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Strategic paper on Health Care Referral System


Health, Population, Nutrition and  Sector Development Programme (HPNSDP)


 Government Hospital

 Private Hospitals & Clinics

 Private Diagnostic Centre

 Private Blood Bank

 Medical Board

 Medical Waste Management

 Hospital Accreditation

 Quality Assurance

 Risk Management

 Total Quality Management

 Clinical Protocol

 Management Development 

 Emergency Management

 Poisoning Management

 Hospital Autonomy

 Safe Blood Transfusion

 Community Participation

 Operational Plan

 Women Friendly Hospital 

 EOC & Gender

 Capacity Development

 Establishment of Shishu
 Bikash Kendra at 14MCHs

Country overview

 One of the key reforms identified to be implemented is of the entire health system with

Decentralization to local bodies. In order to ensure decentralization system is functioning well, it is very necessary to combine the decentralization process with an effective referral system.

Findings of the recently published Demographic Health Survey has indicated various kinds of reasons faced by the women in accessing health care which prevent them from getting medical advice or treatment for themselves when they are sick. In that survey a random sample of women between 15-49 age group had been interviewed on there accessibility to health care.

As of these findings it is noted that large number of the female community is facing difficulties in accessing health care services even at the nearest health care station. In this scenario it is obvious that obtaining any special care is becoming a remote possibility for them. Despite the access to health care being a major health services problem only minimal action has been taken on referral systems.

Besides the positive steps undertaken by the Health ministry to achieve the set goals and targets, there has been slow progress in implementing activities on decentralization. Implementation of the decentralization process is a must and need to be considered as an urgent need. Considering the geographical situation  and the status of the physical access to health care services, establishment of a functioning referral care system along with effective decentralized health care management is essential if it is to provide Essential health care services to its people on an equitable basis.

Although there is some mechanism established for patient referrals by the Ministry of Health & Family welfare it is not functioning properly at present. Government has introduced a referral form where the health care personal at the primary care centers are expected to fill it and forward while transferring the patients. This mechanism may not function well because of the lack of other requirements for an efficient referral system.

In a study conducted on referral mechanism in  district it was reported that although the  facilities are using the referral system, only small number of patients are to be attended the  secondary care institution after referral. Even there most of the patient are coming from nearby centers. It is also observes that the existing referral system does not greatly improved the access to secondary care for more remote, and probably for more needy communities.

Future Plan

 While establishing well functioning and effective health care referral system there is some key factors to be considered:

1.       Identification of types of services to be provided through each level of institutions This will enable to identify the level of care to be available at each level institution. Whenever the patients need of higher level of care the patients needs to be transferred to upper level of institutions.

 2.     Development of referral protocols and referral cards Present referral slip could be  revised and amended. The referral slip need to be designed to facilitate communications in both directions. Development of the referral protocols will be much beneficial to health care personal at each level to follow a unified procedure while referring patients. This also will enable to prevent any unnecessary referrals

 3.      Streamline the referral procedures.

          As the present system of referral mechanism is not functioning in an efficient way, the MOHFW and the DGHS need to revisit it and streamline the procedures. Review the referral  manual in-cooperating all the instructions and guidelines on referral mechanism will be beneficial.

 4.     Creating awareness among the health staff and the communities on the referral mechanism While establishing a referral system, providers at all levels of health care system needs to be oriented and trained on functioning of the system. Further. The staff at each level needs to be thorough on recognizing the need of referral care with regard to each condition.

 5.      Provision of adequate resources based on the norms for each level of institutions Availability of the services as for the identified norms at each level of care will generate the trust on the referral mechanism among the health care providers as well as among the people.

 6.     Establishment of proper communication mechanism between PHCs and other higher level referral centers. Development of suitable communication facilities at each level of care will enable the system to be functional more effectively.

 7.     Identification of suitable transport mechanisms to transfer the patients in need for referral care. Developing transport systems to transfer the patient to the higher level is also very essential. If the health care institutions do not owns suitable vehicular arrangements with them, it is always better to identify the alternative mechanisms in transferring patients to higher level institutions at the earliest.  



Referral system is a process, which ensures the accessibility to higher levels of medical care to the patients from the community or primary level health care facility.

