Facility managers and supervisors at all levels should monitor all referrals made to and from facilities in their area each month. Usually between 5% and 10% of clients seen in a primary health care facility will be referred to a higher level for diagnostic services or more specialized care. Supervisors should discuss referred cases:
• Identify those which should have been properly treated at the facility itself without referral
• Identify cases which should have been referred but were handled locally
• Check the back referrals received to determine whether the information is adequate and being acted upon by the facility
• Follow up cases that have been referred but no feedback yet received to assure that the client has arrived at the higher level
• Identify any issues regarding timing, promptness and completeness of information sent
Results of this analysis can be covered at meetings with hospital and clinic staff together. As the issues are discussed, staff will identify what is needed to improve things - this might include clinical training or strengthening of particular parts of the referral system or its procedures. Facility managers and supervisors need to ensure that such items are followed-up and acted on. In-service education and capacity strengthening can be reinforced by good supervision.
Long-term treatment of chronic illnesses such as diabetes, hypertension, epilepsy and psychiatric illness can be managed at suitably resourced health centres - this assures not only high quality of care for the client, but also greater convenience and less burden on the client and the higher levels of the health system.