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Referral Systems Page 1 / 9 A MAKER Summary
Referral Systems - a summary of key processes to guide
health services managers
An effective referral system ensures a close relationship between all levels of the health system and helps to
ensure people receive the best possible care closest to home. It also assists in making cost-effective use of
hospitals and primary health care services. Support to health centres and outreach services by experienced
staff from the hospital or district health office helps build capacity and enhance access to better quality care.
In many developing countries, a high proportion of clients seen at the outpatient clinics at secondary facilities
could be appropriately looked after at primary health care centres at lower overall cost to the client and the
health system. A good referral system can help to ensure:
Clients receive optimal care at the appropriate level and not unnecessarily costly
Hospital facilities are used optimally and cost-effectively
Clients who most need specialist services can accessing them in a timely way
Primary health services are well utilized and their reputation is enhanced
Being a system, examination of a referral system requires consideration of all its parts. Important
components of a referral system are listed in Box 1 and referral flows are depicted in Figure 1. These can be
adjusted as relevant to the local situation. The design and functioning of a referral system in any individual
country will be influenced by:
health systems determinants: capabilities of lower levels; availability of specialized personnel;
training capacity; organizational arrangements; cultural issues, political issues, and traditions
general determinants, such as: population size and density; terrain and distances between urban
centres; pattern and burden of disease; demand for and ability to pay for referral care
Figure 1. Referral system flows
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Box 1. Components of a referral system
Definition of terms
A referral can be defined as a process in which a health worker at a one level of the health system, having
insufficient resources (drugs, equipment, skills) to manage a clinical condition, seeks the assistance of a
better or differently resourced facility at the same or higher level to assist in, or take over the management
of, the client’s case. Key reasons for deciding to refer either an emergency or routine case include:
to seek expert opinion regarding the client
to seek additional or different services for the client
to seek admission and management of the client
to seek use of diagnostic and therapeutic tools
1. Health System
a. Service providers (public and private sector) and quality of care
i. Strengthened primary health care services
ii. Clarity of level and role of each facility
iii. Availability of protocols of care for conditions for each level of facility
iv. Availability of communication and transport
b. Performance expectations
i. Expectation to refer appropriately and follow protocols of care
ii. Expectations that health workers and clients adhere to the referral discipline
iii. Regular supervision and capacity building
c. Involvement of organizations
i. Ministry of Health
ii. Medical and nursing schools
iii. Medical and nursing professional associations
2. Initiating facility
a. The client and their condition
b. Protocol of care for that condition at that level of service
c. Treat and stabilize client document treatment provided
d. Decision to refer
3. Referral practicalities
a. Outward referral form
b. Communication with receiving facility (make arrangements as appropriate)
c. Information to the client and their family/support network
i. Reasons and importance of referral, risks of non-referral
ii. How to get to the receiving facility location and transport
iii. Who to see and what is likely to happen
iv. Follow-up on return
d. Empathy - understanding of implications for client and family/support network
i. Overall fear
ii. Cost of transport, treatment and family accommodation
e. Referral register to monitor follow-up and gather statistics
4. Receiving Facility
a. Anticipate arrival and receive client and referral form
b. Provide care document treatment provided
c. Plan rehabilitation or follow-up with client and family/support network
d. Back referral form
e. Feedback to initiating facility on appropriateness of referral
f. Referral register to monitor follow-up and gather statistics
5. Supervision and capacity building
a. Monitor outward and back referrals
i. Number and appropriateness of referrals compliance with protocols
ii. Quality of documentation
iii. Consistency of follow-up
b. Provide feedback, support and training for health staff
c. Provide feedback to central level
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In this paper, the facility that starts the referral process is called the initiating facility, and they prepare an
outward referral to communicate the client condition and status (see sample tool 1).
The facility that accepts the referred case is called the receiving facility and at the end of their involvement,
they prepare a back referral on the lower part of the forms to let the initiating facility know what has been
done (see sample tool 1). This completes the referral loop between the 2 facilities.
A referral register is a means of maintaining a list of all outward and inward referrals for one facility or
service provider (see sample tool 2). Information registered includes client referred, to where, when and why,
whether the case is closed or continuing (the retuning referral form has been received with any necessary
rehabilitation or follow-up), and whether it was an appropriate referral or if there were any issues.
Some areas maintain a directory of services that lists all organizations providing specialist care. Such a
directory can facilitate the search for the most appropriate service provider for a particular referral. Where
such a directory is used, it is important that the contact information is kept up-to-date.
These terms are not hard and fast, but are used here to assist clarity of description. The referral system in
your country might use different terms.
Description of components of the referral system
1. Health system issues
a. Service providers (public and private) and quality of care
For a referral system to work at its best, relationships between service providers are formalized and
referral procedures agreed. All levels of the health system, including primary health care services,
need to be functioning appropriately. This includes each facility:
being clear about their role, responsibilities and limitations
having readily available protocols of care for conditions for that level of service
having suitable means of communication and transport. Communication is generally by the
referral form but may in addition be by radio, phone or fax. Where government is unable to
provide an ambulance for health centres, a community-based system of organizing
transport may sometimes be possible.
Clients’ bypassing lower level services is a common problem which leads to overcrowding of high