Some of the challenges in health referral systems in most developing countries include noncompliance with referrals [ 12 ] delays in referral completion [ 9 ], high numbers of self-referrals to higher-level referral facilities [ 13 ] weak health information systems to capture referral data, poor transport arrangements for emergency referrals [ 14 ] and inadequately resourced referral facilities [ 13 ].
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According to Ramdas [ 15 ], communication to both the users of the service and their families are mandatory when the referrals related to the users are being made to the various levels of services. The use of a provincially standardized referral letters that would serve to channel clinical information both upward and downwards in the referral chain is obligatory. All institutions must be knowledgeable of the contact details of the key managers and the key clinicians on duty.
Transport is identified as a key constraint on achieving the child and maternal health goals in many of the developing countries in Africa. There must be smooth and prompt vehicles to address emergency cases and referral cases at every level of health care. From literature review transport causes delay in deciding to seek care and receiving care at health facilities identified as contributing to deaths among women with obstetric complications Farm, ; Maine, Studies on the accessibility of referral hospital care have repeatedly confirmed the existence of a steep distancedecay function, in countries such as Ethiopia [ 16 ] and Nigeria, indicating that individuals with a given need for a clinical service will be less likely to access that service the farther away from the referral center they live.
In general, physicians receive little training on when to make a referral [ 17 ]. While providing feedback to providers, improving training, or holding regular meetings between providers might help in improving referrals. Other studies have looked at the benefits of physicians training on how to write referral letters. Few studies have examined the effect of electronic medical records EMRs on care coordination in general or on referral process in particular [ 18 ]. Computer access to compare notes has been associated with increased communication between referring physicians and specialists.
Specialists receive written or e-mail referral letters twice as often than by telephone or other verbal communication [ 19 ]. In most developing countries appropriate allocation of resources to referral hospitals within the national health system has long been a controversial issue in health system planning according to [ 20 ]. Perhaps the most frequent theme in research literature on referral hospitals in developing countries is the inappropriate utilization of higher-level facilities and the apparent failure of most referral systems in developing countries to function as intended [ 21 ].
The study was be based on theoretical model of Referral- Pathway which explains how the Referral process actually takes place in a given country. In most countries there are tiered systems of health care, often having three levels [ 22 ]. Kenya follows in this category.
Cross-sectional research design was used on this study that was carried out in the month of June The study was carried out in Kiambu County Kenya. It is located in the central region and has a population of 1,, milliom as per the Census. The researcher used random sampling to get a target population of 5 Sub Counties whose health workers were sampled from dispensaries, Health Centres and Hospitals [ 24 ]. The researcher purposively chose to interview the following stratified cadres nurses, medical doctors, consultants, health record officer, medical laboratory technologists and facility administrators.
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These were considered as the cadres with pertinent information on referrals Table 1. Kiambu County public health facilities have a total workforce of different medical cadres, from a total of 80 public health facilities [ 25 ]. The study adopted stratified random sampling. Analysis of the data was done using SPSS version To carry out the study, formal clearance was received from Kenya Methodist University as well as Kiambu County Health Research department, head of the institution where the study was carried out.
The researcher explained to the respondents about the research and that the study was for academic purposes only. The participants had informed consent to make the choice to participate or not. They were guaranteed that their privacy was protected by strict standard of anonymity. The data was collected from 1st June to 30th June questionnaires were used to collect primary data from all respondents and interview guide from health administrators and nursing officers in charge in sampled facilities done through face to face interviews.
A total of Table 2: Whether the health facility had transport facilities for patients on referrals. The researcher wanted to establish whether the health facilities had transport facilities. According to the analysis of the findings, from data above a majority Therefore it was concluded that most institutions in Kiambu County lacked transport facilities for patients on referrals [ 26 ]. The researcher asked the respondents to rate the level of adequacy of necessary facilities in the following phases of referral. According to the findings of the study those indicated not sufficient were on statements that transportations of patients is insufficient with a mean of 2.
Transportation of experts to the referral hospitals with a mean of 1. Table 3: Rating the level of efficiency of necessary transport facilities in the following phases of referral. Thus, it can be concluded that the availability of necessary transport facilities in the phases of referral in, transportations of patients and client parameters, experts and specimen at the referral hospitals was not sufficient. The study wanted to establish whether health facilities had skilled work force on referral guidelines Table 4.
Table 4: Whether the health facilities had skilled work force on referral guidelines. The findings of the study data above reveal that a majority Therefore it can be concluded that a majority of the respondents were not trained on referral guidelines. The researcher wanted to establish whether the health facilities had adequate human capacity to address referral cases Table 5. Table 5: Whether the health facilities had adequate human capacity to address referral cases. The researcher wanted to find out whether the health facilities had standardized referral documents for referrals.
