Functional Referral System Research Articles

Women's suggestions on how to improve the quality of maternal and newborn care: A qualitative analysis from the IMAgiNE EURO survey in Italy during the two years of the COVID-19 pandemic.

Collecting women's views and suggestions for improving quality of maternal-newborn care (QMNC) is a crucial aspect of maternity care evaluation often overlooked in Italy and globally. Childbearing women experienced numerous challenges during the COVID-19 pandemic including the rapid and significant reorganization of maternity services and care. Their perspective on what to prioritize for QMNC improvement is hence pivotal. The aim of this study was to explore maternal suggestions for QMNC improvement from women who gave birth during the two years of the COVID-19 pandemic. Data were collected from an open-ended question included in a validated online questionnaire administered to mothers who gave birth in an Italian hospital between November 2020 to March 2022. The responses were analyzed using thematic analysis and mapped against the WHO Standards for improving QMNC and the WHO Framework of QMNC. The thematic analysis identified five main themes from the 2017 responses: 1) Support for mothers during the postnatal period; 2) Better use of resources; 3) Improvement of the maternity environment; 4) Reconsideration of organizational aspects; and 5) Guarantee of respectful practices. Women commented on all dimensions of the WHO framework except for two provision of care subdomains 'actionable information and functional referral systems'. This is the first qualitative study in Italy focusing on women's suggestions for improving QMNC during the COVID-19 pandemic. Its findings can be used to inform what aspects of QMNC need improvement in Italy. Collection of women's views should be incorporated in routine monitoring of the QMNC, and data should be used for quality improvement purposes.

Improving Contraceptive Service Quality and Accessibility for Adolescents and Youth Through Proprietary Patent Medicine Vendors in Four Nigerian States.

In Nigeria, health care services and commodities have increasingly been accessed through private sector entities, including retail pharmacies and drug shops (also called proprietary patent medicine vendors [PPMVs]). However, PPMVs cannot provide long-acting or permanent methods, and concerns have been raised about their quality of services and their need to better comply with government regulations. This article describes how The Challenge Initiative's (TCI) family planning program supported 4 state governments in Nigeria to develop a model to strengthen public-private partnerships between PPMVs and primary health centers (PHCs) to leverage PPMVs to provide adolescents and youth with high-quality contraceptive information, services, and referrals to PHCs. The intervention implemented a hub-spoke model by strengthening the linkages between neighboring PPMVs and large PHCs for delivering contraceptive services to adolescents and youth. The steps in the implementation process included: (1) introducing the intervention to state governments, (2) selecting PPMVs as spokes and high-volume PHCs as hubs, (3) conducting whole-site orientations jointly with PPMV and PHC staff, (4) strengthening referral links between PPMVs and PHCs, (5) implementing supportive supervision and coaching, and (6) strengthening client data management. TCI worked with the state and local ministry of health to improve PPMV operators' knowledge, attitudes, and skills to deliver adolescent- and youth-friendly services. Implementing the PPMV intervention with state governments and PHCs strengthened the public-private partnership. A functional referral system in Plateau State demonstrated significant success, enabling increased contraceptive choice and adherence to regulations for adolescents and youth. We recommend that the government strengthen the working relationship between PPMVs and PHCs, incorporate PPMVs into the routine supportive supervision of the state health system, and incorporate a referral linkage with PHCs into the design and implementation of PPMV programs.

Standards of care and determinants of women’s satisfaction with delivery services in Nepal: a multi-perspective analysis using data from a health facility-based survey

