“Ehalati”: Evaluation of the Referral System in Primary Health Care Centres in Saudi Arabia

Abstract

Introduction: The burden of diseases has changed in recent years, and chronic Non-Communicable Diseases NCD have become an emerging pandemic in Saudi Arabia. At the same time, healthcare provision is shifting from free services provided directly by the state to a privatised model of healthcare delivery. An effective referral system is fundamental to manage the potential fragmentation of privatisation, and provide the integrated care needed to meet the NCD challenge. This paper evaluates the current “Ehalati” referral system; “Ehalati” is an Arabic word means “my referral”. It examines the experiences of physicians working within this referral system, from the assessment to the monitoring of referred patients. It pays particular attention to the referral processes for patients with chronic NCD in Primary Health Centres [PHCs]. Method: Semi-structured face-to-face interviews were conducted in 15 PHCs of the Ministry of Health MOH in Riyadh city, Saudi Arabia. Nineteen physicians from these PHCs were interviewed using questions drawn from the Referral System Assessment and Monitoring RSAM evaluation tool. All interviews were audio-recorded and transcribed verbatim. Results: The current referral system falls well short of ideal integrated care. Physicians reported that the feedback procedure was almost non-existent. Although referral protocols and guidelines existed, these were not available in all PHCs. The system relies on accurate knowledge of the referral network, but directories of hospitals in the network were not available in all PHCs. When we asked physicians “how do you know the type of services provided in a hospital,” their response was clearly “don’t know.” There is consistency between the referral information reported in the referral letters in all PHCs. Some physicians were unhappy about the patients’ role in the referral letter that is generated only “Upon Patient’s Request.” Data of the referrals were collected and analysed in most PHCs. Most of these analyses were sent to MOH’s “Ehalati” management. Some physicians reported that these analyses should be shared with and among physicians. There was no standard satisfaction measurement for referred patients. It found that uneven availability of training of physicians. Training for physicians on the referral guideline and system was not available for all of them. Most physicians reported that the current referral system and appointment time management limits the choices of referrals. Physicians cannot track or monitor their patients, and they do not know if patients completed the referral unless patients tell them verbally. Discussion: Physicians complained about not receiving feedback from hospitals, this aligns with previous studies that reported low feedback rate with poor quality 1.   Conclusion: Improvement to the referral system is needed, particularly appointment time management, provision of up to date directory of hospitals, training to the physicians from primary care and an improved increased awareness of the significance of feedback from hospitals. Lessons learned: Involvement of patients in the evaluation of the referral system is essential. Limitations: Study was conducted only in one city and findings may not be applicable to other cities. Suggestion for future research: Future research should be focusing on feedback procedures from hospitals to PHCs.