Zimbabwe's hospital referral system: does it work?

Patterns of facility and patient related factors to the orthopedic and trauma admissions at the Kenyatta National Hospital: A qualitative assessment

Inappropriate utilization of higher-level health facilities and ineffective management of the referral processes in resource-limited settings is increasingly becoming a concern in health care management in developing countries. This is characterized by self-referrals and frequent bypassing of nearest health facilities coupled with low formal referral mechanisms. This scenario lends itself to a situation where uncomplicated medical conditions are unnecessarily managed in a high-cost health facility. This situation compromises the ability and capacity of Kenyatta National Hospital (KNH) to function as a tertiary referral health facility as envisioned by Kenya Health Sector Referral Implementation Guidelines of 2014, Kenya 201 constitution and KNH legal statue of 1987. The study objective was to assess the patterns of facility and patient related factors to the orthopaedic and trauma admissions at the KNH. This was a descriptive qualitative study design. The study was conducted amongst the orthopaedic and trauma admission caseload for 2021. Data collection was done through a) data abstraction from 905 patients charts admitted during February to December 2021 and b) 10 (ten) semi-structured interviews with 10 major health facilities that refer to KNH to understand the reasons for referral to KNH. Quantitative data was analysed using Statistical Package for Social Science version 21.0 to calculate the frequency distribution. Qualitative data from the data abstraction and transcripts from the KIIs were analysed using NVivo version 12. The major facility and patient related factors to the orthopaedic and trauma admissions at KNH were inadequate human resource capacity and availability (42.7%), financial constraints (23.3%), inadequate Orthopaedic equipment's and implants availability (20.0%) and inadequate health facility infrastructure (6.3%) while the major patient related factor was patient's preference (23.4%). In conclusion, to decongest KNH requires that the lower-level health facilities need to be better equipped and resourced to handle essential orthopaedic and trauma care.

Exploring the perceptions of radiographers pertaining to the provision of quality radiological services in Zimbabwe

INTRODUCTION

Radiology is part of the service industry; therefore, there is a need to understand quality and its associated factors. The cost of poor service quality is a loss of competitive advantage, increased litigation, misdiagnosis, unnecessary radiation exposure, and patient mortality. There has been little research into the factors influencing the quality of radiological services in Zimbabwe. This work, therefore, aimed to explore the radiographer's perceptions of the factors that affect the quality of radiological services at central hospitals in the Harare Metropolitan Province.

METHODS

A qualitative, explorative study applying the SERVQUAL model was carried out. One-on-one interviews with 10 purposively sampled radiographers employed at central hospitals in the Harare Metropolitan Province were conducted. The data were managed by Nvivo 12 (QSR International) and analyzed by framework analysis.

RESULTS

Radiographer's perceptions of the factors that affect the quality of radiological services were categorized by five themes namely; i. Tangibles - the physical appearance of the radiology department and facilities, ii. Reliability and dependability - the ability to perform the promised service dependably and accurately, iii. Responsiveness - the willingness to help patients and provide prompt service, iv. Assurance - the knowledge and courtesy of radiology staff and their ability to inspire trust and confidence, and v. Empathy - caring, the individualized attention the radiology department provides to its patients.

CONCLUSION

Economically viable, well-designed national strategies are needed to prioritize and fund radiology in Zimbabwe and other resource-constrained settings. Recognition of acquired specialist skills by radiographers to halt the exodus and training of radiologists, radiology nurses, medical physicists, and biomedical engineers by local institutions will go a long way in improving the quality of radiological services.

FIFA football nurse - A task sharing approach in sports and exercise medicine practice in grassroots women's football in low- and middle- income settings. A study protocol for a cluster randomised controlled trial

