Abstract
BackgroundEffective referral systems from the community to the health care facility are essential to save lives and ensure quality and a continuum of care. The effectiveness of referral systems in Mozambique depends on multiple factors that involve three main stakeholders: clients/community members; community health workers (CHWs); and facility-based health care workers. Each stakeholder is dependent on the other and could form either a barrier or a facilitator of referral within the complex health system of Mozambique.MethodsThis qualitative study, aiming to explore barriers and enablers of referral within the lens of complex adaptive health systems, employed 22 in-depth interviews with CHWs, their supervisors and community leaders and 8 focus group discussion with 63 community members. Interviews were recorded, transcribed and read for identification of themes and sub-themes related to barriers and enablers of client referrals. Data analysis was supported by the use of NVivo (v10). Results were summarized in narratives, reviewed, discussed and adjusted.ResultsAll stakeholders acknowledged the centrality of the referral system in a continuum of quality care. CHWs and community members identified similar enablers and barriers to uptake of referral. A major common facilitator was the existence of referral slips to expedite treatment upon reaching the health facility. A common barrier was the failure for referred clients to receive preferential treatment at the facility, despite the presence of a referral slip. Long distances and opportunity and transport costs were presented as barriers to accessibility and affordability of referral services at the health facility level. Supervisors identified barriers related to use of referral data, rather than uptake of referral. Supervisors and CHWs perceived the lack of feedback as a barrier to a functional referral system.ConclusionsThe barriers and enablers of referral systems shape both healthcare system functionality and community perceptions of care. Addressing common barriers to and strengthening the efficiency of referral systems have the potential to improve health at community level. Improved communication and feedback between involved stakeholders – especially strengthening the intermediate role of CHWs – and active community engagement will be key to stimulate better use of referral services and healthcare facilities.
Highlights
Effective referral systems from the community to the health care facility are essential to save lives and ensure quality and a continuum of care
These studies revealed that when key factors to promote referral and health facility use are in place, Community Health Workers (CHWs) can play an important role in reducing barriers to accessing healthcare that stem from socio-economic status, language barriers, transportation, and sociocultural factors [16, 17]
A major common facilitator was the existence of referral slips to expedite treatment upon reaching the health facility
Summary
Effective referral systems from the community to the health care facility are essential to save lives and ensure quality and a continuum of care. In a recent systematic review on access to health care, including equitable service provision in rural areas in settings with limited resources, only six studies considered the role of CHWs in referral of clients to a health facility in their analysis [10,11,12,13,14,15]. These studies revealed that when key factors to promote referral and health facility use are in place, CHWs can play an important role in reducing barriers to accessing healthcare that stem from socio-economic status, language barriers, transportation, and sociocultural factors [16, 17]
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