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

Barriers to proper maternal referral system in selected health facilities in Eastern Ethiopia: a qualitative study

BACKGROUND

Appropriate maternal referral system plays an essential role in curbing maternal mortality. Although the occurrence of obstetric complications is often unpredictable, addressing bottlenecks of the referral system is crucial to facilitate the women to have access to timely lifesaving interventions. Nonetheless, little is known about the barriers to maternal referral system in the eastern Ethiopia. Therefore, this study aimed to explore the barriers to maternal referral system at selected referral hospitals in eastern Ethiopia.

METHODS

Key informant interviews and in-depth interviews were conducted among purposively selected respondents who had a role in maternal referral processes. A total of 12 key informants that comprised of liaison officers, healthcare providers and three in-depth interviews with referred women were conducted. Semi-structured interview guide was developed and used to facilitate the interviews. All the interviews were tape recorded, complemented by note taking. Then audio recorded interviews were transcribed as per verbatim and imported to NVivo for coding and merging. The data were thematically synthesized.

RESULTS

The study identified a range of barriers that affect the maternal referral system in Eastern Ethiopia. The main barriers are grouped into three domains, such as: communication, transportation, and healthcare system. The most commonly reported barriers were lack of pre-referral communication and feedback, using informal communication, incomplete referral forms, poor ambulance service including misuse of ambulances, lack of skilled healthcare escort and lack of medical equipment at emergency, unnecessary self-referrals, poor referral skills and limited number of health professions.

CONCLUSIONS

The maternal referral system is overwhelmingly affected by lack of skill, logistics (referral form), misuse of available ambulance, poor communication, and limited seeking of feedback. Regular consultative meeting with relevant stakeholders and uptake of feedback are crucial to improve referral communication, proper use of ambulance and building capacity of health workforce about referral are essential to improve maternal referral system.

'Fighting an uphill battle': a qualitative study of the challenges encountered by pharmacy workers when providing services to men who have sex with men in Dar es Salaam, Tanzania

Background

Previous research suggests that Tanzanian MSM might prefer consulting pharmacies and drugstores, rather than public healthcare services, when in need of STI medicines and treatment. Yet, few studies have explored the experiences of providing services to MSM clients among those working at pharmacies and drugstores and examined what challenges they encounter in providing these services.

Objective

To gain increased knowledge and understanding of the perceived challenges encountered by pharmacists and drugstore workers when providing STI services to MSM clients in Dar es Salaam, Tanzania.

Method

In early 2016, 16 semi-structured interviews were conducted with persons working at private pharmacies and drugstores in Dar es Salaam. Data were interpreted through qualitative content analysis.

Results

The overarching theme that emerged was labelled ‘Fighting an uphill battle’, which reflected the challenges pharmacy workers experienced during interactions with MSM clients, and in particular service provision. Pharmacy workers tried to act upon the best of their knowledge to meet the needs of clients, given their understanding of risks and obstacles that MSM faced. Yet, the lack of educational and professional preparedness and insufficient financial and human resources, regarded as necessary to meet the needs of a stigmatised client group, formed barriers for effective service delivery.

Conclusions

In order to support pharmacists and drug-store workers in Tanzania to address perceived challenges for service delivery to MSM clients, systematic and continuous training on MSM’s sexual health is required. Furthermore, inter-professional cooperation that harnesses provider involvement from all tiers in the healthcare system is essential to offer complementary services to ensure proper STI care and treatment. Thus, interventions that focus on inter-professional communication and interaction between pharmacists and physicians could have a positive impact on timely referrals of suspected STI cases among marginalised populations.

Referral systems for preterm, low birth weight, and sick newborns in Ethiopia: a qualitative assessment

BACKGROUND

A responsive and well-functioning newborn referral system is a cornerstone to the continuum of child health care; however, health system and client-related barriers negatively impact the referral system. Due to the complexity and multifaceted nature of newborn referral processes, studies on newborn referral systems have been limited. The objective of this study was to assess the barriers for effective functioning of the referral system for preterm, low birth weight, and sick newborns across the primary health care units in 3 contrasting regions of Ethiopia.

METHODS

A qualitative assessment using interviews with mothers of preterm, low birth weight, and sick newborns, interviews with facility leaders, and focus group discussions with health care providers was conducted in selected health facilities. Data were coded using an iteratively developed codebook and synthesized using thematic content analysis.

RESULTS

Gaps and barriers in the newborn referral system were identified in 3 areas: transport and referral communication; availability of, and adherence to newborn referral protocols; and family reluctance or refusal of newborn referral. Specifically, the most commonly noted barriers in both urban and rural settings were lack of ambulance, uncoordinated referral and return referral communications between providers and between facilities, unavailability or non-adherence to newborn referral protocols, family fear of the unknown, expectation of infant death despite referral, and patient costs related to referral.

CONCLUSIONS

As the Ethiopian Federal Ministry of Health focuses on averting early child deaths, government investments in newborn referral systems and standardizing referral and return referral communication are urgently needed. A complimentary approach is to lessen referral overload at higher-level facilities through improvements in the scope and quality of services at lower health system tiers to provide basic and advanced newborn care.