Football (soccer) is a very popular team sport among African women and girls, with player numbers continuing to rise at all levels of the sport. Whereas the participation in football and associated injuries are on the rise, there are not enough sports and exercise medicine (SEM) personnel to attend to these women football players. While Africa may not currently have enough SEM trained medical doctors and/or physiotherapists, it has relatively higher numbers of other healthcare workers; for example, nurses, who lead healthcare services provision from community to tertiary levels. The primary objective of this study will be to compare sports medicine practices; injury prevention behaviours; injury risk parameters; incidence and prevalence of injuries and illnesses in teams with and without a Football Nurse during one competitive season in Malawi's Women's football league. This study will be a cluster randomised control trial will recruit 24 teams from the Women's Football League in Malawi, which will be randomised to either the intervention group or the control group. A cohort of 12 nurses will receive training in basic football medicine; after which they will be attached to a total of 12 women's football teams (intervention group) during one competitive season. The Football Nurses will be directly report to a physiotherapist or doctor in their district to whom they will refer serious injuries for investigations, or further management. The teams with Football Nurses will be compared to other teams that will not have Football Nurses. We expect to develop a low cost, sustainable and context relevant solution to manage the treatment gap of football injuries/illnesses in underserved communities such as women's football. Trial registration number: Pan African Clinical Trial Registry (PACTR202205481965514).

Patterns of orthopedic and trauma admissions to a tertiary teaching and referral health facility in Kenya: Chart review

Tertiary hospitals in resource-limited countries should treat referred patients but in reality, are the first level of care for the vast majority of patients. As a result, the tertiary facility effectively functions as a primary health care facility. The urban phenomenon of widespread self-referral is associated with low rates of formal referral from peripheral health facilities. The study objective was to determine the patterns of orthopaedic and trauma admissions to Kenyatta National Hospital. This was descriptive study design. 905 patient charts were reviewed in 2021. The mean age was 33.8 years (SD 16.5) with range of 1-93 years. Majority 66.3% were between 25-64 years with those above 65 years being 40 (4.4%). Children 0-14 years comprised 10.9% of the admissions. Of the 905 admissions, 80.7% were accident and trauma-related admissions while 17.1% were non-trauma related admissions. About 50.1% were facility referrals while 49.9% were walk-ins. Majority of admissions were through Accident and Emergency Department 78.1%, Corporate Outpatient Care 14.9% and orthopedic Clinic 7.0%. About 78.7% were emergency admissions while 20.8% were elective admissions. Approximately 48.5% were due to Road Traffic Accidents and 20.9% due to falls. Close to 44.8% were casual workers and 20.2% unemployed. About 34.0% attained primary education and 35.0% secondary education. About 33.2% of female admissions were due to non-trauma conditions as compared to male admissions (12.8%) (p<0.001). Admissions for those aged 25-64 years were 3.5 more likely to have emergency admission as compared to those aged 0-14 years. Male were 65.1% less likely to have elective admissions compared to female (p<0.001). Whereas lower limb injuries and non-trauma related conditions were the most commonly admitted conditions, Lower limb injury and spine cases were mostly facility referred while non-trauma conditions were walk-in patients. Vast majority (89.2%) of admissions were from Nairobi Metropolitan region.

The Clinical Profile, Early Warning Score, and Outcome of Children Aged 0–12 Years Referred to a Tertiary Care Hospital in North India

Pediatric patients are referred for multiple reasons, either for better therapeutic services or diagnostic purposes. The clinical condition of patients at the time of referral can significantly affect the outcome of such patients and there is not much data on this aspect. The overall objective of this study was to study the demographic and clinical profile, the causes for referral, and the outcome of pediatric patients being referred to a single tertiary care hospital. This was a prospective observational study done in the Department of Pediatrics of a single tertiary care hospital in North India over the course of 1 year. Patients referred from other health facilities in the age group 0 to 12 years who were admitted in the pediatric ward of the hospital were enrolled. The primary objective was to study the clinical profile and outcome (mortality) of these patients. The secondary objectives were to study the referral pattern of the referred patients, causes for referral, and the severity of illness at the time of admission as assessed by Irish Pediatric Early Warning Score (PEWS) and its correlation with the outcome. The outcomes were categorized as: discharge, death, left against medical advice, referred to other centers, others. Early warning scores are useful to measure the severity of disease and to follow patients' progress. The Irish PEWS score was used in this study to provide a rapid measure of the degree of sickness. Respiratory system disorders and neonatal illnesses were the most common illnesses observed. Most patients had low disease severity as per Irish PEWS score. The overall mortality rate among the referred patients was 19.25%. Patients with younger age, higher scores, neonatal illnesses, and neurological disorders had higher risk of mortality. Training of health personnel at primary and secondary levels in the commonly encountered illnesses will improve provision of care at the local level and decrease low risk referrals.

