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

Abstract

BackgroundPrimary 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 FindingsWe 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.ConclusionsThe 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.

Time spent in referral process and its determinants among clients of maternal and child health service in Jimma zone, Ethiopia, 2020; A cross-sectional study.

“…In this study, among the referred cases majority 108(87.8%) of women were referred from health center to primary hospital. This nding is higher than study conducted in Ethiopia which indicated that among the referred cases to the hospital, most (74%) had been referred by health center (14), and also different from study conducted in Nigeria in which most of the patients referred were from private clinics (15). The difference in the Ethiopian studies may be attributed to difference in study period and for the Nigeria study it might be because of the structures of health care delivery systems.…”

“…In another study only 10% of patients were referred and majority of (74%) patients in the hospital were referred by a health center whereas among those who were referred to the health center, 32% came from a nearby hospital and only 18% referred from health post (14). A study in Nigeria revealed that only (7.1%) of patients were referred to the hospital mostly from private clinics while the rest (92.9%) were selfreferral (15).…”

Determinants of Self-referral among Outpatients at Referral Hospitals in East Wollega, Western Ethiopia

“…In spite of primary health care elements providing essential care and prevention resources for rural populations in Ethiopia, patients often access secondary levels of care without first using primary health care provided by primary level health facilities [7]. The study conducted in western Ethiopia at general hospital revealed 82% of patients bypassed the first level referral facilities and 74.9% of them did not first contact nearest health facilities [8] and the fundamental message of referral system is still unchanged [9].…”

An Observational Study of a National Referral System: An Analysis of 14,266 Referrals in Sierra Leone

“…Our study only included referrals if the referring facility made a referral phone call or if a referral note was written. Finally, many patients will not utilise formal referral systems and will bypass lower levels of care 4 , we are unable to quantify this and therefore self-referrals are not included in our study.…”

“…2 Referrals systems are essential to; ensure patients receive timely appropriate care; increase access to specialist services; increase uptake of primary healthcare and optimise hospital utilisation 3 . Presently, referrals systems in Low and Middle Income Countries (LMICs) and the interface between different levels of the health system are both under-utilised 4 and under-researched. 5 6 7 Whilst access to care is regularly described as a key issue in LMIC health systems, formal referral systems are rare, standardised data on how patients are referred through the health system is sparse and there is little evidence on interventions to improve referral 8 .…”