BackgroundCompliance with standards of care is required for sustained improvement in the quality of delivery services. It thus represents a key challenge to improving maternal survival and meeting the Sustainable Development Goal (SDG) target of reducing the maternal mortality ratio to 70 deaths per 100,000 live births. This study examines the extent to which normal low-risk health facility deliveries in Nepal meet the standards of quality of care and assesses the effect of the standards of quality of care and various contextual factors on women’s satisfaction with the services they receive.MethodsDrawing on the 2021 Nepal Health Facility Survey, the sample comprised 320 women who used health facilities for normal, low-risk delivery services. A weighted one-sample t-test was applied to examine the proportion of deliveries meeting the eight standards of care. Women’s overall satisfaction level was computed from seven satisfaction variables measured on a Likert scale, using principal component analysis. The composite measure was then dichotomized. Binary logistic regression was used to analyze the determinants of women’s satisfaction with delivery care services.ResultsDeliveries complying with the eight standards of care and its 53 indicators varied widely; output indicators were more frequently met than input indicators. Of the eight standards of care, the “functional referral system” performed highest (92.0%), while “competent, motivated human resources” performed the least (52.4%). Women who were attended by a provider when they called for support (AOR: 5.29; CI: 1.18, 23.64), who delivered in health facilities that displayed health statistics (AOR 3.16; CI: 1.87, 5.33), who experienced caring behaviors from providers (AOR: 2.59; CI: 1.06, 6.30) and who enjoyed audio-visual privacy (AOR 2.13; CI: 1.04, 4.38) had higher satisfaction levels compared to their counterparts. The implementation of the Maternity Incentive Scheme and presence of a maternal waiting room in health facilities, however, were associated with lower satisfaction levels.ConclusionsNepal performed moderately well in meeting the standards of care for normal, low-risk deliveries. To meet the SDG target Nepal must accelerate progress. It needs to focus on people-centered quality improvement to routinely assess the standards of care, mobilize available resources, improve coordination among the three tiers of government, and implement high-impact programs.

Midwife-led birthing centres in four countries: a case study

BackgroundMidwives are essential providers of primary health care and can play a major role in the provision of health care that can save lives and improve sexual, reproductive, maternal, newborn and adolescent health outcomes. One way for midwives to deliver care is through midwife-led birth centres (MLBCs). Most of the evidence on MLBCs is from high-income countries but the opportunity for impact of MLBCs in low- and middle-income countries (LMICs) could be significant as this is where most maternal and newborn deaths occur. The aim of this study is to explore MLBCs in four low-to-middle income countries, specifically to understand what is needed for a successful MLBC.MethodsA descriptive case study design was employed in 4 sites in each of four countries: Bangladesh, Pakistan, South Africa and Uganda. We used an Appreciative Inquiry approach, informed by a network of care framework. Key informant interviews were conducted with 77 MLBC clients and 33 health service leaders and senior policymakers. Fifteen focus group discussions were used to collect data from 100 midwives and other MLBC staff.ResultsKey enablers to a successful MLBC were: (i) having an effective financing model (ii) providing quality midwifery care that is recognised by the community (iii) having interdisciplinary and interfacility collaboration, coordination and functional referral systems, and (iv) ensuring supportive and enabling leadership and governance at all levels.ConclusionThe findings of this study have significant implications for improving maternal and neonatal health outcomes, strengthening healthcare systems, and promoting the role of midwives in LMICs. Understanding factors for success can contribute to inform policies and decision making as well as design tailored maternal and newborn health programmes that can more effectively support midwives and respond to population needs. At an international level, it can contribute to shape guidelines and strengthen the midwifery profession in different settings.

Postnatal care services in rural Zambia: a qualitative exploration of user, provider, and community perspectives on quality of care

BackgroundPostnatal care (PNC) is an important set of services offered to the mother and her newborn baby immediately after birth for the first six weeks to prevent maternal and neonatal complications and death. This qualitative study explored user and provider perspectives on quality of PNC services in the selected health facilities within the context of the Maternity Homes Access in Zambia project in the Saving Mothers Giving Life districts in rural Zambia.MethodsBetween October 2018 and February 2019, forty focus group discussions (FGDs) (n = 160 participants) and twelve in-depth interviews (IDIs) were conducted in four districts in Southern and Eastern provinces. FGDs comprised women who delivered within the last year, fathers, community elders, and volunteers. IDIs comprised health workers at facility, district, and provincial levels. Data were analysed using content analysis guided by the international quality of care domains derived from the World Health Organization quality of care framework. Findings were triangulated to understand perceptions.ResultsOverall, study participants perceived PNC services to be beneficial. Nevertheless, respondents had mixed feelings on the quality of PNC services and expressed a stark difference in their perception of factors affecting service quality. Service users described challenges arising from ineffective communication about the new PNC guidelines, and non-adherence of service providers to quality standards regarding respect, preservation of dignity and emotional support. Other factors were long waiting hours, small examination rooms providing inadequate privacy, and low levels of confidentiality. In contrast, service providers attributed poor service quality to various health system-related factors including low staffing levels, dysfunctional referral services, low supply of essential medicines, supplies, vaccines and equipment for optimal routine emergency obstetric and newborn care and management of complications.ConclusionThese findings highlight important intervention opportunities to improve quality of PNC services in Zambia through better communication and raising awareness on PNC guidelines, respect, preservation of dignity and emotional support to mothers. Interventions should also focus on addressing contextual health system challenges including staffing levels, supply chain for essential medicines and commodities, shortening waiting time, and ensuring functional referral system.

