A GUIDE FOR ESTABLISHING REFERRAL MECHANISM IN URBAN HEALTH SYSTEM OF INDIA

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TABLE OF CONTENTS

PU R POSE OF T HE TOO LK I T .................................................................................................................................... 3

KE Y TER M S AND DEF I N IT IO NS .............................................................................................................................. 3

SEC TI ON I : BA CK G RO U ND ....................................................................................................................................... 5

REFERRAL IN HEALTH SYSTEMS ................................................................................................................................. 5

COMPONENTS OF A REFERRAL SYSTEM ................................................................................................................... 5

THE GLOBAL SCENARIO .............................................................................................................................................. 6

NEED FOR A UNIFIED REFERRAL SYSTEM IN INDIA: ................................................................................................. 7

CURRENT STATUS OF REFERRAL MECHANISMS IN INDIA ....................................................................................... 8

RATIONALE, BENEFITS AND OBJECTIVES .................................................................................................................. 9

Se ct i on I I : TC I HC ’s ROL E IN T HE RE FE RRA L ME CH AN IS M ........................................................................ 10

TCIHC PROJECT BACKGROUND ................................................................................................................................ 10

ROLE OF THE TCHIC TEAM ........................................................................................................................................ 10

ADAPTATION AND EXPANSION OF THE REFERRAL MODEL BY TCIHC ................................................................. 11

SEC TI ON I I I : GE TT IN G S TA RTE D ......................................................................................................................... 12

DEFINING THE REFERRAL PROCESS AND PATHWAY ............................................................................................. 12

INSTRUCTIONS FOR ESTABLISHING A REFERRAL MECHANISM ........................................................................... 13

SECTION IV: COMPONENTS TO THE PROCESS OF INITIATION OF A REFERRAL MECHANISM ............................... 14

1. CAPACITY BUILDING OF THE HEALTH SYSTEM: OWNERSHIP OF THE REFERRAL MECHANISM BY LOCAL GOVERNMENT ............................................................................................................................................................ 14

2. REFERRAL TECHNICAL COMMITTEE – ITS COMPOSITION, ROLES AND RESPONSIBILITIES...................... 15

3. BASELINE ASSESSMENT OF EXISTING REFERRAL SYSTEMS AND FACILITY SERVICES ............................. 16

4. DEFINING THE REFERRAL NETWORK, AND LINKING UPHCS TO HIGHER FACILITIES ................................. 17

5. REFERRAL DIRECTORY AND ITS COMPONENTS ............................................................................................ 18

6. GUIDANCE NOTE FOR DEVELOPING REFERRAL PROTOCOLS/HEALTH CARE PATHWAYS AND PILOTING OF TOOLS .................................................................................................................................................................... 20

7. CAPACITY BUILDING OF THE HEALTH SYSTEM: TRAINING STAFF ............................................................... 21

8. MONITORING AND EVALUATION .................................................................................................................... 22

9. SUGGESTION: USE OF TECHNOLOGY TO IMPROVE IMPLEMENTATION OF THE REFERRAL MECHANISM 24

10. INTER-PHASE MEETINGS ON REFERRAL MECHANISM IMPLEMENTATION ............................................ 24

11. PARTNERSHIP WITH MEDICAL COLLEGES AND NURSING INSTITUTIONS .............................................. 25

12. DEVELOPING REFERRAL CHAMPIONS IN DISTRICTS................................................................................. 26

SEC TI ON I V: CON CL US I ON .................................................................................................................................... 27

REF ER ENC ES ............................................................................................................................................................... 29

1. Referral Systems - a summary of key processes to guide health services managers ............................................ 29

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ANNE X URE ................................................................................................................................................................... 30

PURPOSE OF THE TOOLKIT

This toolkit is designed from the first-hand experience of The Challenge Initiative for Healthy Cities (TCIHC)

team in successfully establishing a referral mechanism in Indore city, Madhya Pradesh. It provides a

comprehensive understanding of the need and usefulness of a referral mechanism and suggests best

practices for its initiation. The toolkit focuses primarily on how a referral mechanism can strengthen health

provision in urban settings, where the primary level is comparatively underutilized and higher healthcare

facilities are overburdened. TCIHC’s implementation process to establish the referral mechanism is

explained carefully and step-by-step in this toolkit. The aim of the toolkit is to strengthen the existing

referral system within the government set up. The tool should be used as a guidance document and is meant

to aid the design, delivery and evaluation of a referral mechanism but it is NOT A POLICY DOCUMENT.

KEY TERMS AND DEFINITIONS

1. REFERRAL: A process in which a health worker at one level of the health system, having insufficient

resources (e.g. drugs, equipment, skills), manages a clinical condition, seeks the assistance of a better

or differently resourced facility at the same or higher level to assist in or take over the management of

a client’s case.

2. INITIATING/REFERRING FACILITY): The facility (e.g. organization, clinic) that starts the referral

process. This is the point in the referral process where an outward referral is prepared to communicate

the client’s condition and status.

3. RECEIVING FACILITY: The facility (e.g. organization, clinic) that accepts the referred client’s case and

provides needed services.

4. INITIATING/REFERRING SERVICE: The type of service from which the referral was initiated (e.g.

family planning, antenatal care or general primary care).

5. RECEIVING SERVICE: The type of service to which the client is referred (e.g. family planning,

antenatal care or HIV testing and counseling).

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6. FACILITATED REFERRAL: Every beneficiary is referred through a specific protocol, which includes

triad of proper information transfer (referral slip, counseling); feedback & tracking (completion of

referral loop) and evidence of efforts overcoming barriers (geographical, financial etc.)