Modelling improved efficiency in healthcare referral systems for the urban poor using a geo-referenced health facility data: the case of Sylhet City Corporation, Bangladesh

Background

An effective referral system is critical to ensuring access to appropriate and timely healthcare services. In pluralistic healthcare systems such as Bangladesh, referral inefficiencies due to distance, diversion to inappropriate facilities and unsuitable hours of service are common, particularly for the urban poor. This study explores the reported referral networks of urban facilities and models alternative scenarios that increase referral efficiency in terms of distance and service hours.

Methods

Road network and geo-referenced facility census data from Sylhet City Corporation were used to examine referral linkages between public, private and NGO facilities for maternal and emergency/critical care services, respectively. Geographic distances were calculated using ArcGIS Network Analyst extension through a “distance matrix” which was imported into a relational database. For each reported referral linkage, an alternative referral destination was identified that provided the same service at a closer distance as indicated by facility geo-location and distance analysis. Independent sample t-tests with unequal variances were performed to analyze differences in distance for each alternate scenario modelled.

Results

The large majority of reported referrals were received by public facilities. Taking into account distance, cost and hours of service, alternative scenarios for emergency services can augment referral efficiencies by 1.5–1.9 km (p < 0.05) compared to 2.5–2.7 km in the current scenario. For maternal health services, modeled alternate referrals enabled greater referral efficiency if directed to private and NGO-managed facilities, while still ensuring availability after working-hours. These referral alternatives also decreased the burden on Sylhet City’s major public tertiary hospital, where most referrals were directed. Nevertheless, associated costs may be disadvantageous for the urban poor.

Conclusions

For both maternal and emergency/critical care services, significant distance reductions can be achieved for public, NGO and private facilities that avert burden on Sylhet City’s largest public tertiary hospital. GIS-informed analyses can help strengthen coordination between service providers and contribute to more effective and equitable referral systems in Bangladesh and similar countries.

Transfer of primary care patients receiving chronic care: the next step in the continuum of care

The burden of chronic conditions is increasing rapidly in low- and middle-income countries. Chronic conditions require long-term and continuous care, including for patients transferring between facilities. Patient transfer is particularly important in the context of health service decentralization, which has led to increasing numbers of primary care facilities at which patients can access care, and high levels of migration, which suggest that patients might require care at multiple facilities. This article provides a critical review of existing evidence regarding transfer of stable patients receiving primary care for chronic conditions. Patient transfer has received limited consideration in people living with HIV, with growing concern that patients who transfer are at risk of poor outcomes; this appears similar for people with TB, although studies are few. There are minimal data on transfer of patients with non-communicable diseases, including diabetes. Patient transfer for chronic conditions has thus received surprisingly little attention from researchers; considering the potential risks, more research is urgently required regarding reasons for and outcomes of transfers, transfer processes and interventions to optimize transfers, for different chronic conditions. Ultimately, it is the responsibility of health systems to facilitate successful transfers, and this issue requires increased attention from researchers and policy-makers.

An audit of licensed Zimbabwean radiology equipment resources as a measure of healthcare access and equity

Introduction

Approximately two-thirds of the world's population has no access to diagnostic imaging. Basic radiological services should be integral to universal health coverage. The World Health Organization postulates that one basic X-ray and ultrasound unit for every 50000 people will meet 90% of global imaging needs. However, there are limited country-level data on radiological resources, and little appreciation of how such data reflect access and equity within a healthcare system. The aim of this study was a detailed analysis of licensed Zimbabwean radiological equipment resources.

Methods

The equipment database of the Radiation Protection Authority of Zimbabwe was interrogated. Resources were quantified as units/million people and compared by imaging modality, geographical region and healthcare sector. Zimbabwean resources were compared with published South African and Tanzanian data.

Results

Public-sector access to X-ray units (11/10⁶ people) is approximately half the WHO recommendation (20/10⁶ people), and there exists a 5-fold disparity between the least- and best-resourced regions. Private-sector exceeds public-sector access by 16-fold. More than half Zimbabwe's radiology equipment (215/380 units, 57%) is in two cities, serving one-fifth of the population. Almost two-thirds of all units (243/380, 64%) are in the private sector, routinely accessible by approximately 10% of the population. Southern African country-level public-sector imaging resources broadly reflect national per capita healthcare expenditure.

