Referral practices and experiences of patients at three government referral hospitals in Kampala: Challenges and implications for policy and practice

Abstract

Introduction: Within any health system, a well-functioning referral system determines whether continuity and in turn quality of services will be achieved. Many service delivery challenges can be attributed to a poorly functioning referral system. Uganda has recently implemented a policy to de-congest the National referral hospital. This has been done by referring most clients to surrounding lower lever facilities for care. However, there has not been extensive sensitization for the surrounding communities. Besides, Uganda has experienced health system referral challenges due to several reasons among which are lack of ambulances, poor road networks, ineffective communication between facilities, inadequate emergency medicines and the limited capacity of the lower-level facilities to handle some of the cases that they should be handling. In the current environment, the experiences of patients in a weak referral system can negatively compromise the quality of care General objective: To describe the referral practices and experiences of patients referred to the referral hospitals of Kiruddu, Naguru and Kawempe highlighting the challenges and the implications for policy and practice Methods: A cross-sectional descriptive study with both quantitative and qualitative methods was carried out. A total of 283 patients participated in the quantitative survey. Eighteen key informants (heads of department of internal medicine, obstetrics and gynecology, pediatrics, surgery, accident and emergency unit, nutritional unit and the burns unit were also chosen for the qualitative survey. The participants were interviewed with pretested questionnaires and data obtained was entered into Microsoft Excel and analyzed with STATA 12. Univariate analysis was used to describe the study participants using frequencies and proportions. Bivariate and multivariate data were analyzed using logistic regression. Data from the key informants were triangulated and coded to find explanations and attach meaning and significance. Results: Out of 283 patients 147 (52%) were referred by a health care professional, 45% (128) were self-referred and 3% (8) were referred by a third party. The factors associated with self referral included living in an urban area (COR, 95%CI 0.14 (0.07, 0.26), p value< 0.001) and age 21-30 years (COR, 95%CI 2.60 (1.20, 5.63), p value=0.02) and 31-40 years (COR, 95% CI

2.48(1.06, 5.58), p value= 0.04). The commonest reasons for self-referral were further management (92.1%), availability of services (59.1%) and availability of specialists (55.7%). Many of the challenges faced by patients were related to the environment and these were unavailability of transport (25%), long-distance (17%) and traffic jams (10%). Health system challenges included lack of essentials (drugs and diagnostics) (16%), delay to receive treatment (11%), poor treatment by the health workers (7%) and lack of personnel at the facility (7%). The individual factors that challenged the patients were financial constraints (28%). Conclusion: Professional referral is more frequently done than self-referral among the inpatients in Kiruddu, Naguru and Kawempe hospitals. However, due to the lack of a streamlined referral system in terms of unavailability of transport, long-distance, lack of drugs and diagnostics, delay in receiving treatment, unavailability of personnel, patients that were referred by health care professionals faced similar challenges to those that were self-referred. Recommendation: Government needs to provide clear guidelines on the referral process with effective monitoring at the facility level. Efforts should also be made by the government to improve the transport infrastructure and providing more ambulances to transport referred patients that are very ill. Furthermore, there should be a move by the government and the ministry of health to increase the capacity of lower-level facilities especially health centre IVs and IIIs so that they provide a wider range of services than they are doing as well as offer training to the health care providers on the referral process.