7. COUNTER-REFERRAL: The process in which clients are directly reaching the facility, then the facility

staff after providing the necessary treatment sends clients to their respective UPHCs. The UPHC staff

then completes the loop at the community level.

8. BACK REFERRAL: The process by which the receiving facility sends the client back to the initiating

facility with information about services provided there and any needed follow-up. This completes the

referral loop between the two facilities.

9. REFERRAL NETWORK: The interconnected group of service providers among which referrals are

made. Referral systems are used to integrate networks of service providers.

10. REFERRAL PROTOCOLS/HEALTH CARE PATHWAYS: For any particular clinical condition or

service, each beneficiary has to go through multiple stages of management. Each stage needs him/her

to pass through a series of health facilities and health providers. So, in a particular referral system for a

particular clinical condition, the referral protocols or health care pathway of that condition gives

beneficiary / health provider a predefined map of stages of clinical condition mentioning what, where,

whom, and how to manage it in spectrum of illness to health and well-being.

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SECTION I: BACKGROUND

REFERRAL IN HEALTH SYSTEMS

A referral can be defined as a process in which a health worker at one level of the health system, having

insufficient resources (drugs, equipment, skills), manages a clinical condition, and seeks the assistance of a

better or differently resourced facility at the same or higher level to assist in or take over the management

of, the client’s case (1). Key reasons for deciding to refer either an emergency or routine case include:

1. Seeking expert opinion regarding the client

2. Seeking additional or different services for the client

3. Seeking admission and management of the client

4. Seeking use of diagnostic and therapeutic tools

The health system in India is hierarchical, like most others in the world, starting with primary care to

secondary care facilities and ending at the highest level of care. This consists of tertiary level facilities that

provide highly specialized services. However, in most developing countries, health referral systems across

the various levels of care are weak at present, affecting the overall performance of the health system (2).

An active referral system ensures a handy relationship between every level of health care delivery system

i.e. primary, secondary and tertiary health care. It also ensures optimal utilization of health services as it

connects the populations with service locations which they may chose on preference or proximity or both.

To create a good referral system, it is important to consider the following points (3):

1. Patients should be given optimal care at the right level, right time and right cost

2. Optimal and cost-efficient utilization of health care systems

3. Optimal and appropriate utilization of specialist services for patients in need

4. Optimal utilization of primary health care services

COMPONENTS OF A REFERRAL SYSTEM

A referral system at all levels of the healthcare can facilitate the flow of patient referrals among government

and private healthcare providers. When implemented efficiently, referral systems contribute to high

standards of care and optimal use of medical services and resources. It is a critical component of quality

healthcare as a functioning referral system both decreases costs and improves patients’ health. An optimal

referral process should be in place for the effectiveness, safety and efficiency of high standard medical care.

A referral process is an inherently complex activity that has two aspects - Referral Decision and Referral

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Communication. A Referral Decision is a clinical decision made by doctors or other healthcare providers on

whether a referral is needed, and at what level the referral must be made. Referral Communication deals

with interactions between referring and referred-to providers once a referral decision is made. To have an

efficient referral mechanism, it is important to prioritize both components and the implementation of

effective healthcare provision with a government health set up (4).

THE GLOBAL SCENARIO

In developed countries, where healthcare provision is primarily insurance driven, referral systems are quite

systematic and clearly defined. On the other hand, in countries, where the health system is weak, and little

to no referral system framework exist, development of a referral system happens at a slow pace . The table

given below illustrates the difference in referral systems in developed and developing countries.

Referral system in Developed Countries

Referral system in Developing Countries

Healthcare provision is mostly insurance driven

Healthcare provision is largely dependent on either government funding or out of patients’ pockets

In most countries, people use public healthcare facilities instead of private healthcare, making regulation comparatively easy

In most countries, people have near equal choice between public and private healthcare services, hence regulation becomes difficult

General Practitioner (GP) is considered as a gatekeeper in the referral pathway. Patient cannot access higher facilities without the letter of referral from their registered GP

Although Medical Officers at Primary Health Centres are responsible for referrals, direct access to higher facilities is still permitted and weakens referral pathway

Referral guidelines are clearly laid out, ensuring efficient implementation

Although referral guidelines exist, implementation is weak due to various factors

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NEED FOR A UNIFIED REFERRAL SYSTEM IN INDIA:

The referral system in rural India is formally structured. A Primary Health Centre with a qualified Medical

Officer is the first point of contact for a community. The Medical Officer can refer cases to rural hospitals as

per the medical requirement. Cases from the rural hospital can be referred to the district hospital and above

as per the requirement. Although the implementation of this mechanism is weak in rural areas, it is

noteworthy that the system is clearly laid out for the rural health system.

Unlike rural India, the urban health system is a recent development in the Indian health system and is still at

a preliminary stage of development. There are several differences in urban and rural context that need to be

considered while strengthening the referral system in urban areas. First, unlike in rural areas, there is no

uniform governing body in place in urban areas. For example, in a couple of states the municipal corporation

and the local governing body are responsible for health in urban cities whereas in some states, health is a

shared responsibility between the state and local body. Furthermore, other large stakeholders such as the

army or railway companies provide health services as well. The presence of so many options dilutes the

possible route of referral as individuals have access to any of these services. Unlike rural areas, the lack of

geographic demarcation in urban areas makes it difficult to distribute the community across primary health

DATA SHOWING THE UTILIZATION OF HEALTHCARE FACILITIES

1. In developing countries, less than 40%

patients seeking care at the tertiary

level facilities were being referred

from the lower level facilities.

2. More than 60% patients directly

access higher level facilities on their

own.