Audit of emergency obstetric referrals at a tertiary center in Kano.

Maternal and perinatal deaths could be prevented if functional referral systems are in place to allow pregnant women to get appropriate services when complications occur. The study was a 1-year retrospective study of obstetric referrals in Aminu Kano Teaching hospital, from 1st January to 31st December 2019. Records of all emergency obstetrics patients referred to the hospital for 1 year were reviewed. A structured proforma was used to extract information such as sociodemographic characteristics of the patients, indications for referral, and pre-referral treatment. The care given at the receiving hospital was extracted from the patients' folders. An Audit standard was developed and the findings were compared with the standards in order to determine how the referral system in the study area perform in relation to the standard. There were total of 180 referrals, the mean age of the women was 28.5 ± 6.3 years. Majority (52%) of the patients were referred from Secondary Centres and only 10% were transported with an ambulance. The most common diagnosis at the time of referral was severe preeclampsia. More than half of the patients (63%) had to wait for 30 to 60 minutes before they see a doctor. All the patients were offered high quality care and majority (70%) were delivered via caesarean section. There were lapses in the management of patients before referral; failure to identify high risk conditions, delay in referral, and lack of treatment during transit to the referral centre.

MOHALLA (OR COMMUNITY/ NEIGHBORHOOD) CLINICS TO REINFORCE PRIMARY HEALTHCARE IN DELHI, INDIA: A SYSTEMATIC REVIEW BASED ON PRISMA 2020 GUIDELINES

“Mohalla” in Hindi language means community or neighborhood. In July 2015, government of Delhi started establishing Mohalla (or community/neighbourhood) clinics (MCs) for strengthening primary healthcare services in Delhi, India. Primary objectives these clinics include making primary care accessible and affordable, reducing burden on tertiary care facilities etc. This article contains a review of past publications concerned with MCs to assess their performance. A systematic review based on PRISMA 2020 guidelines was carried out and database search was completed on 8 Feb, 2022. A total of 24 studies were finally selected for review. The review revealed that MCs have the potential to make primary care services accessible and can help in achieving universal health coverage. These clinics provide cost-effective primary care services and avoid overcrowding in big hospitals. MCs circumvent self-medication practices and are highly effective in low-income settings. To improve efficiency of MCs, it is suggested to strengthen health workforce and expansion of MCs beyond primary care. Additionally, there is a need of functional referral system along with launching telemedicine services at MCs

A Call for a Stroke Referral Network Between Primary Care and Stroke-Ready Hospitals in the Philippines: A Narrative Review.

The increasing stroke burden, inequity in the distribution of local neurologists, and the recent signing of the Universal Health Care Law in the Philippines provide compelling reasons for policy-makers to devise strategies to establish networks between primary care and stroke-ready hospitals. In this review, we explored the current literature and evidence that emphasized the roles of primary care providers (PCPs) and specialists, care transition, and telemedicine/teleneurology in various stages of stroke management. Clear delegation of stroke care responsibilities among PCPs and specialists is needed. Due to the limited number of specialists/neurologists, PCPs may contribute to addressing the insufficiency of community knowledge of acute stroke symptoms/risk factors, coordination with specialists and stroke-ready hospitals during acute stroke, and continuity of care during the poststroke stage. At present, the Philippines has only 49 stroke-ready hospitals; thus, an efficient and functional referral system for the care transition between the PCPs and specialists must be organized in our country. To provide remote access to expert stroke care for underserved areas and to increase thrombolysis utilization, the establishment of an effective telestroke system is indispensable. The empowerment of PCPs in teleneurology may assist in strengthening communication and networking with specialists with the ultimate goal of improving patient outcomes. In the era of Universal Health Care in the Philippines, the roles of PCP and specialists must be delineated. Increased access to stroke care through the establishment of networks among PCPs and stroke-ready hospitals (ie, via effective transition of care/teleneurology) must be prioritized especially in resource-constrained settings.