A majority of the respondents, The findings of the study deduced that most health facilities had no standardized referral documents for referrals. The researcher required the participants to rate the status of referral documents in their respectful health facility Table 6. Table 6: Whether the health facilities institution had standardized referral documents for referrals.
A majority of the respondents, 99 In addition, the findings of the study revealed that 6. Therefore, it can be established that a majority of the respondents indicated that health information systems in the health facility was fair. From the findings of the study, it is evident that most health facilities face the challenge of providing referral documentation. The researcher wanted to find out whether the health facility had budgetary allocation for referrals. Based on the study findings, a majority The study concludes that a majority of the health facilities had no budgetary allocation for referrals Table 8.
Therefore, it can be revealed that most respondents indicated that there were no enough funds for referral cases. The researcher required the participants to rate the adequacy of funds for referrals. A majority In addition, Therefore, it can be revealed that most respondents indicated that there is no enough funds for referral cases Table 9. The study found that majority of health care facilities in Kiambu County have challenges in Infrastructure This implies that if the above challenges are addressed it would be possible to implement referral system for quality health care services in Kiambu County.
These findings are consistent with evidence from other countries where referral system has been studied. Transport is identified as a key constraint in achieving the child and maternal health goals in most of the developing countries in Africa as per. Transport and Health are inextricably linked. From literature review transport causes delay in deciding to seek care and receiving care at health facilities identified as contributing to deaths among women with obstetric complications. Studies on the accessibility of referral hospital care have repeatedly confirmed the existence of a steep distance-decay function, in countries such as Ethiopia [ 16 ] and Nigeria, indicating that individuals with a given need for a clinical service will be less likely to access that service the farther away from the referral centre they live.
Performance is considered to be a combination of staff being available that is retained and present being competent and responsive. Since the start of joint learning initiative JLI in , the human resource crisis in low-income Countries LICs has received global attention, particularly the crisis in sub-Sahara Africa. This situation seriously comprises the health status of the communities, particularly the poor. Referrals are a link between primary and specialty care. Visits to specialists constitute more than half of outpatient physicians visits in the United States.
Referral guidelines also have been promoted as a means of improving the appropriateness of referrals. It is believed referral guidelines can provide an important foundation for improving the referral process Referral guidelines seeks to formalize and clarify those aspects of the referral process on which there is a disagreement, including which conditions should be managed by specialists or primary care physicians, what type of communication is preferred by the referring and specialist physicians before and after a referral written, verbal or both , and what tests should be ordered before a referral.
In general, physicians receive little training on when to make a referral, while providing feedback to providers, improving training, or holding regular meetings between providers might help in improving referrals. Even though all physicians value communication between referring primary care providers and specialists, both PCPs and specialists cite the lack of effective information Transfer as one of the greatest problem in the referral process. Both primary and specialist physicians value this information exchange for shared patient. According to Ramdas [ 15 ], communication to both the users of the service and their families are mandatory, when the referrals related to the users are being made to the various levels of services.
Web-based Referrals systems have improved scheduling benefits of e-mail communication about referrals and include the option for asynchronous communication, increased flexibility, opportunities for back-and-forth exchange and enhanced rapport.
Idea: Portable irrigation technology helping sub-Saharan smallholder farmers grow crops out of season. Problem: When it comes to food supply, Africa faces enormous instability due to unpredictable climate and poor resources. Method: Kick Start , a not-for-profit organisation that specialises in irrigation technology, is making portable water pumps accessible to farming communities across Africa — most significantly in Kenya, Tanzania and Mali. Solution: Kick Start told The Atlantic that, since , their pumps have lifted , people out of poverty, helping to "create an entrepreneurial middle class, starting with the family farm".
They have pumped new revenues equivalent to 0. Idea: A computer tablet diagnoses heart disease in rural households with limited access to medical services. Problem: Cardiovascular diseases kill some 17 million worldwide annually. In many African countries, those at risk often have to spend huge amounts of money and travel hundreds of miles to reach heart specialists concentrated in main urban centres.
Electrodes are fixed near the patient's heart. Idea: The Inye computer tablet that can connect to the internet via a dongle surmounts the price and infrastructure barriers in one go. Problem: Tech-savvy youths, who make up the bulk of the continent's population, face being left behind by a growing "digital divide". While much of Africa has skipped the desktop internet era and gone straight to mobile tech, big name brands retail in price ranges that remain out of reach for a majority in sub-Saharan Africa.
Infrastructure is also straining under rapid population growth, and wireless and broadband technology is not yet widely available in many public places. Run on Android systems, it can be connected to the internet via widely used dongles rather than wirelessly. IT provider Encipher also offers add-on bundles from games to specifically tailored apps.