3. More than 50% of population that is

being catered at the tertiary level

could be treated optimally at the

lower level facility

Most health initiatives focus on

behaviour change at the

community level and generate

demand for seeking care.

Referral as a mechanism

focuses on behaviour change of

care givers and care managers

and ensures patient-centered,

respectful, safe, appropriate

and quality care.

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centers. Implementation of any health activity is also quite challenging due to tangible social norms,

stratification of community groups and other underlying social characteristics in urban areas. The figure

below illustrates the various levels of health service facilities and their utilization without a proper referral

pathway.

CURRENT STATUS OF REFERRAL MECHANISMS IN INDIA

There are several initiatives being implemented in parts of the country. Kerala state created guidelines for

referrals especially designed for health facilities working under the Government of Kerala. The states of

Jammu and Kashmir, have a similar initiative, where the Department of Health Administration from Sheri-

Kashmir Institute of Medical Sciences has developed a proposal for referral policy for Public Health Facilities

for Jammu and Kashmir. The development of this policy seeks to address shortcomings of the existing

referral system in the Health Care Institutions. TCIHC has taken initiative to strengthen the referral

mechanism in the Public Healthcare system by providing technical guidance and support to the existing

healthcare system to ensure its long-term sustainability.

In India, the National Health Policy (NHP) 2017 and the National Urban Health Mission (NUHM) framework

2013 are the primary drivers of policy. Both emphasize the establishment of an appropriate referral

mechanism as one of the key components to deliver a continuum of care in urban areas. This

acknowledgement signifies the enabling environment to establish a referral system in the country, which

must be realized and acted on. There is an urgent need to prioritize the primary health care needs of the

urban population. The special focus should be on poor populations living in listed and unlisted slums, other

vulnerable populations such as homeless individuals, rag-pickers, street children, rickshaw pullers,

construction workers, sex workers and temporary migrants. The communities in these pockets of the urban

population are the primary users of government health systems in urban areas. As the public urban health

system is still in the development stage, there is a need to use existing healthcare facilities efficiently to

District Hospital

Sub District

Hospital

Secondary

Hospital

Primary Health

Centre

Access to any health facility for any

minor condition

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cater to an increasing population. With a functional referral mechanism in place, primary, secondary and

tertiary level health facilities will be used more efficiently, and specific services can be prioritized. The

effective implementation of a referral system in healthcare will ensure satisfaction from both sides. For

providers, it will ensure the satisfaction of providing appropriate care at the appropriate facility. For patients,

it will give confidence to reach out to the first point of contact for the right care at the right time and right

place.

RATIONALE, BENEFITS AND OBJECTIVES

While the most vulnerable and poor communities of urban populations are the target population for

improvements made to the urban public healthcare system, the rationale for implementing an effective

referral mechanism, is far wider. A referral mechanism can support quality health service delivery to entire

urban populations in India in the following ways:

1. Coordination and standardization of referral services

2. Continuity of care across the different levels of care

3. Cost-effectiveness of health services provided to the community

4. Promotion of universal coverage and equity in provision of health services

5. Healthcare planning based on performance monitoring of the referral system

A well-functioning referral system will have the following benefits:

1. Maximize efficiency of the health system by ensuring appropriate use of health services

2. Strengthen lower-level facilities and improve capacity for decision-making by health workers at all

levels

3. Create opportunities for balanced distribution of funds, services, and human resources

4. Promote linkages across the different levels of care and between public and private entities

5. Ensure that care is provided at the lowest possible cost

A referral mechanism has the following objectives:

1. Increase the use of services at lower levels of the health care system

2. Reduce self-referral to the higher levels of care

3. Develop service providers’ capacity to offer services and appropriately refer at each level of the

health care system

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4. Improve the health system’s ability to transfer patients, patient parameters, specimens and

expertise between the different levels of the health care system.

5. Improve supportive supervision, thereby ensuring up-to-date management practices are used

across the country

6. Improve referral performance monitoring and coordination and referral feedback information

systems including procedures for counter-referral

7. Strengthen outreach systems for provision of referral health services to marginalized and vulnerable

populations

Section II: TCIHC’s ROLE IN THE REFERRAL MECHANISM

TCIHC PROJECT BACKGROUND

To strengthen the maternal and child health services in urban areas, a three-year project, “TCIHC”, was

initiated in India. The program is supported by the United States Agency for International Development

(USAID) through the Maternal and Child Survival Program (MCSP), and the Bill & Melinda Gates Foundation

(BMGF), through Gates Institute (GI). The aim of this project is to strengthen city-level health systems to

improve access to and demand for family planning (FP) and maternal, newborn and child health care

(MNCH), information, products and services to reduce preventable maternal, newborn and child deaths

among the urban poor in 31 cities in three states in India.

TCIHC puts cities in the driver’s seat under a “demand driven” model to ensure sustainable impact and

unlock public and private resources to implement proven health solutions for the urban poor.

ROLE OF THE TCHIC TEAM

1. To achieve the long-term objectives of TCIHC, the project team is providing technical support to

local governing bodies who are positioned to implement the referral mechanism.

2. The TCIHC team’s role is to strengthen the capacity of existing healthcare staff to implement the

referral mechanism without additional resources to ensure long-term sustainability of the public

healthcare system.

3. The following flowchart shows activities which the TCIHC team carried out to initiate the

comprehensive referral mechanism in their project cities.

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ADAPTATION AND EXPANSION OF THE REFERRAL MODEL BY TCIHC

PUNE CITY REFERRAL MODEL

The referral mechanism was established in collaboration with the Municipal Corporation of Pune city.

A successful referral mechanism was established in Pune city through a series of steps such as situation analysis on MNH health, a mapping exercise of all facilities, training of staff to understand the process of referral and monitoring and evaluation.

