A GUIDE FOR ESTABLISHING REFERRAL MECHANISM IN URBAN ...
Transcript of A GUIDE FOR ESTABLISHING REFERRAL MECHANISM IN URBAN ...
A GUIDE FOR ESTABLISHING REFERRAL MECHANISM IN URBAN HEALTH SYSTEM OF INDIA
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TABLE OF CONTENTS
PU R POSE OF T HE TOO LK I T .................................................................................................................................... 3
KE Y TER M S AND DEF I N IT IO NS .............................................................................................................................. 3
SEC TI ON I : BA CK G RO U ND ....................................................................................................................................... 5
REFERRAL IN HEALTH SYSTEMS ................................................................................................................................. 5
COMPONENTS OF A REFERRAL SYSTEM ................................................................................................................... 5
THE GLOBAL SCENARIO .............................................................................................................................................. 6
NEED FOR A UNIFIED REFERRAL SYSTEM IN INDIA: ................................................................................................. 7
CURRENT STATUS OF REFERRAL MECHANISMS IN INDIA ....................................................................................... 8
RATIONALE, BENEFITS AND OBJECTIVES .................................................................................................................. 9
Se ct i on I I : TC I HC ’s ROL E IN T HE RE FE RRA L ME CH AN IS M ........................................................................ 10
TCIHC PROJECT BACKGROUND ................................................................................................................................ 10
ROLE OF THE TCHIC TEAM ........................................................................................................................................ 10
ADAPTATION AND EXPANSION OF THE REFERRAL MODEL BY TCIHC ................................................................. 11
SEC TI ON I I I : GE TT IN G S TA RTE D ......................................................................................................................... 12
DEFINING THE REFERRAL PROCESS AND PATHWAY ............................................................................................. 12
INSTRUCTIONS FOR ESTABLISHING A REFERRAL MECHANISM ........................................................................... 13
SECTION IV: COMPONENTS TO THE PROCESS OF INITIATION OF A REFERRAL MECHANISM ............................... 14
1. CAPACITY BUILDING OF THE HEALTH SYSTEM: OWNERSHIP OF THE REFERRAL MECHANISM BY LOCAL GOVERNMENT ............................................................................................................................................................ 14
2. REFERRAL TECHNICAL COMMITTEE – ITS COMPOSITION, ROLES AND RESPONSIBILITIES...................... 15
3. BASELINE ASSESSMENT OF EXISTING REFERRAL SYSTEMS AND FACILITY SERVICES ............................. 16
4. DEFINING THE REFERRAL NETWORK, AND LINKING UPHCS TO HIGHER FACILITIES ................................. 17
5. REFERRAL DIRECTORY AND ITS COMPONENTS ............................................................................................ 18
6. GUIDANCE NOTE FOR DEVELOPING REFERRAL PROTOCOLS/HEALTH CARE PATHWAYS AND PILOTING OF TOOLS .................................................................................................................................................................... 20
7. CAPACITY BUILDING OF THE HEALTH SYSTEM: TRAINING STAFF ............................................................... 21
8. MONITORING AND EVALUATION .................................................................................................................... 22
9. SUGGESTION: USE OF TECHNOLOGY TO IMPROVE IMPLEMENTATION OF THE REFERRAL MECHANISM 24
10. INTER-PHASE MEETINGS ON REFERRAL MECHANISM IMPLEMENTATION ............................................ 24
11. PARTNERSHIP WITH MEDICAL COLLEGES AND NURSING INSTITUTIONS .............................................. 25
12. DEVELOPING REFERRAL CHAMPIONS IN DISTRICTS................................................................................. 26
SEC TI ON I V: CON CL US I ON .................................................................................................................................... 27
REF ER ENC ES ............................................................................................................................................................... 29
1. Referral Systems - a summary of key processes to guide health services managers ............................................ 29
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ANNE X URE ................................................................................................................................................................... 30
PURPOSE OF THE TOOLKIT
This toolkit is designed from the first-hand experience of The Challenge Initiative for Healthy Cities (TCIHC)
team in successfully establishing a referral mechanism in Indore city, Madhya Pradesh. It provides a
comprehensive understanding of the need and usefulness of a referral mechanism and suggests best
practices for its initiation. The toolkit focuses primarily on how a referral mechanism can strengthen health
provision in urban settings, where the primary level is comparatively underutilized and higher healthcare
facilities are overburdened. TCIHC’s implementation process to establish the referral mechanism is
explained carefully and step-by-step in this toolkit. The aim of the toolkit is to strengthen the existing
referral system within the government set up. The tool should be used as a guidance document and is meant
to aid the design, delivery and evaluation of a referral mechanism but it is NOT A POLICY DOCUMENT.
KEY TERMS AND DEFINITIONS
1. REFERRAL: A process in which a health worker at one level of the health system, having insufficient
resources (e.g. drugs, equipment, skills), manages 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
a client’s case.
2. INITIATING/REFERRING FACILITY): The facility (e.g. organization, clinic) that starts the referral
process. This is the point in the referral process where an outward referral is prepared to communicate
the client’s condition and status.
3. RECEIVING FACILITY: The facility (e.g. organization, clinic) that accepts the referred client’s case and
provides needed services.
4. INITIATING/REFERRING SERVICE: The type of service from which the referral was initiated (e.g.
family planning, antenatal care or general primary care).
5. RECEIVING SERVICE: The type of service to which the client is referred (e.g. family planning,
antenatal care or HIV testing and counseling).
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6. FACILITATED REFERRAL: Every beneficiary is referred through a specific protocol, which includes
triad of proper information transfer (referral slip, counseling); feedback & tracking (completion of
referral loop) and evidence of efforts overcoming barriers (geographical, financial etc.)
