, ambulance transfers, and antenatal appointments.

What connects those experiences is not any single action. It is the system that allows care to move across distance and through critical moments where every minute matters.

When referrals fail, transport is delayed, or triage systems break down, maternal deaths become more likely. The MCOE in Kono District was designed to strengthen these connected systems, so that health complications can be identified earlier and treatment delivered in time.

Why Maternal Mortality is a Systems Problem

The importance of these systems became starkly visible in 2014, when PIH began working in West Africa.

"It was the height of the 2014 Ebola outbreak," recalls Jonathan Lascher, former executive director of PIH Sierra Leone from 2017 to 2021. "The obstetric complications routinely managed in well-resourced hospitals were the very ones killing women in Sierra Leone.

"Rapid Ebola tests would have allowed us to triage pregnant women," Lascher says, referring to the easy-to-use tests to diagnose various diseases within minutes. "But in the fall of 2014, test results took days. Electricity was unreliable, water scarce, and pharmacy shelves sat empty."

The problems extended beyond testing. "One ambulance served 500,000 people," Lascher recalls. Transport delays often meant women arrived too late for clinicians to intervene.

"Women were dying because the district's health infrastructure, even after years of improvements, was still insufficient," Lascher explains. "Too few ambulances meant women in remote villages who made it to rural clinics were unable to reach emergency care in time. High-risk pregnancies arrived too late to be saved. Reducing maternal mortality requires long-term commitment across multiple systems. I knew PIH could not do everything, nor could we do anything alone."

Triage and Patient Flow

Isata Dumbuya, director of nursing and midwifery for reproductive, maternal, neonatal, child and adolescent health for PIH Sierra Leone, comforts Fanta Jimmy as she is prepared for the first cesarean section at the MCOE on Feb. 14, 2026. Photo by Caitlin Kleiboer / PIH

Systems are not abstract; they determine whether a mother's condition is recognized and referred in time or whether she can reach care at all.

In Kono, that process often begins at a smaller local clinic, where pregnant women are expected to attend prenatal appointments and be assessed over time. But if warning signs or complications emerge beyond what the local facility can safely manage, staff call the National Emergency Medical Services (NEMS) toll-free number to request an ambulance to the MCOE.

When the MCOE opened in February to patients, the first ambulance soon arrived carrying Sia Jimissa, a 33-year-old pregnant mother of three. Throughout her pregnancy, Jimissa had attended prenatal appointments at her local clinic. But after several hours of labor throughout the morning, staff at her clinic identified complications beyond what they could safely manage.

They decided to escalate Jimissa's care, setting multiple parts of the maternal referral network in motion. The clinic contacted NEMS to transfer Jimissa by ambulance approximately two hours to the MCOE.

"When a complication is identified, they call our numbers," says Joyce Senesie, regional operations coordinator for NEMS.

NEMS operates in every district in Sierra Leone. In Kono alone, NEMS supports 111 facilities across all 14 chiefdoms. Ambulances are strategically positioned to cover the widespread district as efficiently as possible.

Once the call is received, the nearest ambulance is dispatched.

"An ambulance is not just an ambulance," says Senesie. "We have medical equipment, including oxygen. We have the driver and the paramedic, and while the patient is in the ambulance, we provide pre-hospital care to sustain her life before she reaches the MCOE."

By the time Jimissa arrived at the MCOE later that afternoon, she had already moved through multiple layers of care: from community-based prenatal services to emergency referral, ambulance transport, and pre-hospital stabilization along the way.

Inside the MCOE

Fanta Jimmy holds her newborn daughter in the neonatal intensive care unit, the first in Sierra Leone, at the MCOE on Feb. 16, 2026. Photo by Chiara Herold / PIH

When a patient ultimately reaches the MCOE, the process begins with registration and an initial clinical assessment. If it is her first visit, she is registered, given an ID, and entered into the electronic medical record system. From there, staff begin evaluating the case based on why a patient has come and how she presents.

At the MCOE, the triage area has become the point where those uncertainties are resolved. Some women require outpatient review. Others need admission to the antenatal or labor ward. Women in critical condition, or whose babies show signs of distress, are moved quickly toward surgery or other urgent care.

For patients like Jimissa, that sorting process is critical. The sooner clinicians understand what kind of care is needed, the sooner treatment can begin.

Before the MCOE, in the prior maternity ward at KGH, that distinction was often impossible. There was no dedicated outpatient triage space to assess women before sending them onward; patients who appeared distressed were often moved directly into labor and delivery, even when they were not yet at that birthing stage.

The previous labor ward had four beds, while three additional observation beds also served as a post-delivery space. Women in labor often shared that setting with mothers recovering alongside newborns, as well as patients arriving with unrelated emergencies.

Now, with the introduction of a dedicated triage system at the MCOE, that flow has changed. Patients are assessed and stabilized before even entering the ward. Once registration staff have entered a patient into the system, clinicians can immediately see who is waiting and review cases sooner.

And when multiple emergencies arrive at once, clinical teams must prioritize rapidly. Decisions are made based first on the mother's condition and then on the level of risk to the baby-cases such as severe preeclampsia, postpartum hemorrhage, fetal distress, or near-immediate delivery demand fast coordination.

After completing a thorough assessment, the triage team determined that Jimissa had prolonged labor and her baby was in distress. She was moved swiftly to an operating theater-one of three at the MCOE-where she underwent an emergency C-section with no complications and delivered a healthy baby boy.

Keeping the System Running

Sia Jimissa, 33, rests with her newborn son in the postoperative ward at the MCOE on Feb. 16, 2026. Photo by Chiara Herold / PIH

For clinicians to respond quickly when medical complications occur, such as those faced by Jimissa, the MCOE's electricity, laboratory services, oxygen supply, and the communication infrastructure supporting the entire system must function continuously.

"Hospitals run all day, every day," says Henry Amoakwa, a biomedical engineer supporting the MCOE. "There cannot be a gap or a breakdown otherwise lives are at risk."

When one systematic link fails, the consequences travel quickly. When those links function together, patients reach care sooner, and clinicians gain time to respond.

For women like Jimissa, those connections can mean the difference between arriving too late and arriving on time; it can mean survival.