The following learnings arose from the Pune city model

o Referral protocols and tools

o Facility specific referral plans

o Interface between initiating &

receiving facilities, managers and

administrators

ROLE OF TCIHC IN THE ESTABLISHMENT OF THE

REFERRAL MECHANISM

Learning from Pune City Referral Model

Adaptation and expansion of the Referral

Model

Introduction of community referral in

addition to adaptation of facility referral

Piloting of an adapted referral model in

Indore city of Madhya Pradesh

Expansion of referral mechanism by

introducing the referral toolkit

REFERRAL MECHANISM

PILOTED IN INDORE CITY

Adaptation of facility

level referral mechanism

Monitoring - Evaluation and

improvisation mechanism

Feedback mechanism strengthened through back referral and counter referral

Customization of

protocols and tools

Introduction of

community level referral

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SECTION III: GETTING STARTED

DEFINING THE REFERRAL PROCESS AND PATHWAY

The Government healthcare system has defined healthcare facilities at each level including in the urban

areas. Tertiary care, in the form of a hospital, is available in cities to provide specialized care, while secondary

care hospitals are meant to provide clinical care, such as obstetric care. The Urban Primary Health Centers

(UPHC)s are developed at the primary level with an aim to provide preventive and basic curative services.

Despite the supposed proximity of the urban poor to urban health facilities, their access is severely

restricted. This is on account of the facilities being “crowded out” due to the inadequacy of the urban public

health delivery system. A weak referral system also limits the access of urban poor to health care services.

To rule service delivery weakness, the following referral pathway, described step-by-step below can be

effective:

ORGANIZING THE SYSTEM FOR REFERRAL

1. All health facilities should be informed, and the capacities of staff built in preparation for

implementation of the referral mechanism.

2. A two-way referral system shall be implemented in all facilities. In this regard, referral can be from;

a) Community to UPHC/Secondary/Tertiary facility b) UPHC to Secondary/Tertiary facility c)

Secondary to tertiary facility and vice versa for each.

ON-SITE REFERRAL PROCESS IN THE FIELD

1. A completed referral slip shall accompany any patient who is referred either from the community or

from the facility.

2. A copy of the referral slip shall be kept with referring facility or with community worker.

3. Necessary instructions shall also be given to the patient and his/her facility.

COMMUNICATION AND TRANSPORTATION

1. When possible, the receiving facility shall be informed about the referral patient.

2. If possible, especially from lower facility to higher facility, the referral patient shall be transferred

using an ambulance or other appropriate means of transportation.

3. In higher facilities, a staff member will be dedicated to managing all communication with other

facilities regarding referrals.

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4. In counter referrals, the lower facility shall be informed about the appropriate treatment for which

the patient is being referred.

FEEDBACK

1. Feedback regarding the treatment received shall be sent to the referring facility or the community

worker.

2. The referral slip with detailed feedback shall be given to the patient who will be encouraged to

return to the referring facility/community health worker with their feedback, leading to the final

step of;

INSTRUCTIONS FOR ESTABLISHING A REFERRAL MECHANISM

To implement the referral mechanism, the following steps can be used as a guide. These steps were followed

while establishing the referral mechanism in Indore city. The activities can be adapted as per the city’s

specific situation and need.

Step I: Ownership of referral mechanism by local government

Step II: Constitution of a referral technical committee

Step III: Baseline Assessment of Facilities

Step IV: Defining the referral network and linking UPHCs to higher facilities

Step V: Customization of referral tools and a referral directory

Step VI: Piloting of referral tools

Step I: Ownership of referral mechanism by local government

Step VII: Training of community level workers and staff at the facility level

Step VIII: Implementation of the referral mechanism, with direct support

Step X: Data generation and monitoring of referral mechanism

Step IX: Routine meetings between facility staff and community workers

Step XI: Feedback mechanism and quality improvement

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SECTION IV: COMPONENTS TO THE PROCESS OF INITIATION OF A

REFERRAL MECHANISM

1. CAPACITY BUILDING OF THE HEALTH SYSTEM: OWNERSHIP OF THE REFERRAL

MECHANISM BY LOCAL GOVERNMENT

Background and need:

The first and foremost essential element of establishing a referral mechanism is to place roots within the

existing health system. As mentioned in the first section, a referral pathway already exists in rural areas, but

is missing in urban India. Thus, the first step of establishing a referral mechanism is to liaison with the city

health management unit and communicate the need for a similar system in urban areas. Primarily, two types

of capacity building activities are essential to root and initiate the referral mechanism in regular systems of

health service delivery. These are System Strengthening and Thematic Strengthening.

In System Strengthening, program managers primarily at the city level have to be trained to understand

what a referral system is, what the components of referral are, what the importance of initiating a referral

system is, and what the process for initiation in existing scenarios includes. After initial meetings with

district officials, a oneto twodays workshop should be arranged with all program managers. During the

workshop, the importance and need of a referral mechanism should be emphasized, as well as the steps of

implementation, such as, baseline assessment of facilities to understand their readiness to provide services,

a quick survey of community needs, geographic mapping of facilities to understand the existing reach of

each facility, creating referral loops and a referral directory, analyzing the type of health services offered at

each facility along with other points.

Thematic Strengthening refers to the training of medical and technical staff at each facility so that facilities

will be ready for increased demand as a result of referral process. Primarily, adhering to specific protocols

for treatment and learning about referral protocols will be discussed during the training. Details of this

training will be explained in the training component.

Process:

1. Arrange a meeting with the government officials to discuss the need, process and anticipated

impact of referral mechanism.