7. COUNTER-REFERRAL: The process in which clients are directly reaching the facility, then the facility
staff after providing the necessary treatment sends clients to their respective UPHCs. The UPHC staff
then completes the loop at the community level.
8. BACK REFERRAL: The process by which the receiving facility sends the client back to the initiating
facility with information about services provided there and any needed follow-up. This completes the
referral loop between the two facilities.
9. REFERRAL NETWORK: The interconnected group of service providers among which referrals are
made. Referral systems are used to integrate networks of service providers.
10. REFERRAL PROTOCOLS/HEALTH CARE PATHWAYS: For any particular clinical condition or
service, each beneficiary has to go through multiple stages of management. Each stage needs him/her
to pass through a series of health facilities and health providers. So, in a particular referral system for a
particular clinical condition, the referral protocols or health care pathway of that condition gives
beneficiary / health provider a predefined map of stages of clinical condition mentioning what, where,
whom, and how to manage it in spectrum of illness to health and well-being.
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SECTION I: BACKGROUND
REFERRAL IN HEALTH SYSTEMS
A referral can be defined as a process in which a health worker at one level of the health system, having
insufficient resources (drugs, equipment, skills), manages a clinical condition, and 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 (1). Key reasons for deciding to refer either an emergency or routine case include:
1. Seeking expert opinion regarding the client
2. Seeking additional or different services for the client
3. Seeking admission and management of the client
4. Seeking use of diagnostic and therapeutic tools
The health system in India is hierarchical, like most others in the world, starting with primary care to
secondary care facilities and ending at the highest level of care. This consists of tertiary level facilities that
provide highly specialized services. However, in most developing countries, health referral systems across
the various levels of care are weak at present, affecting the overall performance of the health system (2).
An active referral system ensures a handy relationship between every level of health care delivery system
i.e. primary, secondary and tertiary health care. It also ensures optimal utilization of health services as it
connects the populations with service locations which they may chose on preference or proximity or both.
To create a good referral system, it is important to consider the following points (3):
1. Patients should be given optimal care at the right level, right time and right cost
2. Optimal and cost-efficient utilization of health care systems
3. Optimal and appropriate utilization of specialist services for patients in need
4. Optimal utilization of primary health care services
COMPONENTS OF A REFERRAL SYSTEM
A referral system at all levels of the healthcare can facilitate the flow of patient referrals among government
and private healthcare providers. When implemented efficiently, referral systems contribute to high
standards of care and optimal use of medical services and resources. It is a critical component of quality
healthcare as a functioning referral system both decreases costs and improves patients’ health. An optimal
referral process should be in place for the effectiveness, safety and efficiency of high standard medical care.
A referral process is an inherently complex activity that has two aspects - Referral Decision and Referral
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Communication. A Referral Decision is a clinical decision made by doctors or other healthcare providers on
whether a referral is needed, and at what level the referral must be made. Referral Communication deals
with interactions between referring and referred-to providers once a referral decision is made. To have an
efficient referral mechanism, it is important to prioritize both components and the implementation of
effective healthcare provision with a government health set up (4).
THE GLOBAL SCENARIO
In developed countries, where healthcare provision is primarily insurance driven, referral systems are quite
systematic and clearly defined. On the other hand, in countries, where the health system is weak, and little
to no referral system framework exist, development of a referral system happens at a slow pace . The table
given below illustrates the difference in referral systems in developed and developing countries.
Referral system in Developed Countries
Referral system in Developing Countries
Healthcare provision is mostly insurance driven
Healthcare provision is largely dependent on either government funding or out of patients’ pockets
In most countries, people use public healthcare facilities instead of private healthcare, making regulation comparatively easy
In most countries, people have near equal choice between public and private healthcare services, hence regulation becomes difficult
General Practitioner (GP) is considered as a gatekeeper in the referral pathway. Patient cannot access higher facilities without the letter of referral from their registered GP
Although Medical Officers at Primary Health Centres are responsible for referrals, direct access to higher facilities is still permitted and weakens referral pathway
Referral guidelines are clearly laid out, ensuring efficient implementation
Although referral guidelines exist, implementation is weak due to various factors
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NEED FOR A UNIFIED REFERRAL SYSTEM IN INDIA:
The referral system in rural India is formally structured. A Primary Health Centre with a qualified Medical
Officer is the first point of contact for a community. The Medical Officer can refer cases to rural hospitals as
per the medical requirement. Cases from the rural hospital can be referred to the district hospital and above
as per the requirement. Although the implementation of this mechanism is weak in rural areas, it is
noteworthy that the system is clearly laid out for the rural health system.
Unlike rural India, the urban health system is a recent development in the Indian health system and is still at
a preliminary stage of development. There are several differences in urban and rural context that need to be
considered while strengthening the referral system in urban areas. First, unlike in rural areas, there is no
uniform governing body in place in urban areas. For example, in a couple of states the municipal corporation
and the local governing body are responsible for health in urban cities whereas in some states, health is a
shared responsibility between the state and local body. Furthermore, other large stakeholders such as the
army or railway companies provide health services as well. The presence of so many options dilutes the
possible route of referral as individuals have access to any of these services. Unlike rural areas, the lack of
geographic demarcation in urban areas makes it difficult to distribute the community across primary health
DATA SHOWING THE UTILIZATION OF HEALTHCARE FACILITIES
1. In developing countries, less than 40%
patients seeking care at the tertiary
level facilities were being referred
from the lower level facilities.
2. More than 60% patients directly
access higher level facilities on their
own.
