Referral Systems – components and effects of FHC-I Dr. Heidi Jalloh-Vos, MRC Sue Clarke IRC 2010 HIPCC

Referral System Components Ambulance with ambulance nurse, ambulance driver, radio or mobile phone, medical kit PHUs with solar powered radios or phone and essential medical supplies/equipment and trained staff Community and local authorities involvement Awareness raising about referral system Hospital emergency preparedness Ambulance base with 24hrs call service (radio, telephone, radio operator) Regular updated referral database Management systems (repair, maintenance, logbook, etc.)

MRC Referral system Bo North Based on: high child/maternal mortality, partially due to poor geographical access to higher levels of health care History of ambulance system in Bo North Request of community (esp. Komboya chiefdom) for ambulance system Fruitful discussion with local partners and outside donors Covers : 23 primary health care clinics in 6 chiefdoms estimated population 2010: 77,120 Covers all emergency (obstetric, paediatric, others) Free for Pregnant and Lactating Women and U5 since 27 th April, others pay 25,000 to 50,000 dependant on distance

Does increase of attendance give similar increase in referrals? 4 chiefdoms in Bo North (13 PHUs) Attendance Jan-April = 8802 (2201/month) Referrals Jan-April = 46 (12/month) Attendance May-July = (4509/month) Expected referrals = 24/month Actual referrals seen = 140 (47/month)

Referral systems presentation to HIPCC - Sept Increased referral percentage January to April 2010 May to July 2010 ChiefdomAttendance Patients referre d% Attendanc e Patients referred% Badjia Bagbe Komboya Niawa Lenga Total Average monthly

Patient categories

Referral system – nr. Obstetric cases versus expected nr. cases Catchment population 2010 = 77,120 Expected number of pregnant women (4%) = 3085 Expected number of deliveries with complications estimated as 15% of 3085 = 463 (some could be managed at e.g. a CHC) Expected number of caesarean sections estimated as minimum 5% of 2907 = 154 (who would all need to come to the hospital) Now 8 months into 2010 (January to August): – 24 PW before FHCI – 73 pregnant women referred after FHCI – Expected (extrapolation) until end 2010: 71 – Total = 168 – which is more than the 5% calculated Can we conclude that we are now missing less obstetric cases??

Kenema District Programme coverage includes: Direct beneficiaries 55,000 (women aged 15-45) 37,350 children under five All chiefdoms supporting 65 PHUs and the Government hospital one of the aims being to enable and support the continuum of care from the PHU to the CEmOC Support to the ambulance and the blood transfusion service started in 2007 Always been a free service for pregnant women

Mode of Referrals to KGH

Patient referral numbers / month

Blood Transfusion Service Kenema Government Hospital

Units of Blood Collected

Donor Sources

Beneficiaries of Kenema Blood Transfusion Service in 2010

Common constraints High cost of running a referral system, especially after FHCI although reduced cost per patient Increased workload and demands on resources at receiving facilities Human Resource issues compounded by service demands PHU Staff do not have all essential skills to handle emergencies – gradually improving through supportive supervision and training Some patients still refuse transportation and delay reaching the facilities, so ongoing need for continued awareness and information sharing.

Lessons learnt The power of collaboration – system successful due to close cooperation with district council, hospital, DHMT, chiefs, communities etc. All elements in the chain are important to ensure that the referral is not raising unrealistic expectations Unexpected effect: CHC/CHPs advising lower level PHUs by radio or in person when called upon by radio or telephone Uptake first gradual – after the launch of free health care there was the predicted surge in numbers even in Kenema where the services were already free Increased trust in receiving free care at hospital contributes to increased uptake and utilisation of services