Referral is usually pursued in order to obtain expert professional advice, undergo a diagnostic technique, seek a therapeutic intervention or receive in-patient care when these are not available all the referring facility. The presence of well established referral system is important for the proper functioning of the health system based on primary health care. Referral hospital is an institution to which patients with complex medical condition can be sent for diagnosis, treatment and care and which can also act as a resource center for the health worker of the peripheral health institutions. It is to provide efficient, effective affordable and equitable services to their community.


n       Providing twenty-four hour medical care.

n       Rehabilitation that requires a higher level of competence than the source of referral.

n       Hospital has the capacity for diagnosis, treatment and institutional care.

n       All patients referred or referring them safely to more complex levels of care.

n       Referring patient back to the source of referral with appropriate information.

n       Capability of supporting the development of primary health care services through training and continuing education programme for all levels.



n       All patients referred or referring them safely to more complex levels of care.

n       Referring patient back to the source of referral with appropriate information.

n       Capability of supporting the development of primary health care services through training and continuing education programme for all levels.

n       Overlapping and competition between various level are to be avoided in order to prevent wastage that may affect the efficiency of the referring Hospital and referred hospital.

n       Ideally the referring health center is where first diagnosis should be done and responsible for providing comprehensive, integrated and continuing care.

n       Distances, transport and finances are factors that cannot be ignored and that affect the way in which patient are managed.

n        Every patient should first receive care at the health unit at first contact level, where appropriate initial treatment can be given and a decision made about the need for referral to the first referral hospital,

 Referral Rules

 *      Treatment costs for every one are greater in higher level facilities.

*      Quality of services at all levels should be acceptable to patients.

*      Patients are well informed about the services available at each level of network.

*      Patient should not by pass one level of system without the consent of the personnel of that level.

*      Public, private and NGOs providers would be the  source of medical care . Follow up care is also needed to provide  in the referral system.

*      Entry point in to the referral system is the primary level and patients/clients proceeding onward will be taken care of by the health system itself.

*      The primary level could be union sub-centre, upazilla health complex. Initially all patients will be received, examined and treated by the health care provider at the primary level.


Referral may be required for

*      Emergency

*      Medico-legal

*      Curative

*      Preventive


In case of emergency and medico legal, patients may be referred to the emergency department of the referral hospital.  Level of referral may be decided by the health care provider according to the need for the proper management of that patient. It could be directly from primary level to divisional or tertiary if the specialty does not exist at upazilla health complex or district hospital. For curative or preventive purposes. The patient/client will be referred to next higher level for expert advice, technical intervention, technical examination or inpatient care.  For all referrals, the health care provider referring the case will fill the referral form. Elective referrals will report to the referral desk at the referral hospital. Receptionist/ clerk of the referral desk will record the information in the Referral register and guide to the patient to the relevant specialist / department. Specialist may treat the referred as an outpatient by giving expert advice or doing the necessary technical examination / intervention.  Patient will visit the referral desk, necessary information is recorded in the referral register and is sent back to primary level with the filled referral form mentioning the advice for follow up.

Patients may need further referral. New referral form will be filled in by the specialist and patient reports the referral desk at the next higher level for    management. Patient may be admitted for indoor management. When cured they will be sent back to primary level with the discharge slip and the feedback part of referral form for onward management.


Referral Component

 n       The referral system is designed in a way that its structure is integrated with the primary health care. At each level of system the mix of patients to be 
       seen and services available are consistent and well defined. Referral criteria are set out for major diagnostic, characteristics and diseases categories.


  Specific component

n       Referral policy

n       Pattern of diseases

n       Hospital capacity

n       Training of the health providers

n       Communication infrastructure

n       Transportation

n       Education


Referral Level

n       Referral health system is more concerned with the referral levels.

n        People should be encouraged first to use primary centers and enter in to the referral channel as and where they find it more feasible irrespective of administrative zone.

n       At the bottom of the pyramid, should be the most frequently occurring conditions that are mostly, manageable at the primary level and least expensive to treat.

n        At the top should be the rarest condition that are most expensive to treat and not manageable at primary level.

n       The consistent with the fact that patient should bear a minimum cost for their treatment. Patients / clients should be encouraged to use lower levels of referral pyramid.


Service Delivery

n       Primary level           : Upazilla health complex

n       Secondary Level     : District Hospitals.

n       Tertiary level           : Medical College Hospital, Specialized Hospital.

      Rural health center will be a resource center for basic health unit

n       First Referral Level      > Upazilla Health Complex

n       Second Referral Level >District Hospital

n       Third Referral Level    >Medical College Hospital &  Specialized hospital.