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2. Present Evidence of Success of the Referral Mechanism, such as, the impact of the referral

mechanism implemented in Indore city. If possible, invite a representative from Indore city to share

their experiences.

3. Discuss the detailed plan of action for establishing the referral mechanism in the city. This may

include arranging further workshops for all district level program managers where a plan of action

for rolling out the referral mechanism should be clear.

4. Regular follow ups with the city program management unit (CPMU) to ensure timely issuance of

letters and instructions.

2. REFERRAL TECHNICAL COMMITTEE – ITS COMPOSITION, ROLES AND

RESPONSIBILITIES

Background and Need:

Technical inputs from a spectrum of experts is as an essential element for the establishment of any

mechanism in any system. The constitution of a technical committee to provide inputs for the referral

mechanism’s initiation should be completed simultaneously as with liaisons with government stakeholders.

Composition of the Referral Technical Committee:

1. Representatives from government offices such as the Urban Health and District RCH Offices

2. Administrative officials

3. External experts from private health institutions

4. Representatives from medical colleges

5. Any other relevant officials could be invited to participate in the committee as per requirement.

Roles and responsibilities:

The primary responsibilities of this committee will include but are not limited to:

1. Providing technical inputs while adapting the referral tools

2. Technical inputs in referral slips.

3. Providing insights while creating the referral directory and referral route, referral protocols, and

health care pathways based on prior experience

4. Any other technical support required during the process of establishing the referral mechanism.

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Process:

1. List the prime organizations that work in the city’s health sector

2. The short-listed representatives from these institutions shall be approached by taking prior

appointment.

3. After seeking initial permission, the inception meeting with these representatives shall be

organized. The purpose of the meeting shall be explained and the impact of the referral system in

the previous project cities shall be shown to the participants.

4. The committee shall be constituted after final approval from these representatives and the primary

responsibility shall be explained to the members of the committee.

5. After identifying and forming a committee of experts, regular meetings shall be held with the

committee to discuss progress. Any issues arising during the process shall be put forward in these

meetings and technical advice shall be sought from the members.

3. BASELINE ASSESSMENT OF EXISTING REFERRAL SYSTEMS AND FACILITY

SERVICES

Background and need

Baseline assessment of the status of referral systems,

existing referral protocols and processes under various

thematic groups vis-a-vis health facilities will be helpful to

assess the basic health needs of communities, the current

trend of health facility utilization, to assess the existing

infrastructure, staff, supply of equipment and drugs, and

current patient referral practices in emergencies.

Once the technical committee is formulated, the

immediate need to initiate the referral process is to assess

the present situation of health facilities of cities. The

baseline assessment of the facilities shall be the next step.

Aim:

The aim of the assessment is to check functioning facilities, available systems of referral and basic

requirements needed to improve the functioning of facilities.

BASELINE ASSESSMENT IN GWALIOR

CITY

1. The assessment was carried out in all UPHCs,

civil dispensaries and Maternity homes.

2. Except for frontline workers, particularly

ANMs, facility staff did not know the wards

to be covered, and the total population to be

covered by their facility.

3. Most of the primary health facilities did not

have telephones, a preliminary requirement

for referral.

4. Facilities lacked clinical and facility

protocols, service directories, and referral

review mechanisms, while very few facilities

had referral slips.

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Process:

1. Data collection tools shall be developed for the baseline assessment. Components such as the

availability of infrastructure, staff, essential drugs and supplies, and accessibility of the facility from

the community should be incorporated in the tool.

2. The baseline assessment tool used in Gwalior city can be customized and used as per specific needs

of the city. For reference, the report of baseline assessment carried out in Gwalior city is also

provided in the annexure.

3. All UPHCs, secondary hospitals and tertiary hospitals shall be assessed during the baseline

assessment.

4. A meeting with government partners shall be arranged to discuss the requirements so that the

referral system can be initiated.

4. DEFINING THE REFERRAL NETWORK, AND LINKING UPHCS TO HIGHER

FACILITIES

Background and need:

As mentioned in the earlier section, the urban health system is not as well developed as the rural health

system. In order to create an effective referral mechanism, it is of utmost importance that all health facilities

from community to primary to secondary and to higher level of facilities should be linked through a formal

process.

City level program managers shall be responsible to create the referral network where each UPHC should

be linked with nearest secondary health facility. This step is essential as the UPHC staff will know the

immediate secondary facility where the case should be referred for further treatment.

Once referral networks are mapped, the thematic teams (maternal health, child heath, family planning etc.)

can develop referral protocols or health care pathways for their respective clinical condition.

Process:

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1. While the baseline assessment is being carried out, another activity shall be conducted to define

zones and the levels of referrals, and to map the UPHCs and secondary facilities in each zone.

2. Defining zones is required to create a referral loop of UPHC to secondary facility. Once the zones or

the wards are finalized, the next activity is to list the UPHCs, secondary and tertiary level facilities.

3. Once the list is ready, the final referral loop will indicate which UPHC will refer a case to which

secondary facility. This step is important because UPHC staff, as well as community staff, will be

trained and informed on how and where the patient can be referred.

4. The community staff along with secondary facility staff shall also be trained and informed about the

names of UPHCs which the facility will cater to make back referrals easy.

5. While linking the UPHCs in each zone to secondary facilities, the following points should be kept in

mind:

a. Accessibility: distance from the UPHC

b. Availability: of required services and staff

c. The technical committee shall be responsible for finalizing the referral protocols or health care

pathways.