Critical comparative analysis of data sources toward understanding referral during pregnancy and childbirth: three perspectives from Nigeria

BackgroundThe highest risk of maternal and perinatal deaths occurs during and shortly after childbirth and is preventable if functional referral systems enable women to reach appropriate health services when obstetric complications occur. Rising numbers of deliveries in health facilities, including in high mortality settings like Nigeria, require formalised coordination across the health system to ensure that women and newborns get to the right level of care, at the right time. This study describes and critically assesses the extent to which referral and its components can be captured using three different data sources from Nigeria, examining issues of data quality, validity, and usefulness for improving and monitoring obstetric care systems.MethodsThe study included three data sources on referral for childbirth care in Nigeria: a nationally representative household survey, patient records from multiple facilities in a state, and patient records from the apex referral facility in a city. We conducted descriptive analyses of the extent to which referral status and components were captured across the three sources. We also iteratively developed a visual conceptual framework to guide our critical comparative analysis.ResultsWe found large differences in the proportion of women referred, and this reflected the different denominators and timings of the referral in each data source. Between 16 and 34% of referrals in the three sources originated in government hospitals, and lateral referrals (origin and destination facility of the same level) were observed in all three data sources. We found large gaps in the coverage of key components of referral as well as data gaps where this information was not routinely captured in facility-based sources.ConclusionsOur analyses illustrated different perspectives from the national- to facility-level in the capture of the extent and components of obstetric referral. By triangulating across multiple data sources, we revealed the strengths and gaps within each approach in building a more complete picture of obstetric referral. We see our visual framework as assisting further research efforts to ensure all referral pathways are captured in order to better monitor and improve referral systems for women and newborns.

Overcoming the challenges of community-engaged emergency referrals in a rural district of Pakistan

A functional referral system for addressing maternal and child health issues requires coordinated efforts by health system stakeholders and community. Using Rural Health Program (RHP) Thatta as platform provided by an academic institution, district health system stakeholders and community of Mirpur Sakro taluka of Thatta were engaged to strengthen the emergency referral system for maternal and child health emergencies through active community engagement. Through combined consultation, referral system plan for maternal and child health emergencies was developed. Community volunteers from each village liaised for transportation, referring patients to health facilities and maintaining referral documentation. An ambulance service under contract with health department and private transporters were taken on-board to facilitate patients’ transportation. Community’s experiences of referral system were assessed through qualitative in-depth interviews. Patients’ experiences of referral system improved but faced structural challenges including out of pocket transport expenses, direct self-referrals, Continuous...

Overcoming the challenges of community-engaged emergency referrals in a rural district of Pakistan.

A functional referral system for addressing health emergencies requires coordinated efforts by health system's stakeholders and the community. Using the Rural Health Programme (RHP) Thatta as a platform provided by an academic institution, district health system stakeholders and the community of Mirpur Sakro, taluka of Thatta, were engaged to strengthen the referral system for health emergencies through active community engagement. Through consultations with stakeholders, a referral system plan was developed with community volunteers from each village as focal persons for transportation, referring patients to health facilities and maintaining referral documentation. The stakeholders' experience and perceptions about the referral system were assessed through qualitative in-depth interviews. Patients' experiences of referral system improved with enhanced transport availability, but they faced structural challenges, including out of pocket transport expenses, weak back-referral links, lack of trust between the community and healthcare providers and poor availability of medicines.

Family and provider perceptions of quality of care in the management of sick young infants in primary healthcare settings in four counties of Kenya

BackgroundUnderstanding the perceptions of quality of care given to sick young infants in primary healthcare settings is key for developing strategies for effective uptake and utilisation of possible severe bacterial...

Impact of macro-socioeconomic determinants on sustainable perinatal health care in Portugal: a qualitative study on the opinion of healthcare professionals and experts