Local developers are designing apps that address issues such as HIV, water and sanitation and education. Verdict: The group is now retailing its Inye 2 model to popular demand. Long-term, there are plans to expand beyond Africa's most populous country. Idea: Refining locally sourced cassava into ethanol fuel to provide cleaner cooking fuel.
Problem: Forests in Africa are being cut down at a rate of 4m hectares a year, more than twice the worldwide average rate.
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The smoke from cooking using these solid fuels also triggers respiratory problems that cause nearly 2 million deaths in the developing world each year. Method: CleanStar Mozambique , a partnership between CleanStar and Danish industrial enzymes producer Novozymes , has opened the world's first sustainable cooking-fuel plant in Mozambique. CleanStar has steered clear of monoculture crops in favour of sustainable farming methods. One-sixth of the final yield comes from locally harvested cassava, which requires farmers to plant in rotation with other edible crops to keep the soil fertile.
A Sofala Province-based plant transforms the products into ethanol, which is sold on the local market along with adapted cooking stoves also produced by the company. Verdict: "City women are tired of watching charcoal prices rise, carrying dirty fuel, and waiting for the day that they can afford a safe gas stove and a reliable supply of imported cylinders," CleanStar marketing director Thelma Venichand said.
Idea: Danish brothers David and Christopher Mikkelsen founded Refugees United in after they helped a young Afghan refugee in Copenhagen search for lost family members. Realising the futile paper trail that many refugees were faced with when looking for missing relatives, the brothers wanted to find an easier way that refugees could trace their families. Problem: There are 43 million forcibly displaced people worldwide with hundreds of thousands of refugee families scattered across the globe.
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Before all family tracing was done by refugee agencies, which still rely on paper forms and postal systems to try to locate people. There was no online global data bank that could be accessed or used by refugees themselves. Technique: Refugees United is an online search tool, where refugees can create a free profile and start their search for family via an online database using the internet or a mobile phone. Verdict: More than , people are registered on the Refugees United family tracing platform.
It is available in dozens of different languages and contains searchable information on refugees from more than 82 countries. It is currently helping 15, people trace family in the Kakuma refugee camp, home to 80, refugees and asylum-seekers, in Kenya. The main challenge is actually reaching the refugees, often the poorest of the poor, who don't have ready access to computers or mobile phones.
Annie Kelly. Problem: For a continent so in need of quick, affordable emergency relief, not to mention so riddled with unemployment, there's a cruel irony about the provenance of emergency supplies. Smaller African manufacturers have traditionally been unable to compete with Chinese prices, or to meet the vast demand for emergency goods within Africa.
As a result, aid agencies such as Unicef have forged links with foreign producers better able to produce these supplies at the scale, cost and quality required. Yet this inevitably requires longer lead times and higher transportation costs than sourcing goods locally — and Africans lose out on the work.
Method: Advance Aid is an organisation that wants to make aid destined for Africa available within Africa, from blankets and mosquito nets to basic cooking equipment and hygiene kits. The organisation acts as an intermediary between large aid agencies and African producers, putting together packages of aid supplies sourced locally. This has been very effective in Kenya, where Advance Aid have supplied 5, locally sourced emergency kits to World Vision and another 14, jerry cans to Catholic Relief Services , who distributed them in Dadaab, the refugee camp near the Somalian border.
Founder David Dickie says: "Aid is not working. I'm trying to turn the market on its head by creating jobs in Africa. Building this capacity in Africa will make a real difference to agencies, to the beneficiaries of the aid and to local businesses… [It] is a very efficient way of bringing together the development and humanitarian agendas.
Idea: To carry out scientific research on sickle cell disease SCD and show that large-scale, cutting-edge genomic studies are possible in Africa. Problem: Every year, , children worldwide are born with SCD, a genetic blood disorder that can result in severe anaemia. Seventy percent of these children, or ,, are born in Africa. However, many of these deaths could be prevented by early diagnosis and treatment.
The Muhimbili Wellcome Programme originally aimed to follow children but is now following 2,, making it one of the largest, biomedical SCD resources in the world. Dr Makani says that the work "provides validation that it is possible to conduct genomic research in Africa". Dr Makani stands as a role model for other young African scientists wishing to make a difference. Idea: To offer emergency credit through mobile phones to people who don't have access to credit cards or bank loans.
Problem: Credit cards are still rarely available to Kenyans and bank loans are only authorised for large amounts of cash or as investments for buying homes or starting businesses. M-Pepea was launched to try to bridge this gap. Method: M-Pepea, set up in late , provides its customers with emergency funds within a few hours. The money is accessed through their mobile phones, with M-Pepea sending a special pin code to be used in cash machines.
Verdict: M-Pepea has currently partnered with 20 businesses and has around subscribers, and is hoping to have increased this to 20, by the end of Its partnership with Safaricom is encouraging but the company has run into problems with businesses defaulting.