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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

Referral Systems Page 1 / 9 A MAKER Summary

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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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 determinan ...
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