Referral revisited: community financing schemes and emergency transport in rural Africa
Introduction
Since the Alma Ata Declaration (WHO/UNICEF, 1978) the professional health community has repeatedly asserted that referral is an important link in the primary health care (PHC) chain. For example, the Declaration emphasises “primary health care activities are supported by successive levels of referral facilities... and [well functioning referral systems are] essential to create confidence in the whole system”. The Declaration continues by stating that “the transportation of patients to and from referral services has to be properly organized, making the most of available facilities”. Thus the designers of the PHC paradigm fully accepted and expected, that referral between levels of care should be integral to a well-functioning health system. Yet, as all practitioners can attest, a functioning referral system assumes that treatment is given at the appropriate level of health care, i.e. that general primary care is given at the entry point and more specialized care is given further long the chain, according to appropriate referral from within the system. Two main problems immediately arise in connection to referral. First, there is inappropriate use of the more specialized institutions: persons seek care by self-referring themselves to a referral centre, as opposed to entering the system at the primary level and being referred onward only if necessary (Paine and Tjam, 1988, Sanders et al. 1998). The second problem arises when patients, who enter the system at the primary level, receive a referral notice to seek treatment from a specialist or secondary care institution, but then fail to access the appropriate care due to numerous barriers between first and second or third levels of care. The first problem plagues urban health systems in much of the developing world (Barnum and Kutzin, 1993). The second problem, which is the focus of this paper, is endemic to health systems in rural areas throughout the developing world (Paine and Tjam, 1988, Maine, 1997).
This study addresses the problem of referral between first- and second-level care in rural Africa. It does this by exploring one of several barriers to successful referral: the availability and financing of transport services for patients in need of emergency referral. By exploring the problems inherent in the sustainability and availability of transport in emergencies, this paper exposes a major challenge that faces health managers and communities throughout much of the developing world, but may be particularly severe in rural Africa.
Emergency transport is an obvious yet understudied factor that affects the efficiency of referral, as well as a determinant of the extent to which a community places trust in its health care providers in times of crisis. From the logistical aspects of availability and cost, willingness and ability of the patient to travel, to the problems of measuring and evaluating outcomes of referral, this area is fraught with difficulties. Interventions designed to improve transport for emergency referral are important to individuals and communities for three main reasons. First, emergency referral can save lives and the consequences of delay in referral or failure to reach the point of referral may result in death or permanent disability. Second, community financing schemes that at least partially focus on providing and maintaining referral options in emergency situations can build trust between communities and the health systems that are intended to serve them. A health crisis that is solved, or at least dealt with, is obviously more likely to engender feelings of support for local health providers and reflect well on the system as a whole. Thirdly, this trust is, we believe, an essential component of the sustainability of health systems.
This paper is organized as follows. First, a conceptual framework introduces the main barriers to effective utilization of referral that are currently facing households in rural Africa. Second, through an analysis of research on transport, we highlight instances reported as being important in the reason for delay of care. Third, an overview is presented of risk-sharing strategies. We discuss both what they are and why they may, theoretically, be important in relieving some of the burden on households and health systems in the need for emergency transport. Finally, our empirical work includes findings from a rural health project in northern Kenya. This case provides evidence as to how a rural community prioritizes referral in emergency contexts and how this same community has attempted to overcome some of the barriers to referral in the past decade.
Section snippets
Conceptual framework and previous research
In this section, we review previous research on the referral process. Emphasis is placed on the role of transportation costs as an important barrier to utilization of referral and the potential role of community risk-sharing programs as a way to lessen the burden of transport costs, thereby strengthening the link between primary and secondary-level care1
Geographic context
Samburu district, in Rift Valley province, Kenya (20,808 km2), lies 350 km north of Nairobi (see Fig. 2). This is a semi-arid region of flat savannah plains (altitude 500 m), broken by mountain ranges rising to about 1400 m above sea level. The population is mainly Samburu, with some communities of Turkana, Rendille, Ariaal and Somali, interspersed across the district: all of these ethnic groups are pastoralists and most live as semi-nomads in small, scattered communities. The most recent
Discussion
The data used in this analysis is unusual for several reasons. First, we know very little about referral rates or their determinants in rural Africa. The limited literature on this subject most often focuses on the problem of unnecessary self-referrals at referral-receiving sites, or the problem of transport as a delay factor in maternal health. Second, there is little formal presentation of referral data over time, even in the existing literature on this subject. Third, the unusualness of the
Conclusion
As quoted at the beginning, referral has been the long regarded as an area vital to the health of the health system. In a report of a WHO Expert Committee (WHO, 1987), the problems of referral are outlined as follows:
Referral systems are easy to design but extremely difficult to put into practice. The effectiveness of a referral system will depend on the patients' confidence in the different levels of the health system; the trust they have in the personnel; the effectiveness of the information
Acknowledgements
This research was partially funded by the Mellon Foundation. We also thank SAIDIA's staff, especially Eleanor Monbiot, Felistus Ugi and Mohamed Gabriel Lochgan for their time and help. We are grateful to the communities and individuals of Lesirikan and Ngilai who welcomed questions during September and October 1996.
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