Conclusion

There exists an overall shortfall in basic radiological equipment resources in Zimbabwe, and inequitable distribution of existing resources. The national radiology equipment register can reflect access and equity in a healthcare system, while providing medium-term radiological planning data.

Strengthening referral systems in community health programs: a qualitative study in two rural districts of Maputo Province, Mozambique

BACKGROUND

Effective referral systems from the community to the health care facility are essential to save lives and ensure quality and a continuum of care. The effectiveness of referral systems in Mozambique depends on multiple factors that involve three main stakeholders: clients/community members; community health workers (CHWs); and facility-based health care workers. Each stakeholder is dependent on the other and could form either a barrier or a facilitator of referral within the complex health system of Mozambique.

METHODS

This qualitative study, aiming to explore barriers and enablers of referral within the lens of complex adaptive health systems, employed 22 in-depth interviews with CHWs, their supervisors and community leaders and 8 focus group discussion with 63 community members. Interviews were recorded, transcribed and read for identification of themes and sub-themes related to barriers and enablers of client referrals. Data analysis was supported by the use of NVivo (v10). Results were summarized in narratives, reviewed, discussed and adjusted.

RESULTS

All stakeholders acknowledged the centrality of the referral system in a continuum of quality care. CHWs and community members identified similar enablers and barriers to uptake of referral. A major common facilitator was the existence of referral slips to expedite treatment upon reaching the health facility. A common barrier was the failure for referred clients to receive preferential treatment at the facility, despite the presence of a referral slip. Long distances and opportunity and transport costs were presented as barriers to accessibility and affordability of referral services at the health facility level. Supervisors identified barriers related to use of referral data, rather than uptake of referral. Supervisors and CHWs perceived the lack of feedback as a barrier to a functional referral system.

CONCLUSIONS

The barriers and enablers of referral systems shape both healthcare system functionality and community perceptions of care. Addressing common barriers to and strengthening the efficiency of referral systems have the potential to improve health at community level. Improved communication and feedback between involved stakeholders - especially strengthening the intermediate role of CHWs - and active community engagement will be key to stimulate better use of referral services and healthcare facilities.

Initiating a Standardized Regional Referral and Counter-Referral System in Guatemala: A Mixed-Methods Study

Background:Few data exist for referral processes in resource-limited settings. We utilized mixed-methods to evaluate the impact of a standardized algorithm and training module developed for locally identified needs in referral/counter-referral procedures between primary health centers (PHCs) and a Guatemalan referral hospital. Methods: PHC personnel and hospital physicians participated in surveys and focus groups pre-implementation and 3, 6, and 12 months post-implementation to evaluate providers’ experience with the system. Referred patient records were reviewed to evaluate system effectiveness. Results: A total of 111 initial focus group participants included 96 (86.5%) from PHCs and 15 from the hospital. Of these participants, 53 PHC physicians and nurses and 15 hospital physicians initially completed written surveys. Convenience samples participated in follow-up. Eighteen focus groups achieved thematic saturation. Four themes emerged: effective communication; provision of timely, quality patient care with adequate resources; educational opportunities; and development of empowerment and relationships. Pre- and post-implementation surveys demonstrated significant improvement at the PHCs (P < .001) and the hospital (P = .02). Chart review included 435 referrals, 98 (22.5%) pre-implementation and 337 (77.5%) post-implementation. There was a trend toward an increased percentage of appropriately referred patients requiring medical intervention (30% vs 40%, P = .08) and of patients requiring intervention who received it prior to transport (55% vs 73%, P = .06). Conclusions: Standardizing a referral/counter-referral system improved communication, education, and trust across different levels of pediatric health care delivery. This model may be used for extension throughout Guatemala or be modified for use in other countries. Mixed-methods research design can evaluate complex systems in resource-limited settings.

A Patient-Centered Understanding of the Referral System in Ethiopian Primary Health Care Units

Background

Primary healthcare systems in sub-Saharan Africa have undergone substantial development in an effort to expand access to appropriate facilities through a well-functioning referral system. The objective of this study was to evaluate the current patterns of seeking prior care before arriving at a health center or a hospital as a key aspect of the referral system of the primary health care unit (PHCU) in three regions in Ethiopia. We examined what percentage of patients had either sought prior care or had been referred to the present facility and identified demographic and clinical factors associated with having sought prior care or having been referred.