3. More than 50% of population that is
being catered at the tertiary level
could be treated optimally at the
lower level facility
Most health initiatives focus on
behaviour change at the
community level and generate
demand for seeking care.
Referral as a mechanism
focuses on behaviour change of
care givers and care managers
and ensures patient-centered,
respectful, safe, appropriate
and quality care.
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centers. Implementation of any health activity is also quite challenging due to tangible social norms,
stratification of community groups and other underlying social characteristics in urban areas. The figure
below illustrates the various levels of health service facilities and their utilization without a proper referral
pathway.
CURRENT STATUS OF REFERRAL MECHANISMS IN INDIA
There are several initiatives being implemented in parts of the country. Kerala state created guidelines for
referrals especially designed for health facilities working under the Government of Kerala. The states of
Jammu and Kashmir, have a similar initiative, where the Department of Health Administration from Sheri-
Kashmir Institute of Medical Sciences has developed a proposal for referral policy for Public Health Facilities
for Jammu and Kashmir. The development of this policy seeks to address shortcomings of the existing
referral system in the Health Care Institutions. TCIHC has taken initiative to strengthen the referral
mechanism in the Public Healthcare system by providing technical guidance and support to the existing
healthcare system to ensure its long-term sustainability.
In India, the National Health Policy (NHP) 2017 and the National Urban Health Mission (NUHM) framework
2013 are the primary drivers of policy. Both emphasize the establishment of an appropriate referral
mechanism as one of the key components to deliver a continuum of care in urban areas. This
acknowledgement signifies the enabling environment to establish a referral system in the country, which
must be realized and acted on. There is an urgent need to prioritize the primary health care needs of the
urban population. The special focus should be on poor populations living in listed and unlisted slums, other
vulnerable populations such as homeless individuals, rag-pickers, street children, rickshaw pullers,
construction workers, sex workers and temporary migrants. The communities in these pockets of the urban
population are the primary users of government health systems in urban areas. As the public urban health
system is still in the development stage, there is a need to use existing healthcare facilities efficiently to
District Hospital
Sub District
Hospital
Secondary
Hospital
Primary Health
Centre
Access to any health facility for any
minor condition
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cater to an increasing population. With a functional referral mechanism in place, primary, secondary and
tertiary level health facilities will be used more efficiently, and specific services can be prioritized. The
effective implementation of a referral system in healthcare will ensure satisfaction from both sides. For
providers, it will ensure the satisfaction of providing appropriate care at the appropriate facility. For patients,
it will give confidence to reach out to the first point of contact for the right care at the right time and right
place.
RATIONALE, BENEFITS AND OBJECTIVES
While the most vulnerable and poor communities of urban populations are the target population for
improvements made to the urban public healthcare system, the rationale for implementing an effective
referral mechanism, is far wider. A referral mechanism can support quality health service delivery to entire
urban populations in India in the following ways:
1. Coordination and standardization of referral services
2. Continuity of care across the different levels of care
3. Cost-effectiveness of health services provided to the community
4. Promotion of universal coverage and equity in provision of health services
5. Healthcare planning based on performance monitoring of the referral system
A well-functioning referral system will have the following benefits:
1. Maximize efficiency of the health system by ensuring appropriate use of health services
2. Strengthen lower-level facilities and improve capacity for decision-making by health workers at all
levels
3. Create opportunities for balanced distribution of funds, services, and human resources
4. Promote linkages across the different levels of care and between public and private entities
5. Ensure that care is provided at the lowest possible cost
A referral mechanism has the following objectives:
1. Increase the use of services at lower levels of the health care system
2. Reduce self-referral to the higher levels of care
3. Develop service providers’ capacity to offer services and appropriately refer at each level of the
health care system
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4. Improve the health system’s ability to transfer patients, patient parameters, specimens and
expertise between the different levels of the health care system.
5. Improve supportive supervision, thereby ensuring up-to-date management practices are used
across the country
6. Improve referral performance monitoring and coordination and referral feedback information
systems including procedures for counter-referral
7. Strengthen outreach systems for provision of referral health services to marginalized and vulnerable
populations
Section II: TCIHC’s ROLE IN THE REFERRAL MECHANISM
TCIHC PROJECT BACKGROUND
To strengthen the maternal and child health services in urban areas, a three-year project, “TCIHC”, was
initiated in India. The program is supported by the United States Agency for International Development
(USAID) through the Maternal and Child Survival Program (MCSP), and the Bill & Melinda Gates Foundation
(BMGF), through Gates Institute (GI). The aim of this project is to strengthen city-level health systems to
improve access to and demand for family planning (FP) and maternal, newborn and child health care
(MNCH), information, products and services to reduce preventable maternal, newborn and child deaths
among the urban poor in 31 cities in three states in India.
TCIHC puts cities in the driver’s seat under a “demand driven” model to ensure sustainable impact and
unlock public and private resources to implement proven health solutions for the urban poor.
ROLE OF THE TCHIC TEAM
1. To achieve the long-term objectives of TCIHC, the project team is providing technical support to
local governing bodies who are positioned to implement the referral mechanism.
2. The TCIHC team’s role is to strengthen the capacity of existing healthcare staff to implement the
referral mechanism without additional resources to ensure long-term sustainability of the public
healthcare system.
3. The following flowchart shows activities which the TCIHC team carried out to initiate the
comprehensive referral mechanism in their project cities.
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ADAPTATION AND EXPANSION OF THE REFERRAL MODEL BY TCIHC
PUNE CITY REFERRAL MODEL
The referral mechanism was established in collaboration with the Municipal Corporation of Pune city.
A successful referral mechanism was established in Pune city through a series of steps such as situation analysis on MNH health, a mapping exercise of all facilities, training of staff to understand the process of referral and monitoring and evaluation.