5. REFERRAL DIRECTORY AND ITS

COMPONENTS

Background and need:

In developed countries, even in strong and well-established

health care systems, a single health facility can rarely

deliver all the services which patients need. Thus, a well-

established referral system along with an updated referral

directory is needed globally. The need is higher in countries

like India as management of patient loads on higher level

facilities, prioritization of treatment requirements at each

level of health facility and appropriate use of primary health

services, especially in urban areas, are the additional facets

of a referral mechanism. Well-equipped primary, secondary

and tertiary health facilities, appropriate and regular supply

of drugs and equipment, trained health staff proportionate to the population where the facility is located,

regular training of staff for referral services and a regularly updated referral service directory are some of

LEVEL OF REFERRALS IN INDORE CITY

Level -2: Community members including ASHAs

and MAS

Level -1: Universal Health and Nutrition Days

(UHND)

Level 0: Primary level – UPHCs and Civil

Dispensaries

Level Plus 1: Maternity hospitals conducting

normal deliveries with Basic Emergency

Obstetric Care (BEmOC)

Level Plus 2: Maternity Hospitals conducting

Cesarean sections and emergency care services

for children

Level Plus 3: Specialized and super-specialty

services at medical college hospitals

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the essential components of the referral system. These components are interdependent as, if even one of

the components is not strengthened, the whole system of referral mechanism cannot be implemented.

Referral Service Directory and its importance:

Referral service directory is the list of all health facilities including public and private facilities that can

provide diagnostic and specialist services. Such a directory can facilitate a search for the most appropriate

service provider for a referral. For example, in high risk delivery situations, if a referral directory is available

at the Urban Primary Health Centre (UPHC), the patient can immediately be referred to a nearest facility

that has specialized care. As the directory includes contact information for these facilities, in emergency

situations, the facilities can immediately be informed of referred cases. Thus, prompt treatment can be

initiated, eliminating the chances of facility delay, which in turn improve the health outcome indicators.

Process:

1. Once the referral network is created, the referral directory should be made for each city.

2. Data required for creating this directory should be collected from each facility.

3. The health staff at each facility should be trained to use the referral directory.

4. Each health facility including UPHCs and all community staff, including ASHA workers and ANMs

should be provided with the directory so that they can refer patient based on the need and

availability of services to avoid possible facility delays.

5. The referral directory should include the following details about facilities:

a. Name of facility

b. Address

c. Type of facility (Public or Private)

d. Available Specialist services

e. Contact information of facility

ADAPTATION AND REVISION OF REFERRAL TOOLS IN INDORE

While using referral tools at the community level, it was observed that there was a lack of back-referral

communications in that the Medical Officer at the UPHC was not informed whether a patient reached the

secondary facility or details of treatment received. The referral slip was thus revised to add the back-referral

details. Similarly, all the symptoms related to MNH care and FP were added in simple language for ASHAs to refer.

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6. GUIDANCE NOTE FOR DEVELOPING REFERRAL PROTOCOLS/HEALTH CARE

PATHWAYS AND PILOTING OF TOOLS

Background and need:

The use of protocols is important to maintain the uniformity and successful implementation of the referral

mechanism. The process of developing referral slips should be initiated immediately after the baseline

assessment. A separate section on the use of referral protocols should be arranged during the training of

community and facility staff members. Referral protocols are not only important to initiate the treatment

process for a patient, but it is also important to document the treatment provided.

Types of referral protocols:

Three types of referral tools are needed for implementation of the referral mechanism starting at

community level.

1. Community level referral tools: To be used by ASHA and ANM

2. Facility referral at the primary level: To be used by MO at UPHC

3. Facility referral at the secondary level: To be used at secondary level facility

Process:

1. The community referral slips will be used by ASHA/ANMs at the community level. Patients will be

identified during house visits or during UHNDs.

2. Based on the severity of the patient’s condition, ASHA/ANMs can refer them to UPHCs or secondary

facilities.

3. Facility level referral slips are to be used at the UPHC and/or at the secondary facility.

4. The referral slips can be adapted from the annexure given in this tool-kit.

5. The slips should be developed as simple and short as possible while adapting to specific needs of the

city.

6. Adapted referral slips shall be presented in front of the technical committee for their feedback.

7. Once the referral slips are finalized and approved by the technical committee and local government

stakeholders, piloting should be done at the community and facility levels.

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8. The slips shall be used by community workers and the staff.

9. Detailed discussions with staff should be carried out to document the feedback. Any changes

suggested by staff should be documented and incorporated in the slips after approval from the

technical committee.

7. CAPACITY BUILDING OF THE HEALTH SYSTEM: TRAINING STAFF

Background and need:

As mentioned in the first component of building the capacity of the health system, training health staff is

the first step towards initiating the referral mechanism. The training has two purposes. First, training is

required to orient the staff about the referral system, its components, why it is essential to implement a

referral system in the city, what the role of each staff member is in implementing the mechanism and how

it can be useful to streamline routine work. Secondly, staff should be trained to carry out each step of the

referral mechanism.

Topics covered in training sessions:

1. Introduction and purpose of training

2. Referral system and examples

3. Role of the referral mechanism in the healthcare system

4. Use of the referral system in streamlining routine work

5. The referral loop, mapping of facilities

6. Referral directory

7. Referral slips

8. How to use referral slips

9. Use of referral in facilities

10. Back referral

11. Counter referral

12. Reporting under referral mechanism

Process:

1. Zone-wise/ward trainings should be arranged for batches of ASHAs/ANMs, for Medical Officers of

UPHCs.

2. Appropriate permission to conduct staff trainings shall be obtained from the local government.

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3. Permission letters shall be issued to all facilities prior to trainings.

4. Separate training sessions shall be arranged for the staff of secondary and tertiary level facilities.

5. Training of staff from secondary level health facilities should include the development of an efficient

communication system with higher and lower level facilities.

