BACKGROUND There is an increasing global recognition of the role of emergency medical services in improving population health. Emergency medical services remain underdeveloped in many low income countries, particularly in sub-Saharan Africa. There have been no previous evaluations of specialist emergency and critical care services in Sierra Leone. METHODS Emergency care capacity was evaluated at a sample of seven public and private hospitals in Freetown, the capital of Sierra Leone. A structured set of minimum standards necessary to deliver emergency and critical care in the low-income setting was used to evaluate capacity. The key dimensions of capacity evaluated were infrastructure, human resources, drug and equipment availability, training, systems, guidelines and diagnostics. A score for each dimension of capacity was calculated based on the availability of a list of specified indicators within each dimension. In addition, an Emergency Care Capacity Score was calculated to demonstrate a composite measure of capacity based on the various indicator scores. This method has been used by the World Health Organisation in evaluating the availability and readiness of healthcare systems in low- and middle-income countries. RESULTS Substantial deficiencies in capacity were demonstrated across the range of indicators and predominantly affecting publically funded facilities. Capacity was weakest in the domain of infrastructure, with an average score of 43%, while the strongest areas of capacity overall were in drug availability, 82%, and human resources, 79%. A marked disparity was noted between public and private healthcare facilities with consistently lower capacity in the former. The overall Emergency Care Capacity Score was 66%. CONCLUSIONS There are substantial deficiencies in emergency care systems in public hospitals in Freetown which are likely to compromise effective care. This represents a serious barrier to access to emergency healthcare. Emergency care systems have an important role in improving population health and as such should a priority for local policy makers.