The following learnings arose from the Pune city model
o Referral protocols and tools
o Facility specific referral plans
o Interface between initiating &
receiving facilities, managers and
administrators
ROLE OF TCIHC IN THE ESTABLISHMENT OF THE
REFERRAL MECHANISM
Learning from Pune City Referral Model
Adaptation and expansion of the Referral
Model
Introduction of community referral in
addition to adaptation of facility referral
Piloting of an adapted referral model in
Indore city of Madhya Pradesh
Expansion of referral mechanism by
introducing the referral toolkit
REFERRAL MECHANISM
PILOTED IN INDORE CITY
Adaptation of facility
level referral mechanism
Monitoring - Evaluation and
improvisation mechanism
Feedback mechanism strengthened through back referral and counter referral
Customization of
protocols and tools
Introduction of
community level referral
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SECTION III: GETTING STARTED
DEFINING THE REFERRAL PROCESS AND PATHWAY
The Government healthcare system has defined healthcare facilities at each level including in the urban
areas. Tertiary care, in the form of a hospital, is available in cities to provide specialized care, while secondary
care hospitals are meant to provide clinical care, such as obstetric care. The Urban Primary Health Centers
(UPHC)s are developed at the primary level with an aim to provide preventive and basic curative services.
Despite the supposed proximity of the urban poor to urban health facilities, their access is severely
restricted. This is on account of the facilities being “crowded out” due to the inadequacy of the urban public
health delivery system. A weak referral system also limits the access of urban poor to health care services.
To rule service delivery weakness, the following referral pathway, described step-by-step below can be
effective:
ORGANIZING THE SYSTEM FOR REFERRAL
1. All health facilities should be informed, and the capacities of staff built in preparation for
implementation of the referral mechanism.
2. A two-way referral system shall be implemented in all facilities. In this regard, referral can be from;
a) Community to UPHC/Secondary/Tertiary facility b) UPHC to Secondary/Tertiary facility c)
Secondary to tertiary facility and vice versa for each.
ON-SITE REFERRAL PROCESS IN THE FIELD
1. A completed referral slip shall accompany any patient who is referred either from the community or
from the facility.
2. A copy of the referral slip shall be kept with referring facility or with community worker.
3. Necessary instructions shall also be given to the patient and his/her facility.
COMMUNICATION AND TRANSPORTATION
1. When possible, the receiving facility shall be informed about the referral patient.
2. If possible, especially from lower facility to higher facility, the referral patient shall be transferred
using an ambulance or other appropriate means of transportation.
3. In higher facilities, a staff member will be dedicated to managing all communication with other
facilities regarding referrals.
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4. In counter referrals, the lower facility shall be informed about the appropriate treatment for which
the patient is being referred.
FEEDBACK
1. Feedback regarding the treatment received shall be sent to the referring facility or the community
worker.
2. The referral slip with detailed feedback shall be given to the patient who will be encouraged to
return to the referring facility/community health worker with their feedback, leading to the final
step of;
INSTRUCTIONS FOR ESTABLISHING A REFERRAL MECHANISM
To implement the referral mechanism, the following steps can be used as a guide. These steps were followed
while establishing the referral mechanism in Indore city. The activities can be adapted as per the city’s
specific situation and need.
Step I: Ownership of referral mechanism by local government
Step II: Constitution of a referral technical committee
Step III: Baseline Assessment of Facilities
Step IV: Defining the referral network and linking UPHCs to higher facilities
Step V: Customization of referral tools and a referral directory
Step VI: Piloting of referral tools
Step I: Ownership of referral mechanism by local government
Step VII: Training of community level workers and staff at the facility level
Step VIII: Implementation of the referral mechanism, with direct support
Step X: Data generation and monitoring of referral mechanism
Step IX: Routine meetings between facility staff and community workers
Step XI: Feedback mechanism and quality improvement
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SECTION IV: COMPONENTS TO THE PROCESS OF INITIATION OF A
REFERRAL MECHANISM
1. CAPACITY BUILDING OF THE HEALTH SYSTEM: OWNERSHIP OF THE REFERRAL
MECHANISM BY LOCAL GOVERNMENT
Background and need:
The first and foremost essential element of establishing a referral mechanism is to place roots within the
existing health system. As mentioned in the first section, a referral pathway already exists in rural areas, but
is missing in urban India. Thus, the first step of establishing a referral mechanism is to liaison with the city
health management unit and communicate the need for a similar system in urban areas. Primarily, two types
of capacity building activities are essential to root and initiate the referral mechanism in regular systems of
health service delivery. These are System Strengthening and Thematic Strengthening.
In System Strengthening, program managers primarily at the city level have to be trained to understand
what a referral system is, what the components of referral are, what the importance of initiating a referral
system is, and what the process for initiation in existing scenarios includes. After initial meetings with
district officials, a oneto twodays workshop should be arranged with all program managers. During the
workshop, the importance and need of a referral mechanism should be emphasized, as well as the steps of
implementation, such as, baseline assessment of facilities to understand their readiness to provide services,
a quick survey of community needs, geographic mapping of facilities to understand the existing reach of
each facility, creating referral loops and a referral directory, analyzing the type of health services offered at
each facility along with other points.
Thematic Strengthening refers to the training of medical and technical staff at each facility so that facilities
will be ready for increased demand as a result of referral process. Primarily, adhering to specific protocols
for treatment and learning about referral protocols will be discussed during the training. Details of this
training will be explained in the training component.
Process:
1. Arrange a meeting with the government officials to discuss the need, process and anticipated
impact of referral mechanism.