BackgroundThe WHO identified the importance of macro-socioeconomic determinants and political context as interlinked key factors affecting healthcare quality and health equity. As a response to the recent economic and financial crisis, Portugal approved in 2011 the Economic Adjustment Programme (EAP) to obtain financial assistance from the Troika in order to reduce public debt. This study aims to analyse the impact of the economic crisis and the EAP on perinatal healthcare quality for very preterm (VPT) and/or very low birth weight (VLBW) infants, as perceived by healthcare professionals and experts, within the health administrative regions of the two major metropolitan areas in Portugal.MethodsA qualitative approach was applied to receive an in-depth understanding and accomplish perspective variability. A purposive sampling technique was used. Semi-structured interviews were conducted with twenty-one healthcare professionals and experts between October 2018–July 2019. Inductive thematic analysis was performed which encompassed a five-step categorization procedure. Data analysis was undertaken by utilizing Nvivo2011 software. Evolved themes were then associated with WHO’s Quality Standards on Maternal and New-born Care. A framework on the impact of macro-socioeconomic determinants on perinatal health care quality was developed.ResultsAlthough participants did not perceive the quality of perinatal care had deteriorated, the analysis of their accounts on work experience revealed that it was indeed adversely modified in all WHO Quality Standards. Health care provision was perceived as detrimental in five main areas: 1) Availability of human resources; 2) Functional referral systems; 3) Competent and motivated human resources; 4) Emotional support; and 5) Essential physical resources available. Policy reforms by the EAP resulted in reduced timeliness of care, increased waiting times, cuts in sequence and duration of consultations, and deficiencies in follow-up care for VPT/VLBW infants and their mothers. The EAP directly influenced working environment of healthcare professionals by causing stress, burnout, work absence, and brain drain.ConclusionAn interrelation between macro-socioeconomic determinants and perinatal health care quality was disclosed. The economic crisis and EAP have adversely modified equitable perinatal health care quality for VPT/VLBW infants and their mothers. Our findings underlined the negative impact of austerity policies on vulnerable populations.

Strengthening Maternal Death Surveillance Systems for Evidence-Based Decision Making in Sub-Saharan Africa: The Case of the Center Region in Cameroon

Background:The article seeks to document the experience of implementing Maternal Death Surveillance and Response (MDSR) in the Center Region of Cameroon. The paper raises awareness on the need for implementing MDSR, shares progress and lessons learned and reflects on the implications for public health practice.Methods:A desk research involving the collection and analysis of secondary data using tables with specific themes in excel, following the review of existing resources at the Regional Delegation of Public Health-Center from the year 2016 to 2019.Results:The findings depict the existence of MDSR policies and sub-regional committees. Although, the number of regional maternal death notifications increased from 19 to 188 deaths between 2016 and 2019, the implementation of death review recommendations was only estimated at 10% in 2019. While 66% of deaths occurred in Yaoundé, 72% of these were deaths reported to have occurred in tertiary institutions out of which 75% were attributed to late referrals. Hemorrhage constituted 70/144 (48.6%) of the known direct causes of death. Maternal death related co-factors such as the use of partograph during labor had a high non-response rate (84%) and represents a weakness in the data set.Conclusion and Global Health Implications:Across the board, stakeholder engagement towards MDSR was increased through continuous awareness-raising, dissemination of surveillance tools, the institutionalization of the District Health Information Software (DHIS 2) and the “No Name No Blame” policy. However, the reporting and investigation of deaths for informed decisions remain a daunting challenge. For a resource-scarce setting with limited access to blood banks, the application of life-saving cost-effective interventions such as the use of partographs and the institution of a functional referral system among health units is likely to curb the occurrence of deaths from hemorrhage and other underlying causes. The success of these will require a robust strengthening of the health system.

The challenges faced by service providers on satellite mental health-care facilities in Yangon, Myanmar: a qualitative study

PurposeMyanmar has an insufficient number of mental health workers with few institutional facilities resulting in a significant treatment gap. Although few mental health services are integrated into primary health care (PHC), the challenges are unknown. This study aimed to assess the challenges perceived by providers in the service delivery of satellite mental health care (SMHC) in two sample townships in Yangon.Design/methodology/approachThe research was based on a case study design by applying a qualitative approach using in-depth interviews (IDIs). In the three types of service providers, a total of six staff participated as interviewees. These consisted of two team leaders, two clinical specialists providing consultations to clients and two mental health nurses.FindingsProviders perceived the following as major challenges in the provision of services: unstable financial resources and management, insufficient human resources and capacity of service providers, restricted outpatient services, the lack of a functional referral system, overcrowding, inadequate individual consultation time, long-waiting hours, finite opening days and hours and poor setting of infrastructure, resulting in lack of privacy.Research limitations/implicationsIn the absence of similar studies in Myanmar, findings could not be placed in the context of the national literature for comparison. Further, the study involved a limited number of respondents, which may have affected the findings.Originality/valueAlthough the challenges revealed were not uncommon in mental health services in developing countries, this study focused on a specific model of mental health care integrated into general healthcare settings in Myanmar. The findings offer a benchmark on efforts to develop decentralized mental health services in Myanmar and provide input for future in-depth studies.