Methods and Findings

We conducted a cross-sectional study using face-to-face interviews in the local language with 796 people (99% response rate) seeking outpatient care in three primary health care units serving approximately 100,000 people each and reflecting regional and ethnic diversity; 53% (N = 418) of the sample was seeking care at hospital outpatient departments, and 47% of the sample was seeking care at health centers (N = 378). We used unadjusted and adjusted logistic regression to identify factors associated with having been referred or sought prior care. Our findings indicated that only 10% of all patients interviewed had been referred to their current place of care. Among those in the hospital population, 14% had been referred; among those in the health center population, only 6% had been referred. Of those who had been referred to the hospital, most (74%) had been referred by a health center. Among those who were referred to the health center, the plurality portion (32%) came from a nearby hospital (most commonly for continued HIV treatment or early childhood vaccinations); only 18% had come from a health post. Among patients who had not been formally referred, an additional 25% in the hospital sample and 10% in the health center sample had accessed some prior source of care for their present health concern. In the adjusted analysis, living a longer distance from the source of care and needing more specialized care were correlated with having sought prior care in the hospital sample. We found no factors significantly associated with having sought prior care in the health center sample.

Conclusions

The referral system among health facilities in Ethiopia is used by a minority of patients, suggesting that intended connections between health posts, health centers, and hospitals may need strengthening to increase the efficiency of primary care nationally.

The use of modern quality improvement approaches to strengthen African health systems: a 5-year agenda

There is a growing international consensus that African health systems need to improve, but no agreement on how to accomplish this. From the perspective of modern quality improvement (QI), a central issue for low performance in these health systems is the relative neglect of health-care processes. Both health system leaders and international donors have focused their efforts elsewhere, producing noteworthy health gains. But these gains are at risk if health systems do not develop the capacity to study and improve care processes. Substantial experience with QI in Africa shows impressive potential for broad-based process improvement. But this experience also highlights the need for modifying these growing programs to incorporate a more rigorous learning component to address challenges that have emerged recently. The addition of a region-wide knowledge management program could increase the efficiency of each country's QI program by learning from the experiences of other programs. With a coordinated donor initiative, it is reasonable to project that within 5 years, evidence-based improvement will become a norm in health services, and African health systems will approach the model of a learning organization.

Promotion of standard treatment guidelines and building referral system for management of common noncommunicable diseases in India

Treatment services constitute one of the five priority actions to face the global crisis due to noncommunicable diseases (NCDs). It is important to formulate standard treatment guidelines (STGs) for an effective management, particularly at the primary and secondary levels of health care. Dissemination and implementation of STGs for NCDs on a country-wide scale involves difficult and complex issues. The management of NCDs and the associated costs are highly variable and huge. Besides the educational strategies for promotion of STGs, the scientific and administrative sanctions and sanctity are important for purposes of reimbursements, insurance, availability of facilities, and legal protection. An effective and functional referral- system needs to be built to ensure availability of appropriate care at all levels of health- services. The patient-friendly "to and fro" referral system will help to distribute the burden, lower the costs, and maintain the sustainability of services.

Assessment of providers' referral decisions in rural Burkina Faso: a retrospective analysis of medical records

BACKGROUND

A well-functioning referral system is fundamental to primary health care delivery. Understanding the providers' referral decision-making process becomes critical. This study's aim was to assess the correctness of diagnoses and appropriateness of the providers' referral decisions from health centers (HCs) to district hospitals (DHs) among patients with severe malaria and pneumonia.

METHODS

A record review of twelve months of consultations was conducted covering eight randomly selected HCs to identify severe malaria (SM) cases among children under five and pneumonia cases among adults. The correctness of the diagnosis and appropriateness of providers' referral decisions were determined using the National Clinical Guidebook as a 'gold standard'.

