Referral Systems – components and effects of FHC-I

Dr. Heidi Jalloh-Vos, MRCSue Clarke IRC2010 HIPCC

Referral System Components

• Ambulance with ambulance nurse, ambulance driver, radio or mobile phone, medical kit

• PHUs with solar powered radios or phone and essential medical supplies/equipment and trained staff

• Community and local authorities involvement

• Awareness raising about referral system

• Hospital emergency preparedness

• Ambulance base with 24hrs call service (radio, telephone, radio operator)

• Regular updated referral database

• Management systems (repair, maintenance, logbook, etc.)

MRC Referral system Bo North

Based on: • high child/maternal mortality, partially due to poor geographical access to

higher levels of health care• History of ambulance system in Bo North• Request of community (esp. Komboya chiefdom) for ambulance system• Fruitful discussion with local partners and outside donors

Covers :• 23 primary health care clinics in 6 chiefdoms• estimated population 2010: 77,120• Covers all emergency (obstetric, paediatric, others)

• Free for Pregnant and Lactating Women and U5 since 27th April, others pay 25,000 to 50,000 dependant on distance

MRC Bo North Referral System - Ambulance patients by month

0

10

20

30

40

50

60

70

80

90

Nr. p

atie

nts

2006

2007

2008

2009

2010

Does increase of attendance give similar increase in referrals?

• 4 chiefdoms in Bo North (13 PHUs)

• Attendance Jan-April = 8802 (2201/month)

• Referrals Jan-April = 46 (12/month)

• Attendance May-July = 13526 (4509/month)

• Expected referrals = 24/month

• Actual referrals seen = 140 (47/month)

Referral systems presentation to HIPCC - Sept. 20106

Increased referral percentage

January to April 2010 May to July 2010

Chiefdom Attendance

Patients referred %

Attendance

Patients referred %

Badjia 1625 3 0.18 2186 17 0.78

Bagbe 2811 18 0.64 4357 46 1.06

Komboya 2321 4 0.17 3317 55 1.66

Niawa Lenga 2045 21 1.03 3665 22 0.60

Total 8802 46 0.52 13526 140 1.04

Average monthly 2201 12 4509 47

Patient categories

MRC Bo North Referral System - Patient categories in % before FHCI (2010)

32%

35%

33%

0%

U5PWLWOther

MRC Bo North Referral System - Patient categories in % after FHCI (2010)

62.24%

25.52%

6.29%

5.94%

U5

PW

LW

Other

Referral system – nr. Obstetric cases versus expected nr. cases

• Catchment population 2010 = 77,120

• Expected number of pregnant women (4%) = 3085

• Expected number of deliveries with complications estimated as 15% of 3085 = 463 (some could be managed at e.g. a CHC)

• Expected number of caesarean sections estimated as minimum 5% of 2907 = 154(who would all need to come to the hospital)

• Now 8 months into 2010 (January to August):

– 24 PW before FHCI– 73 pregnant women referred after FHCI– Expected (extrapolation) until end 2010: 71– Total = 168 – which is more than the 5% calculated

• Can we conclude that we are now missing less obstetric cases??

Kenema District

Programme coverage includes:

• Direct beneficiaries 55,000 (women aged 15-45)• 37,350 children under five

All chiefdoms supporting 65 PHUs and the Government hospital one of the aims being to enable and support the continuum of care from the PHU to the CEmOC

• Support to the ambulance and the blood transfusion service started in 2007

• Always been a free service for pregnant women

Mode of Referrals to KGH

Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-100

20

40

60

80

100

120

140

Ambulance referralsSelf referrals

Patient referral numbers / month

Jan-09

Feb-09

Mar-09

Apr-09

May-09

Jun-09Jul-0

9

Aug-09

Sep-09

Oct-09

Nov-09

Dec-09

Jan-10

Feb-10

Mar-10

Apr-10

May-10

Jun-10Jul-1

00

50

100

150

200

250

Referrals to KGH Referral to Gondama

Blood Transfusion Service

Kenema Government Hospital

Units of Blood Collected

2007 2008 2009 20100

1000

2000

3000

4000

5000

6000

19491442

3135

2068

3192

Donors Projected

Donor Sources

2007 2008 2009 2010 Jan - June

1452

1214

2294

1487

497 (26%)

228 (16%)

607(27%)

581(28%)

Family Replacement Donors Voluntary Donors

Beneficiaries of Kenema Blood Transfusion Service in 2010

22%

70%

6%

2%

MATERNITY PAEDIATRICS MEDICAL SURGICAL

Common constraints

• High cost of running a referral system, especially after FHCI although reduced cost per patient

• Increased workload and demands on resources at receiving facilities

• Human Resource issues compounded by service demands

• PHU Staff do not have all essential skills to handle emergencies – gradually improving through supportive supervision and training

• Some patients still refuse transportation and delay reaching the facilities, so ongoing need for continued awareness and information sharing.

Lessons learnt

• The power of collaboration – system successful due to close cooperation with district council, hospital, DHMT, chiefs, communities etc.

• All elements in the chain are important to ensure that the referral is not raising unrealistic expectations

• Unexpected effect: CHC/CHPs advising lower level PHUs by radio or in person when called upon by radio or telephone

• Uptake first gradual – after the launch of free health care there was the predicted surge in numbers even in Kenema where the services were already free

• Increased trust in receiving free care at hospital contributes to increased uptake and utilisation of services