Readiness of Primary Health Care Diagnostic Laboratory Services to Support UHC Programme in Kenya: A Case Study of Three Counties

Medical diagnostic laboratories have always played a significant role in determining clinical decisions. Given that laboratory diagnosis accounts for up to 70% of all medical decisions, reliable laboratory services is therefore critical to basic clinical care and universal healthcare coverage (UHC) programme. Apparently, a pilot UHC programme in four counties ahead of nationwide roll-out was being tested in Kenya from December 2018 to December 2019. Significantly, a reliable laboratory diagnostic service also support a sustainable functional referral system. However, in majority of low to middle income countries (LMICs) and through-out sub-Saharan Africa including Kenya, common infrastructural, technical and human resource deficiencies are endemic, consequently impacting on the coverage of services, quality, availability, affordability and accessibility of diagnostic tests as well as their ability to provide basic clinical care. For that reason, studies to determine the current status of laboratory diagnostic services, especially at the primary health care (PHC), coverage and their readiness to provide basic clinical care as well as in supporting UHC. The purpose of this pilot descriptive study was to investigate the status and readiness of laboratory diagnostic services in three counties in Kenya to support UHC at a resource-limited PHC setting. By use of structured, pretested questionnaires, general observations and key informant interviews, the study-specific information was obtained from participants. The data was analyzed using SPSS statistical package, interpreted, summarized and presented in tables and bar graphs. Based on the WHO-defined three categories of essential diagnostic list (EDL) for UHC at PHC, all the general basic tests were available in the sampled facilities. However, for the disease-specific and infectious diseases-specific tests there were major gaps in their availability. In addition to common infrastructural, technical, human resource deficiencies, only in 3% of the facilities, the more advanced, molecular-based disease-specific and infectious diseases-specific tests were available. This indicated low readiness to provide reliable basic clinical care and to support of UHC programme implementation at PHC level. Therefore, building of capacities of these services at PHC will have a direct impact not only in the diagnosis, treatment and prevention of diseases but also help in the successful up-scaling nationwide of the UHC programme, hence assisting in attainment of the ‘Big Four’ agenda of UHC, United Nations (UNs) sustainable development goals (SDG) number three (3) on ensuring health for all and promoting well-being for all ages, and the Kenya’s Vision 2030 economic blue print.

Organisation of primary health care systems in low- and middle-income countries: review of evidence on what works and why in the Asia-Pacific region.

IntroductionThis paper synthesises evidence on the organisation of primary health care (PHC) service delivery in low-income and middle-income countries (LMICs) in the Asia Pacific and identifies evidence of effective approaches and pathways of impact in this region.MethodsWe developed a conceptual framework describing key inputs and outcomes of PHC as the basis of a systematic review. We searched exclusively for intervention studies from LMICs of the Asia-Pacific region in an effort to identify ‘what works’ to improve the coverage, quality, efficiency, equity and responsiveness of PHC. We conducted a narrative synthesis to identify key characteristics of successful interventions.ResultsFrom an initial list of 3001 articles, we selected 153 for full-text review and included 111. We found evidence on the impact of non-physician health workers (NPHWs) on coverage and quality of care, though better integration with other PHC services is needed. Community-based services are most effective when well integrated through functional referral systems and supportive supervision arrangements, and have a reliable supply of medicines. Many studies point to the importance of community engagement in improving service demand. Few studies adopted a ‘systems’ lens or adequately considered long-term costs or implementation challenges.ConclusionBased on our findings, we suggest five areas where more practical knowledge and guidance is needed to support PHC systems strengthening: (1) NPHW workforce development; (2) integrating non-communicable disease prevention and control into the basic package of care; (3) building managerial capacity; (4) institutionalising community engagement; (5) modernising PHC information systems.