RESULTS

Among the 457 SM cases affecting children under five, only 66 cases (14.4%) were correctly diagnosed and of those 66 correctly diagnosed cases, 40 cases (60.6%) received an appropriate referral decision from their providers. Within these 66 correctly diagnosed SM cases, only 60.6% were appropriately referred. Among the adult pneumonia cases, 5.9% (79/1331) of the diagnoses were correctly diagnosed; however, the appropriateness rate of the provider's referral decision was 98.7% (78/79). There was only one case that should not have been referred but was referred.

CONCLUSIONS

The adherence to the National Guidelines among the health center providers when making a diagnosis was low for both severe malaria cases and pneumonia cases. The appropriateness of the referral decisions was particularly poor for children with severe malaria. Health center providers need to be better trained in the diagnostic process and in disease management in order to improve the performance of the referral system in rural Burkina Faso.

Why caretakers bypass Primary Health Care facilities for child care - a case from rural Tanzania

Background

Research on health care utilization in low income countries suggests that patients frequently bypass PHC facilities in favour of higher-level hospitals - despite substantial additional time and financial costs. There are limited number of studies focusing on user's experiences at such facilities and reasons for bypassing them. This study aimed to identify factors associated with bypassing PHC facilities among caretakers seeking care for their underfive children and to explore experiences at such facilities among those who utilize them.

Methods

The study employed a mixed-method approach consisting of an interviewer administered questionnaires and in-depth interviews among selected care-takers seeking care for their underfive children at Korogwe and Muheza district hospitals in north-eastern Tanzania.

Results

The questionnaire survey included 560 caretakers. Of these 30 in-depth interviews were conducted. Fifty nine percent (206/348) of caretakers had not utilized their nearer PHC facilities during the index child's sickness episode. The reasons given for bypassing PHC facilities were lack of possibilities for diagnostic facilities (42.2%), lack of drugs (15.5%), closed health facility (10.2%), poor services (9.7%) and lack of skilled health workers (3.4%). In a regression model, the frequency of bypassing a PHC facility for child care increased significantly with decreasing travel time to the district hospital, shorter duration of symptoms and low disease severity.

Findings from the in-depth interviews revealed how the lack of quality services at PHC facilities caused delays in accessing appropriate care and how the experiences of inadequate care caused users to lose trust in them.

Conclusion

The observation that people are willing to travel long distances to get better quality services calls for health policies that prioritize quality of care before quantity. In a situation with limited resources, utilizing available resources to improve quality of care at available facilities could be more appropriate for improving access to health care than increasing the number of facilities. This would also improve equity in health care access since the poor who can not afford travelling costs will then get access to quality services at their nearer PHC facilities.

Compliance with referral for curative care in rural Burkina Faso

BACKGROUND

The goal of this study is to contribute to improving the functioning of the referral system in rural Burkina Faso. The main objective is to ascertain the compliance rate for referral and to identify the factors associated with successful referral.

METHODS

A record review of 12 months of curative consultations in eight randomly selected health centres was conducted to identify referral cases. To assess referral compliance, all patient documents at referral hospitals from the day of the referral up to 7 days later were checked to verify whether the referred case arrived or not. Descriptive statistics were then used to compute the compliance rate. Hierarchical modelling was performed to identify patient and provider factors associated with referral compliance.

RESULTS

The number of visits per person per year was 0.6 and the referral rate was 2.0%. The compliance rate was 41.5% (364/878). After adjustment, females (OR = 0.71; 95% CI = 0.52-0.98), patients referred during the rainy seasons (OR = 0.56; 95% CI = 0.40-0.78), non-emergency referrals (OR = 0.47; 95% CI = 0.34-0.65) and referrals without a referral slip (OR = 0.30; 95% CI = 0.21-0.43) were significantly less likely to comply. Children between 5 and 14 years old (OR = 0.61; 95% CI = 0.35-1.06) were at a higher risk of non-compliance, but the difference did not reach statistical significance. Moreover, none of provider characteristics was statistically significantly associated with non-compliance. CONCLUSIONS In a rural district of Burkina Faso, we found a relatively low compliance with referral after the official referral system was organized in 2006. Patient characteristics were significantly associated with a failure to comply. Interventions addressing female patients' concerns, increasing referral compliance in non-emergency situations, reducing inconvenience and opportunity costs due to seasonal/climate factors, and assuring the issue of a referral slip when a referral is prescribed may effectively improve referral compliance.