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2. Present Evidence of Success of the Referral Mechanism, such as, the impact of the referral
mechanism implemented in Indore city. If possible, invite a representative from Indore city to share
their experiences.
3. Discuss the detailed plan of action for establishing the referral mechanism in the city. This may
include arranging further workshops for all district level program managers where a plan of action
for rolling out the referral mechanism should be clear.
4. Regular follow ups with the city program management unit (CPMU) to ensure timely issuance of
letters and instructions.
2. REFERRAL TECHNICAL COMMITTEE – ITS COMPOSITION, ROLES AND
RESPONSIBILITIES
Background and Need:
Technical inputs from a spectrum of experts is as an essential element for the establishment of any
mechanism in any system. The constitution of a technical committee to provide inputs for the referral
mechanism’s initiation should be completed simultaneously as with liaisons with government stakeholders.
Composition of the Referral Technical Committee:
1. Representatives from government offices such as the Urban Health and District RCH Offices
2. Administrative officials
3. External experts from private health institutions
4. Representatives from medical colleges
5. Any other relevant officials could be invited to participate in the committee as per requirement.
Roles and responsibilities:
The primary responsibilities of this committee will include but are not limited to:
1. Providing technical inputs while adapting the referral tools
2. Technical inputs in referral slips.
3. Providing insights while creating the referral directory and referral route, referral protocols, and
health care pathways based on prior experience
4. Any other technical support required during the process of establishing the referral mechanism.
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Process:
1. List the prime organizations that work in the city’s health sector
2. The short-listed representatives from these institutions shall be approached by taking prior
appointment.
3. After seeking initial permission, the inception meeting with these representatives shall be
organized. The purpose of the meeting shall be explained and the impact of the referral system in
the previous project cities shall be shown to the participants.
4. The committee shall be constituted after final approval from these representatives and the primary
responsibility shall be explained to the members of the committee.
5. After identifying and forming a committee of experts, regular meetings shall be held with the
committee to discuss progress. Any issues arising during the process shall be put forward in these
meetings and technical advice shall be sought from the members.
3. BASELINE ASSESSMENT OF EXISTING REFERRAL SYSTEMS AND FACILITY
SERVICES
Background and need
Baseline assessment of the status of referral systems,
existing referral protocols and processes under various
thematic groups vis-a-vis health facilities will be helpful to
assess the basic health needs of communities, the current
trend of health facility utilization, to assess the existing
infrastructure, staff, supply of equipment and drugs, and
current patient referral practices in emergencies.
Once the technical committee is formulated, the
immediate need to initiate the referral process is to assess
the present situation of health facilities of cities. The
baseline assessment of the facilities shall be the next step.
Aim:
The aim of the assessment is to check functioning facilities, available systems of referral and basic
requirements needed to improve the functioning of facilities.
BASELINE ASSESSMENT IN GWALIOR
CITY
1. The assessment was carried out in all UPHCs,
civil dispensaries and Maternity homes.
2. Except for frontline workers, particularly
ANMs, facility staff did not know the wards
to be covered, and the total population to be
covered by their facility.
3. Most of the primary health facilities did not
have telephones, a preliminary requirement
for referral.
4. Facilities lacked clinical and facility
protocols, service directories, and referral
review mechanisms, while very few facilities
had referral slips.
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Process:
1. Data collection tools shall be developed for the baseline assessment. Components such as the
availability of infrastructure, staff, essential drugs and supplies, and accessibility of the facility from
the community should be incorporated in the tool.
2. The baseline assessment tool used in Gwalior city can be customized and used as per specific needs
of the city. For reference, the report of baseline assessment carried out in Gwalior city is also
provided in the annexure.
3. All UPHCs, secondary hospitals and tertiary hospitals shall be assessed during the baseline
assessment.
4. A meeting with government partners shall be arranged to discuss the requirements so that the
referral system can be initiated.
4. DEFINING THE REFERRAL NETWORK, AND LINKING UPHCS TO HIGHER
FACILITIES
Background and need:
As mentioned in the earlier section, the urban health system is not as well developed as the rural health
system. In order to create an effective referral mechanism, it is of utmost importance that all health facilities
from community to primary to secondary and to higher level of facilities should be linked through a formal
process.
City level program managers shall be responsible to create the referral network where each UPHC should
be linked with nearest secondary health facility. This step is essential as the UPHC staff will know the
immediate secondary facility where the case should be referred for further treatment.
Once referral networks are mapped, the thematic teams (maternal health, child heath, family planning etc.)
can develop referral protocols or health care pathways for their respective clinical condition.
Process:
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1. While the baseline assessment is being carried out, another activity shall be conducted to define
zones and the levels of referrals, and to map the UPHCs and secondary facilities in each zone.
2. Defining zones is required to create a referral loop of UPHC to secondary facility. Once the zones or
the wards are finalized, the next activity is to list the UPHCs, secondary and tertiary level facilities.
3. Once the list is ready, the final referral loop will indicate which UPHC will refer a case to which
secondary facility. This step is important because UPHC staff, as well as community staff, will be
trained and informed on how and where the patient can be referred.
4. The community staff along with secondary facility staff shall also be trained and informed about the
names of UPHCs which the facility will cater to make back referrals easy.
5. While linking the UPHCs in each zone to secondary facilities, the following points should be kept in
mind:
a. Accessibility: distance from the UPHC
b. Availability: of required services and staff
c. The technical committee shall be responsible for finalizing the referral protocols or health care
pathways.