Time to diagnosis, socioeconomic and clinical features of patients with congenital heart diseases in a teaching hospital in Nigeria

Background: Studies have shown that there is an increase in the risk of congenital heart defects (CHD) in the lower socioeconomic classes. A structured and functional referral system is key to effective health care delivery. In Nigeria, there are three tiers of health care but poor referral system has resulted in high patient burden at the tertiary hospitals. The study aimed to describe socioeconomic, clinical features, and time to diagnosis of patients with CHD in a teaching hospital in Nigeria. Methods: A cross-sectional and descriptive study, carried out at the Lagos State University Teaching Hospital (LASUTH), as part of a large study from April 2008 to March 2012. A structured questionnaire was used after obtaining an informed consent. History and physical examinations were performed in all patients with features suggestive of CHD. Echocardiography diagnosis of CHD was made by a Paediatric cardiologist. Relationship between duration of illness prior to diagnosis and social classification of the caregivers was evaluated. Analysis was done using Microsoft Excel statistical software supplemented by MegaStat statistical package. Probability values less than 0.05 were considered statistically significant. Results: A total of 300 patients with structural heart disease participated in the study. The age range was 2 days to 35 years with a mean ± SD of 32.50±48.06 months. About 15% of the subjects presented to the tertiary centre without referral. Fast breathing was the most common presenting complaints (57%) followed by cough (33%). Up to 70% presented more than a year after the onset of illness. There was no statistically significance difference in the various social groups in the duration of illness before presentation (P=0.58). Conclusions: There is a need to develop an educational program to increase awareness on the symptoms suggestive of congenital heart disease and importance of early presentation. There is also a need to develop a referral chain among health system in the region.

Referral system in Iran's health sector and world's leading countries

Referral system is a common and important component of Primary Health Care (PHC) which is usually used for integrating PHC and specialty care settings. This study aimed to identify world's successful referral system's key elements, capabilities and comparison with Iran's existing referral system. We searched electronic data bases including ProQuest, Scopus, Emerald, Web of Knowledge, Springer, Science direct, PubMed and Google Scholar search engines. We also searched Iranian SID, IranMedex, Medlib and IRANDOC data bases. Terms of referral system, referral model, referral project, consultation, health system, health service and medical care were used. We conducted a hand search for reference lists of relevant papers. A predefined inclusion and exclusion criteria were used for assessing the quality of papers which were checked by two reviewers. We identified 5300 initial articles of which 28 articles met the inclusion criteria. Functional and relatively successful referral systems belonged to countries such as UK, Denmark, Finland, Norway, the Netherlands, Australia, New Zealand, Canada, and the United States. Effective referral systems had key functions and capabilities: using clear and agreed upon referral guidelines, structured referral templates, Incorporation of referral process into electronic patient records, centrally referral triage and referral tracking system. Iran's referral system lacks these functionalities. Current referral system of Iran was compared with successful referral evidences in terms of key features and elements. Referral systems have been established as a small and localized manner. Electronic referral system has been emerged in developed countries as a dominant modality. Key features of functional referral systems were severely neglected in Iran's health referral system. Political support and further attention to sociotechnical conditions are recommended.

Midwifery 2030: a woman’s pathway to health. What does this mean?

The 2014 State of the World’s Midwifery report included a new framework for the provision of woman-centred sexual, reproductive, maternal, newborn and adolescent health care, known as the Midwifery2030 Pathway. The Pathway was designed to apply in all settings (high-, middle- and low-income countries, and in any type of health system). In this paper, we describe the process of developing the Midwifery2030 Pathway and explain the meaning of its different components, with a view to assisting countries with its implementation.The Pathway was developed by a process of consultation with an international group of midwifery experts. It considers four stages of a woman’s reproductive life: (1) pre-pregnancy, (2) pregnancy, (3) labour and birth, and (4) postnatal, and describes the care that women and adolescents need at each stage. Underpinning these four stages are ten foundations, which describe the systems, services, workforce and information that need to be in place in order to turn the Pathway from a vision into a reality. These foundations include: the policy and working environment in which the midwifery workforce operates, the effective coverage of sexual, reproductive, maternal, newborn and adolescent services (i.e. going beyond availability and ensuring accessibility, acceptability and high quality), financing mechanisms, collaboration between different sectors and different levels of the health system, a focus on primary care nested within a functional referral system when needed, pre- and in-service education for the workforce, effective regulation of midwifery and strengthened leadership from professional associations. Strengthening of all of these foundations will enable countries to turn the Pathway from a vision into reality.