Monitoring the referral system through benchmarking in rural Niger: an evaluation of the functional relation between health centres and the district hospital

BACKGROUND

The main objective of this study is to establish a benchmark for referral rates in rural Niger so as to allow interpretation of routine referral data to assess the performance of the referral system in Niger.

METHODS

Strict and controlled application of existing clinical decision trees in a sample of rural health centres allowed the estimation of the corresponding need for and characteristics of curative referrals in rural Niger. Compliance of referral was monitored as well. Need was matched against actual referral in 11 rural districts. The referral patterns were registered so as to get an idea on the types of pathology referred.

RESULTS

The referral rate benchmark was set at 2.5 % of patients consulting at the health centre for curative reasons. Niger's rural districts have a referral rate of less than half this benchmark. Acceptability of referrals is low for the population and is adding to the deficient referral system in Niger. Mortality because of under-referral is highest among young children.

CONCLUSION

Referral patterns show that the present programme approach to deliver health care leaves a large amount of unmet need for which only comprehensive first and second line health services can provide a proper answer. On the other hand, the benchmark suggests that well functioning health centres can take care of the vast majority of problems patients present with.

Costs and revenue of health care in a rural Zimbabwean district

The District Health Executive of Tsholotsho district in south-west Zimbabwe conducted a health care cost study for financial year 1997-98. The study's main purpose was to generate data on the cost of health care of a relatively high standard, in a context of decentralization of health services and increasing importance of local cost-recovery arrangements. The methodology was based on a combination of step-down cost accounting and detailed observation of resource use at the point of service. The study is original in that it presents cost data for almost all of the health care services provided at district level. The total annualized cost of the district public health services in Tsholotsho amounted to US$10 per capita, which is similar to the World Bank's Better Health in Africa study (1994) but higher than in comparable studies in other countries of the region. This can be explained by the higher standards of care and of living in Zimbabwe at the time of the study. About 60% of the costs were for the district hospital, while the different first-line health care facilities (health centres and rural hospitals together) absorbed 40%. Some 54% of total costs for the district were for salaries, 20% for drugs, 11% for equipment and buildings (including depreciation) and 15% for other costs. The study also looked into the revenue available at district level: the main source of revenue (85%) was from the Ministry of Health. The potential for cost recovery was hardly exploited and revenue from user fees was negligible. The study results further question the efficiency and relevance of maintaining rural hospitals at the current level of capacity, confirm the soundness of a two-tiered district health system based on a rational referral system, and make a clear case for the management of the different elements of the budget at the decentralized district level. The study shows that it is possible to deliver district health care of a reasonable quality at a cost that is by no means exorbitant, albeit unfortunately not yet within reach of many sub-Saharan African countries today.

The weakest link: competence and prestige as constraints to referral by isolated nurses in rural Niger

BACKGROUND: For a health district to function referral from health centres to district hospitals is critical. In many developing countries referral systems perform well below expectations. Niger is not an exception in this matter. Beyond obvious problems of cost and access this study shows to what extent the behaviour of the health worker in its interaction with the patient can be a barrier of its own. METHODS: Information was triangulated from three sources in two rural districts in Niger: first, 46 semi-structured interviews with health centre nurses; second, 42 focus group discussions with an average of 12 participants - patients, relatives of patients and others; third, 231 semi-structured interviews with referred patients. RESULTS: Passive patients without 'voice' reinforce authoritarian attitudes of health centre staff. The latter appear reluctant to refer because they see little added value in referral and fear loss of power and prestige. As a result staff communicates poorly and show little eagerness to convince reluctant patients and families to accept referral proposals. CONCLUSIONS: Diminishing referral costs and distance barriers is not enough to correct failing referral systems. There is also a need for investment in district hospitals to make referrals visibly worthwhile and for professional upgrading of the human resources at the first contact level, so as to allow for more effective referral patterns.

Hospital costs of high-burden diseases: malaria and pulmonary tuberculosis in a high HIV prevalence context in Zimbabwe

This paper explores the measurement of hospital costs and efficiency in a context where data is scarce, incomplete or of poor quality. It argues that there is scope for using tracers to examine and compare hospital cost structures and relative efficiency in such contexts. Two high-burden diseases, malaria and pulmonary tuberculosis, are used as tracers to calculate the average costs of inpatient care at selected tertiary hospitals. This study shows that it is feasible to prospectively collect cost data for specific diseases and explore in detail both patient cost distribution and susceptible areas for efficiency improvement. The present study found that the critical source of efficiency variation in public hospitals in Zimbabwe lies in the way hospital beds are used.