5. REFERRAL DIRECTORY AND ITS
COMPONENTS
Background and need:
In developed countries, even in strong and well-established
health care systems, a single health facility can rarely
deliver all the services which patients need. Thus, a well-
established referral system along with an updated referral
directory is needed globally. The need is higher in countries
like India as management of patient loads on higher level
facilities, prioritization of treatment requirements at each
level of health facility and appropriate use of primary health
services, especially in urban areas, are the additional facets
of a referral mechanism. Well-equipped primary, secondary
and tertiary health facilities, appropriate and regular supply
of drugs and equipment, trained health staff proportionate to the population where the facility is located,
regular training of staff for referral services and a regularly updated referral service directory are some of
LEVEL OF REFERRALS IN INDORE CITY
Level -2: Community members including ASHAs
and MAS
Level -1: Universal Health and Nutrition Days
(UHND)
Level 0: Primary level – UPHCs and Civil
Dispensaries
Level Plus 1: Maternity hospitals conducting
normal deliveries with Basic Emergency
Obstetric Care (BEmOC)
Level Plus 2: Maternity Hospitals conducting
Cesarean sections and emergency care services
for children
Level Plus 3: Specialized and super-specialty
services at medical college hospitals
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the essential components of the referral system. These components are interdependent as, if even one of
the components is not strengthened, the whole system of referral mechanism cannot be implemented.
Referral Service Directory and its importance:
Referral service directory is the list of all health facilities including public and private facilities that can
provide diagnostic and specialist services. Such a directory can facilitate a search for the most appropriate
service provider for a referral. For example, in high risk delivery situations, if a referral directory is available
at the Urban Primary Health Centre (UPHC), the patient can immediately be referred to a nearest facility
that has specialized care. As the directory includes contact information for these facilities, in emergency
situations, the facilities can immediately be informed of referred cases. Thus, prompt treatment can be
initiated, eliminating the chances of facility delay, which in turn improve the health outcome indicators.
Process:
1. Once the referral network is created, the referral directory should be made for each city.
2. Data required for creating this directory should be collected from each facility.
3. The health staff at each facility should be trained to use the referral directory.
4. Each health facility including UPHCs and all community staff, including ASHA workers and ANMs
should be provided with the directory so that they can refer patient based on the need and
availability of services to avoid possible facility delays.
5. The referral directory should include the following details about facilities:
a. Name of facility
b. Address
c. Type of facility (Public or Private)
d. Available Specialist services
e. Contact information of facility
ADAPTATION AND REVISION OF REFERRAL TOOLS IN INDORE
While using referral tools at the community level, it was observed that there was a lack of back-referral
communications in that the Medical Officer at the UPHC was not informed whether a patient reached the
secondary facility or details of treatment received. The referral slip was thus revised to add the back-referral
details. Similarly, all the symptoms related to MNH care and FP were added in simple language for ASHAs to refer.
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6. GUIDANCE NOTE FOR DEVELOPING REFERRAL PROTOCOLS/HEALTH CARE
PATHWAYS AND PILOTING OF TOOLS
Background and need:
The use of protocols is important to maintain the uniformity and successful implementation of the referral
mechanism. The process of developing referral slips should be initiated immediately after the baseline
assessment. A separate section on the use of referral protocols should be arranged during the training of
community and facility staff members. Referral protocols are not only important to initiate the treatment
process for a patient, but it is also important to document the treatment provided.
Types of referral protocols:
Three types of referral tools are needed for implementation of the referral mechanism starting at
community level.
1. Community level referral tools: To be used by ASHA and ANM
2. Facility referral at the primary level: To be used by MO at UPHC
3. Facility referral at the secondary level: To be used at secondary level facility
Process:
1. The community referral slips will be used by ASHA/ANMs at the community level. Patients will be
identified during house visits or during UHNDs.
2. Based on the severity of the patient’s condition, ASHA/ANMs can refer them to UPHCs or secondary
facilities.
3. Facility level referral slips are to be used at the UPHC and/or at the secondary facility.
4. The referral slips can be adapted from the annexure given in this tool-kit.
5. The slips should be developed as simple and short as possible while adapting to specific needs of the
city.
6. Adapted referral slips shall be presented in front of the technical committee for their feedback.
7. Once the referral slips are finalized and approved by the technical committee and local government
stakeholders, piloting should be done at the community and facility levels.
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8. The slips shall be used by community workers and the staff.
9. Detailed discussions with staff should be carried out to document the feedback. Any changes
suggested by staff should be documented and incorporated in the slips after approval from the
technical committee.
7. CAPACITY BUILDING OF THE HEALTH SYSTEM: TRAINING STAFF
Background and need:
As mentioned in the first component of building the capacity of the health system, training health staff is
the first step towards initiating the referral mechanism. The training has two purposes. First, training is
required to orient the staff about the referral system, its components, why it is essential to implement a
referral system in the city, what the role of each staff member is in implementing the mechanism and how
it can be useful to streamline routine work. Secondly, staff should be trained to carry out each step of the
referral mechanism.
Topics covered in training sessions:
1. Introduction and purpose of training
2. Referral system and examples
3. Role of the referral mechanism in the healthcare system
4. Use of the referral system in streamlining routine work
5. The referral loop, mapping of facilities
6. Referral directory
7. Referral slips
8. How to use referral slips
9. Use of referral in facilities
10. Back referral
11. Counter referral
12. Reporting under referral mechanism
Process:
1. Zone-wise/ward trainings should be arranged for batches of ASHAs/ANMs, for Medical Officers of
UPHCs.
2. Appropriate permission to conduct staff trainings shall be obtained from the local government.
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3. Permission letters shall be issued to all facilities prior to trainings.
4. Separate training sessions shall be arranged for the staff of secondary and tertiary level facilities.
5. Training of staff from secondary level health facilities should include the development of an efficient
communication system with higher and lower level facilities.