6. In addition to the baseline training, on-field training especially of ASHA and ANMs should be

completed at the beginning of the referral system.

7. Once the training sessions have been completed, the referral mechanism should be initiated.

8. All higher facility In-Charge Officers should be informed about the process of the referral

mechanism in a meeting.

9. Frequent follow ups with UPHCs should be done to check on any challenges which community

workers and staff are facing.

10. Continuous support should be extended to troubleshoot any issues with the referral tools.

8. MONITORING AND EVALUATION

Background and need:

To have a precise picture of the implementation of the referral mechanism, and to monitor progress, a well-

defined reporting system and reporting pathway must be properly initiated. Key indicators on the initiation,

implementation and impact of referral must be initially decided to conform with the specific needs at

community, UPHC, secondary facility and city levels. Examples of such indicators are mentioned in the table

below:

INDICATORS TO MONITOR & EVALUATE IMPLEMENTATION OF A REFERRAL MECHANISM

1. Establishment of referral mechanism:

a. Status of any existing referral directory and referral loop

b. Number of training sessions conducted

c. Number of staff trained in referral process

2. Implementation of referral:

a. Number of field visits carried out

b. Number of ANC/PNC cases carrying referral slips of patients referred to the UPHC

c. Number of patients with referral slips at the referred UPHC/Secondary/Tertiary facility

3. Impact of referral:

a. Number of high risk pregnancies in patients carrying referral slips identified and referred

b. Number of high risk infants of patients carrying referral slips identified and referred

c. Number of other cases in patients carrying referral slips identified and referred

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Process:

1. Based on information collected in the referral slip, assessment indicators should be finalized, and

the data should be collected from each facility at regular intervals.

2. The reporting formats at each level, community, UPHC, secondary facility, and city levels should be

developed based off the finalized indicators.

3. These formats should be distributed among community workers and they should regularly be

trained on any updates to the format.

4. Individual reporting formats should be submitted to UPHCs during inter-phase meetings. The UPHC

medical officer or a dedicated staff member should be responsible to collate all data on referral

formats at the different levels during these inter-phase meetings at the secondary facility.

5. Final city level format should be completed at the city level.

The figure below shows how reporting data should flow from the community through city level.

Feedback mechanism to facilitate quality improvement of the referral process

Data flow from the community to higher levels

ASHA / ANM / AWW / MAS

•Point of data origination

•Performs activities

•Reports to UPHC every month

UPHC

•Collects data on work done by ASHA / ANM/ AWW / MAS

•Compiles for UPHC

•Reports to CPMU / DPMU every month

Secondary & Tertiary Facilities

•Compiles data from facility

•Transmits monthly report to CPMU /DPMU

DPMU

•Compiles data from all Levels

•Transmits monthly reports

•Transmits Quarterly report to SPMU / National

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The data collected at regular intervals should be analyzed to understand the progress and issues which arise

during implementation of the referral mechanism.

1. Based on this analysis, monthly interactions with government stakeholders and facility staff shall be

carried out to give feedback on the progress.

2. Based on feedback, points of improvement should be discussed to improve the implementation.

9. SUGGESTION: USE OF TECHNOLOGY TO IMPROVE IMPLEMENTATION OF THE

REFERRAL MECHANISM

Background and Need

An efficient referral system provides access to treatment and skills by linking different levels of care through

appropriate referral points. The medical decision to refer a patient is dependent on many factors, including,

as the skills of staff who are referring patients, the tools available for diagnosis, the availability of specialist

facilities at a given health institution, quality of care at the referral institution, cost of care at either the

referring or receiving facility, location of the facility, transportation and communication. A referral app will

be useful in improving the referral mechanism.

The app can help reduce maternal and child mortality by minimizing the time required to transfer patients

from one facility to another. The app will reduce the paperwork required for frontline workers to complete,

thereby increasing the time they are able to spend in the community. This expedited process will also

streamline patients across primary, secondary and tertiary care facilities based on their health needs,

improve utilization of UPHCs, and reduce patient loads on secondary and tertiary level facilities.

Suggested process

1. The referral app should be in line with ongoing data entry on HMIS portal of the government.

2. The information that should be filled in the app should be easy and less time consuming.

3. The app should be accessible by any android smartphone so that the healthcare worker can easily

use it.

4. The piloting of the developed app should be done at the beginning so that any changes deemed by

healthcare workers can be incorporated in the app.

10. INTER-PHASE MEETINGS ON REFERRAL MECHANISM IMPLEMENTATION

Background and Need:

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Interactive meetings with community and facility staff are referred to as inter-phase meetings. These

meetings should be held on regular intervals. Their purpose should provide regular support to

implementation of the referral mechanism, to generate reports on the progress to date, to discuss any

challenges faced by community workers and facility staff, and to improve overall output by providing regular

support to the staff.

Process:

Once the referral mechanism is initiated, monthly inter-phase meetings should be arranged where ANMs,

ASHAs and the Medical Officer of UPHCs, as well as staff from the secondary facility, shall interact to discuss

the process of referral.

1. These interactions will address the following:

a. Any limitations to the use of referral tools.

b. Any issues at the referring facility.

c. Any need for further capacity building of community workers

d. These meetings should also be used to create individual work plans for the referral process at

community level and to further monitor the individual performance of community workers.

2. These meetings can also be a platform to ensure the quality of care during referral by:

a. A completely and correctly completed referral slip

b. Transfer of patients to other facilities in well-equipped ambulances

c. Ensure the availability of required services at higher facilities before transferring

3. These monthly meetings can also be used as a platform to collect the data related to referral, to give

feedback and to discuss the areas of improvement.

4. Similar meetings can be arranged with government stakeholders to discuss the progress and

feedback of referral mechanism.