Urban primary health care in Africa: a comparative analysis of city-wide public sector projects in Lusaka and Dar es Salaam

Since the 1980s, a number of health system interventions in Sub-Saharan Africa have targeted urban areas, reflecting increasing attention to the contextual contrasts between urban and rural health settings. This article compares attempts in two projects-in Zambia and Tanzania-to strengthen urban primary health care in the public sector and make it more inclusive in a dual sense: making quality services more accessible to the poor; and fostering community involvement in health care and health-related activity. The paper reveals that the projects have produced many similar outcomes (both positive and negative), despite differences in their managerial arrangements. After identifying issues that may need to be considered in other health initiatives, the discussion revisits the urban/rural dimension of health care in relation to three key aspects: the by-passing of primary services, community participation and inter-sectoral action.

Understanding referral from primary care clinics in rural Kenya: using health information systems to prioritize health services

This study analyses the referral patterns of patients, over time, from primary care to secondary or tertiary level facilities in rural Africa. The data come from a health information system of a non-governmental organization with a decade of experience in health services delivery in Samburu District, Kenya. The differential referral patterns from two communities are examined in some detail to shed more light on the meaning of a 'referral rate' in this context. First, referral rates over time for two clinics are calculated and compared. These quantitative data, obtained from monthly reports from 1989 to 1997, are interpreted in the light of qualitative data obtained from interviews with community health workers, nurses and members of the communities. The main differences in referral between these ostensibly similar communities are for malaria, trauma and anaemia. Social, environmental and specific health services factors are used to explain these differences. We demonstrate that basic information from health information systems, which tell us little on their own because referral in this context is a rare event, can be combined with local knowledge from the community to provide evidence for health managers to set priorities for public health and clinical interventions.

Patient referral patterns in Namibia: identification of potential to improve the efficiency of the health care system

In order to assess how the hospital referral system in Namibia was operating, a cross-sectional survey of patients attending three intermediate hospitals and the national hospital was conducted over a 4-week period. The survey was planned by a Ministry of Health and Social Services' working group, with technical support provided by a donor funded health programme. Together with complementary qualitative data, obtained through focus group discussions with the community, the survey generated information on the extent to which the referral system was being bypassed, the types of bypassing and related factors. These included reasons for non-compliance with referral to the intermediate hospitals, perceived barriers to their utilization and community preparedness to use these hospitals after upgrading. The results were used to inform decisions about the classification of the three hospitals and identification of their catchment areas. The results were also shown to be useful for assessing the likely impact of different strategies for reducing bypassing. In Namibia these impacts were expected to be limited, due to the influence of distance and low population densities. Information on the extent and types of bypassing taking place across districts is essential for assessing opportunities to improve the functioning of a pyramidal referral system, which supports a cost-effective primary health care strategy.

Referral revisited: community financing schemes and emergency transport in rural Africa

Referral between first and second levels of care in rural African health systems is an extremely complex problem. Problems that have plagued the process of referral include poor service quality, low availability of trained personnel, inadequate supplies of drugs and medical diagnostic equipment and inadequate communication infrastructure. In this paper, the authors analyse the role of transport costs in the utilization of referral and how community health insurance schemes can help reduce the economic burden of transport costs, thereby improving referral utilization and health outcomes. Following the introduction, the authors provide a conceptual framework of the individual-, household- and community-level factors that affect referral in the rural African context, with particular emphasis on the role of the time and monetary costs of transport and the potential role of community risk-sharing schemes. The paper then presents a detailed case study from Kenya where a community has been experimenting with a health insurance scheme which provides emergency transport for emergency referral. Data from the past eight years of experience in northern Kenya suggests that support for the insurance scheme has depended on the reliability of the health system, as well as the seasons and various external problems, such as political interference, drought and insecurity. Conclusions drawn support the idea of community financing schemes for transport, not merely as a life-saving strategy in remote and resource-poor health infrastructures, but also as a means to help build trust in the health system itself and thus improve sustainability through local institutional support.