An effective referral system ensures a close relationship between all levels of the health system and helps to ensure people receive the best possible care closest to home. It also assists in making cost-effective use of hospitals and primary health care services. Support to health centres and outreach services by experienced staff from the hospital or district health office helps build capacity and enhance access to better quality care. In many developing countries, a high proportion of clients seen at the outpatient clinics at secondary facilities could be appropriately looked after at primary health care centres at lower overall cost to the client and the health system. A good referral system can help to ensure:
• Clients receive optimal care at the appropriate level and not unnecessarily costly
• Hospital facilities are used optimally and cost-effectively
• Clients who most need specialist services can accessing them in a timely way
• Primary health services are well utilized and their reputation is enhanced
Being a system, examination of a referral system requires consideration of all its parts. Important components of a referral system are listed in Box 1 and referral flows are depicted in Figure 1. These can be adjusted as relevant to the local situation. The design and functioning of a referral system in any individual country will be influenced by:
• health systems determinants: capabilities of lower levels; availability of specialized personnel; training capacity; organizational arrangements; cultural issues, political issues, and traditions
• general determinants, such as: population size and density; terrain and distances between urban centres; pattern and burden of disease; demand for and ability to pay for referral care