6. In addition to the baseline training, on-field training especially of ASHA and ANMs should be
completed at the beginning of the referral system.
7. Once the training sessions have been completed, the referral mechanism should be initiated.
8. All higher facility In-Charge Officers should be informed about the process of the referral
mechanism in a meeting.
9. Frequent follow ups with UPHCs should be done to check on any challenges which community
workers and staff are facing.
10. Continuous support should be extended to troubleshoot any issues with the referral tools.
8. MONITORING AND EVALUATION
Background and need:
To have a precise picture of the implementation of the referral mechanism, and to monitor progress, a well-
defined reporting system and reporting pathway must be properly initiated. Key indicators on the initiation,
implementation and impact of referral must be initially decided to conform with the specific needs at
community, UPHC, secondary facility and city levels. Examples of such indicators are mentioned in the table
below:
INDICATORS TO MONITOR & EVALUATE IMPLEMENTATION OF A REFERRAL MECHANISM
1. Establishment of referral mechanism:
a. Status of any existing referral directory and referral loop
b. Number of training sessions conducted
c. Number of staff trained in referral process
2. Implementation of referral:
a. Number of field visits carried out
b. Number of ANC/PNC cases carrying referral slips of patients referred to the UPHC
c. Number of patients with referral slips at the referred UPHC/Secondary/Tertiary facility
3. Impact of referral:
a. Number of high risk pregnancies in patients carrying referral slips identified and referred
b. Number of high risk infants of patients carrying referral slips identified and referred
c. Number of other cases in patients carrying referral slips identified and referred
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Process:
1. Based on information collected in the referral slip, assessment indicators should be finalized, and
the data should be collected from each facility at regular intervals.
2. The reporting formats at each level, community, UPHC, secondary facility, and city levels should be
developed based off the finalized indicators.
3. These formats should be distributed among community workers and they should regularly be
trained on any updates to the format.
4. Individual reporting formats should be submitted to UPHCs during inter-phase meetings. The UPHC
medical officer or a dedicated staff member should be responsible to collate all data on referral
formats at the different levels during these inter-phase meetings at the secondary facility.
5. Final city level format should be completed at the city level.
The figure below shows how reporting data should flow from the community through city level.
Feedback mechanism to facilitate quality improvement of the referral process
Data flow from the community to higher levels
ASHA / ANM / AWW / MAS
•Point of data origination
•Performs activities
•Reports to UPHC every month
UPHC
•Collects data on work done by ASHA / ANM/ AWW / MAS
•Compiles for UPHC
•Reports to CPMU / DPMU every month
Secondary & Tertiary Facilities
•Compiles data from facility
•Transmits monthly report to CPMU /DPMU
DPMU
•Compiles data from all Levels
•Transmits monthly reports
•Transmits Quarterly report to SPMU / National
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The data collected at regular intervals should be analyzed to understand the progress and issues which arise
during implementation of the referral mechanism.
1. Based on this analysis, monthly interactions with government stakeholders and facility staff shall be
carried out to give feedback on the progress.
2. Based on feedback, points of improvement should be discussed to improve the implementation.
9. SUGGESTION: USE OF TECHNOLOGY TO IMPROVE IMPLEMENTATION OF THE
REFERRAL MECHANISM
Background and Need
An efficient referral system provides access to treatment and skills by linking different levels of care through
appropriate referral points. The medical decision to refer a patient is dependent on many factors, including,
as the skills of staff who are referring patients, the tools available for diagnosis, the availability of specialist
facilities at a given health institution, quality of care at the referral institution, cost of care at either the
referring or receiving facility, location of the facility, transportation and communication. A referral app will
be useful in improving the referral mechanism.
The app can help reduce maternal and child mortality by minimizing the time required to transfer patients
from one facility to another. The app will reduce the paperwork required for frontline workers to complete,
thereby increasing the time they are able to spend in the community. This expedited process will also
streamline patients across primary, secondary and tertiary care facilities based on their health needs,
improve utilization of UPHCs, and reduce patient loads on secondary and tertiary level facilities.
Suggested process
1. The referral app should be in line with ongoing data entry on HMIS portal of the government.
2. The information that should be filled in the app should be easy and less time consuming.
3. The app should be accessible by any android smartphone so that the healthcare worker can easily
use it.
4. The piloting of the developed app should be done at the beginning so that any changes deemed by
healthcare workers can be incorporated in the app.
10. INTER-PHASE MEETINGS ON REFERRAL MECHANISM IMPLEMENTATION
Background and Need:
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Interactive meetings with community and facility staff are referred to as inter-phase meetings. These
meetings should be held on regular intervals. Their purpose should provide regular support to
implementation of the referral mechanism, to generate reports on the progress to date, to discuss any
challenges faced by community workers and facility staff, and to improve overall output by providing regular
support to the staff.
Process:
Once the referral mechanism is initiated, monthly inter-phase meetings should be arranged where ANMs,
ASHAs and the Medical Officer of UPHCs, as well as staff from the secondary facility, shall interact to discuss
the process of referral.
1. These interactions will address the following:
a. Any limitations to the use of referral tools.
b. Any issues at the referring facility.
c. Any need for further capacity building of community workers
d. These meetings should also be used to create individual work plans for the referral process at
community level and to further monitor the individual performance of community workers.
2. These meetings can also be a platform to ensure the quality of care during referral by:
a. A completely and correctly completed referral slip
b. Transfer of patients to other facilities in well-equipped ambulances
c. Ensure the availability of required services at higher facilities before transferring
3. These monthly meetings can also be used as a platform to collect the data related to referral, to give
feedback and to discuss the areas of improvement.
4. Similar meetings can be arranged with government stakeholders to discuss the progress and
feedback of referral mechanism.