11. PARTNERSHIP WITH MEDICAL COLLEGES AND NURSING INSTITUTIONS

Background and Need:

To strengthen the health system delivery mechanism, especially in urban areas, it is important to implement

a fully comprehensive strategy. The involvement of medical colleges and nursing institutions can play a vital

role in strengthening the system. The NUHM recognizes the role of the Department of Community Medicine

in Urban Heath System Strengthening and has suggested developing a partnership. Further, the

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Community Medicine Department of Medical College has an important role to play in the provision of health

care services, referral services, outreach services, center of excellence, training center, and research &

innovation in urban health. Medical colleges can also contribute towards strengthening the health system

by providing support in the form of internships at the facilities, providing lab facilities to patients coming

from public health referrals, assisting in the regular monitoring of referral implementation and managing

the data from community level to higher facility level.

Process:

1. Identify medical or nursing colleges that are potential stakeholders in implementing the referral

system.

2. Initiate a dialogue through regular meetings with the relevant departments.

3. Discuss the responsibilities to be shared between medical colleges and nursing institutions.

4. These institutions should take on the following roles and responsibilities:

a. Generate city-specific evidence to institutionalize the referral system to address systemic health

system issues. Examples of this type of evidence are, to identify issues and solutions for self-

referral, patient perceptions on being referred to secondary or tertiary facilities, the desire for

specialist facility, and others.

b. Facilitate the development and strengthening of the city referral technical group.

c. Conduct city technical group meetings on referral involving maternal and pediatric

departments.

d. Establish systems in medical college wards to ensure appropriate referral and counter referral.

e. Provide supportive supervision and mentoring to secondary and tertiary facilities to conduct

interphase meeting with primary facilities to identify and address issues in the referral

mechanism.

f. Involve nursing colleges in the city to support community referral. Allocate UPHC areas to

nursing schools and set up a partnership between the nursing council and NUHM.

g. Develop a draft MoU between the NUHM and Medical Colleges to support Referral and Health

System strengthening at city level. The effort should be made for inclusion in the Project

Implementation Plan.

12. DEVELOPING REFERRAL CHAMPIONS IN DISTRICTS

Background and Need:

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For any new system being embedded in existing healthcare systems, it is beneficial to have demonstration

sites and staff at facilities to show the process of implementation and its impact in smaller settings. While

implementing the referral mechanism, there is a need to establish strong implementers of the system at all

levels, or ‘Referral Champions’. For example, while training ASHA workers, one or two ASHA workers were

identified as active and effective communicators. During implementation of the referral mechanism, these

ASHA workers provided the most referrals and were active in providing information about the referral

system in the community. Thus, these ASHA workers were labeled as ‘Referral Champions’. Staff who

implement the referral mechanism most effectively at their UPHC, secondary and higher-level health

facilities, can also be termed ‘Champions’. Having such ‘Champions’ is beneficial in to the champions by

giving recognition where it is due, thus encouraging them to continue their optimal work and potentially

train other staff or community workers to improve their implementation.

Process:

1. Identify the active health staff at each level – ASHAs and ANMs at community level, Medical Officers

at UPHCs, nurses at secondary level facilities, etc.

2. In the initial phase of implementation, identify key factors of achievement, including, the number

of referrals completed by community workers, number of referrals attended at UPHC and/or

secondary level, staff engaged in community awareness, and others.

3. Based on these factors, shortlist workers for ‘Referral Champions’.

4. Ask ‘Champions’ to share their experiences in monthly meetings to guide other staff to enhance

their capacity.

SECTION IV: CONCLUSION

There is a need to establish a strong referral mechanism in urban India to ensure high quality of healthcare

and optimum utilization of each health facility, improve coordination and governance, regulate private

formal and informal sectors, strengthen public health capacities, and reduce pocket expenditure.

Experience in the pilot city, Indore, Madhya Pradesh, identified a need to develop a guide to explain the

detailed process behind implementation of a referral mechanism within the existing healthcare system. The

purpose of this document is to guide government officials as they implement referral mechanisms in

existing healthcare delivery structures. This guide has been developed in consultation and collaboration

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with a range of consultants from the team of TCIHC involved in the referral mechanism implementation

process in Indore, Madhya Pradesh.

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REFERENCES

1. Referral Systems - a summary of key processes to guide health services managers

Web link- www.who.int/management/Referralnotes.doc

2. Kamau, Osuga, and Njuguna. 2017. Challenges Facing Implementation of Referral System for

Quality Health Care Services in Kiambu County, Kenya. Health Syst Policy Res., Volume 4:1. Web

link-https://www.semanticscholar.org/paper/Challenges-Facing-Implementation-Of-Referral-

System-Kamau-Onyango-Osuga/a314ea5589c4f3bfd805229efce09d0d61828e56

3. Choices National Health Service. GP referrals - The NHS in England - NHS Choices 2017. Web link-

http://www.nhs.uk/NHSEngland/AboutNHSservices/doctors/Pages/gp-referrals.aspx

4. The World Health Report: primary health care: now more than ever. World Health Organization.

2008. Web link- https://www.who.int/whr/2008/whr08_en.pdf

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ANNEXURE

1. Baseline assessment tool

2. Baseline assessment report of Gwalior city, Madhya Pradesh

3. Referral slip at community level

4. Referral slip at facility level

5. Reporting format at the community level

6. Reporting format at the facility level

7. Referral Protocols / Health Care pathways

8. MNCH Matrix

9. Frontline worker training module and Facilitators guide for community workers

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For more details

V i s i t w w w . p s i . o r g

C o n t a c t u s : i n f o @ p s i . o r g . i n