11. PARTNERSHIP WITH MEDICAL COLLEGES AND NURSING INSTITUTIONS
Background and Need:
To strengthen the health system delivery mechanism, especially in urban areas, it is important to implement
a fully comprehensive strategy. The involvement of medical colleges and nursing institutions can play a vital
role in strengthening the system. The NUHM recognizes the role of the Department of Community Medicine
in Urban Heath System Strengthening and has suggested developing a partnership. Further, the
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Community Medicine Department of Medical College has an important role to play in the provision of health
care services, referral services, outreach services, center of excellence, training center, and research &
innovation in urban health. Medical colleges can also contribute towards strengthening the health system
by providing support in the form of internships at the facilities, providing lab facilities to patients coming
from public health referrals, assisting in the regular monitoring of referral implementation and managing
the data from community level to higher facility level.
Process:
1. Identify medical or nursing colleges that are potential stakeholders in implementing the referral
system.
2. Initiate a dialogue through regular meetings with the relevant departments.
3. Discuss the responsibilities to be shared between medical colleges and nursing institutions.
4. These institutions should take on the following roles and responsibilities:
a. Generate city-specific evidence to institutionalize the referral system to address systemic health
system issues. Examples of this type of evidence are, to identify issues and solutions for self-
referral, patient perceptions on being referred to secondary or tertiary facilities, the desire for
specialist facility, and others.
b. Facilitate the development and strengthening of the city referral technical group.
c. Conduct city technical group meetings on referral involving maternal and pediatric
departments.
d. Establish systems in medical college wards to ensure appropriate referral and counter referral.
e. Provide supportive supervision and mentoring to secondary and tertiary facilities to conduct
interphase meeting with primary facilities to identify and address issues in the referral
mechanism.
f. Involve nursing colleges in the city to support community referral. Allocate UPHC areas to
nursing schools and set up a partnership between the nursing council and NUHM.
g. Develop a draft MoU between the NUHM and Medical Colleges to support Referral and Health
System strengthening at city level. The effort should be made for inclusion in the Project
Implementation Plan.
12. DEVELOPING REFERRAL CHAMPIONS IN DISTRICTS
Background and Need:
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For any new system being embedded in existing healthcare systems, it is beneficial to have demonstration
sites and staff at facilities to show the process of implementation and its impact in smaller settings. While
implementing the referral mechanism, there is a need to establish strong implementers of the system at all
levels, or ‘Referral Champions’. For example, while training ASHA workers, one or two ASHA workers were
identified as active and effective communicators. During implementation of the referral mechanism, these
ASHA workers provided the most referrals and were active in providing information about the referral
system in the community. Thus, these ASHA workers were labeled as ‘Referral Champions’. Staff who
implement the referral mechanism most effectively at their UPHC, secondary and higher-level health
facilities, can also be termed ‘Champions’. Having such ‘Champions’ is beneficial in to the champions by
giving recognition where it is due, thus encouraging them to continue their optimal work and potentially
train other staff or community workers to improve their implementation.
Process:
1. Identify the active health staff at each level – ASHAs and ANMs at community level, Medical Officers
at UPHCs, nurses at secondary level facilities, etc.
2. In the initial phase of implementation, identify key factors of achievement, including, the number
of referrals completed by community workers, number of referrals attended at UPHC and/or
secondary level, staff engaged in community awareness, and others.
3. Based on these factors, shortlist workers for ‘Referral Champions’.
4. Ask ‘Champions’ to share their experiences in monthly meetings to guide other staff to enhance
their capacity.
SECTION IV: CONCLUSION
There is a need to establish a strong referral mechanism in urban India to ensure high quality of healthcare
and optimum utilization of each health facility, improve coordination and governance, regulate private
formal and informal sectors, strengthen public health capacities, and reduce pocket expenditure.
Experience in the pilot city, Indore, Madhya Pradesh, identified a need to develop a guide to explain the
detailed process behind implementation of a referral mechanism within the existing healthcare system. The
purpose of this document is to guide government officials as they implement referral mechanisms in
existing healthcare delivery structures. This guide has been developed in consultation and collaboration
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with a range of consultants from the team of TCIHC involved in the referral mechanism implementation
process in Indore, Madhya Pradesh.
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REFERENCES
1. Referral Systems - a summary of key processes to guide health services managers
Web link- www.who.int/management/Referralnotes.doc
2. Kamau, Osuga, and Njuguna. 2017. Challenges Facing Implementation of Referral System for
Quality Health Care Services in Kiambu County, Kenya. Health Syst Policy Res., Volume 4:1. Web
link-https://www.semanticscholar.org/paper/Challenges-Facing-Implementation-Of-Referral-
System-Kamau-Onyango-Osuga/a314ea5589c4f3bfd805229efce09d0d61828e56
3. Choices National Health Service. GP referrals - The NHS in England - NHS Choices 2017. Web link-
http://www.nhs.uk/NHSEngland/AboutNHSservices/doctors/Pages/gp-referrals.aspx
4. The World Health Report: primary health care: now more than ever. World Health Organization.
2008. Web link- https://www.who.int/whr/2008/whr08_en.pdf
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ANNEXURE
1. Baseline assessment tool
2. Baseline assessment report of Gwalior city, Madhya Pradesh
3. Referral slip at community level
4. Referral slip at facility level
5. Reporting format at the community level
6. Reporting format at the facility level
7. Referral Protocols / Health Care pathways
8. MNCH Matrix
9. Frontline worker training module and Facilitators guide for community workers
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For more details
V i s i t w w w . p s i . o r g
C o n t a c t u s : i n f o @ p s i . o r g . i n