Hospitals are the end point of referral hierarchy. The proposed system intends to provide most care at the bottom of pyramid through health care. Movement between various levels of the pyramid occurs by referral and according to need.

Each Upazilla health complex and the referral hospital need to describe the catchments area of its responsibility to which it should provide efficient, effective affordable, and equitable services. Ideally, in the urban area there should be no direct contact of the patient / client with the referral hospital. However, at the moment it may not be possible to raise such a high number of urban health centers to streamline the referral through them. We may permit the first contact through the existing urban health institutions.                                                 

n       The patient coming from the catchments area of an urban institution will be received and treated in the general OPD.

n       The patient referred from here (OPD) and by other health facilities will be entertained in the specialist OPD directly by the specialist and not by the M.O. through the referral desk.


   Existing Referral system, Causes of bypassing, and Benefit of structured referral system

   Existing system

l      One of the major problems in health sector is the tendency on the part of the patients to by pass the primary health care facilities in favour of secondary and tertiary levels hospitals.

l      Peoples usually go to the facilities or individual physician referred by relatives or on the basis their own experience resulting low utilization.

l      Further, there are no financial disincentives for patients if they by-pass primary health care facilities in favour of tertiary level facilities.

l      Proper system of quality patient care is poor at the primary level, which results in their under utilization.


  Problems at the source of referral

l      Poor communication between the attending doctor at the referral facility and the facility at source.

l      Poor briefing to the patient and relatives on the reasons for the referral

l      Lack of equipment and support facilities for emergency treatment or resuscitation of severely injured patient.

l      Inexperienced referring personnel who make an unnecessary referral, a late referral or referral to a wrong discipline

l      Ineffective follow-up of information given to patients by the medical staff.

l      Absence of a proper patient referral information system

l      No defined catchments population


Problem at Centre

l       The overcrowding and over flowing of patients at the referral hospitals

l       Poor, special handling of patients referred from lower levels

l       Shortage of beds in relation to patient load.

l       Long waiting list for operation and investigation.

l       Non availability of proper support services.

l       Difference of opinion between specialists

l       Delay in communications

l       Delay in the examination or treatment of the patient and prolonged stay.

l       Referrals attended by junior doctors and poor documentation.


  Reasons for bypassing the health facilities


  At Community level :

  Community may be unaware of the services available near their homes.


   At Primary level

        Non availability of doctors (sometimes)

        Shortage of trained staff.

        Lack of confidence in the health facility (sometimes)

        Poorly maintained facility building and equipment

        Inadequate budget.

        Weak management (sometimes)

        Low quality of health care. (sometimes)

        Shortage of Medicine supply.


   At Referral Level

l      Non availability of proper support services. (e.g-lab.facility, anesthesia)

l      Improper management and organizational link between different      facilities.

l      Lack of information flow within and between the health facilities.


   Present scenario

l      Non availability of proper support services. (e.g-lab.facility, anesthesia)

l      Improper management and organizational link between different      facilities.

l      Lack of information flow within and between the health facilities.

l      Poor screening skill of the primary level service provider.

l      Poor information about the referral.

l      Proper attention to referral client is not always given.

l      Delay in taking action in case of referral patient

l      Poor institutional linkage in respect of referral.

l      No system of downward referral.

l      Feed back of referral is not given properly.


   Benefit of Structured Referral System 

l      Better patient care with quality.

l      Satisfaction of the client and service provider

l      Proper access to the services.

l      Capacity building of the professional.

l      Establishment of the liaison with the different services providing institution.

l      Minimization of the patient load in the secondary and tertiary level hospital.

l      Acknowledgement of the service provider by the community.

l      Establishment of the client / patient right.


Action Plan

n      Objective setting

n      Formulation of implementation strategy directing towards the set objective.

n      Documentation review of existing referral system.

n      Preparation of referral documentation for holding workshop.

n      Opinion seeking for proposed referral system from service provider.

n      Reflection of service providers opinion in the development of structured referral system specially in respect of process, format and fixation of the role of hospital / institution( level wise.)

n      Final preparation of the referral system documentation for piloting.


Step of Piloting

n      Selection of district

n      Preparation of the intervention schedule

n      Orientation and training of the service provider.

n      Supply of logistic

n      Formation of local referral management team.

n      Operationalizing of the system.

n      Supervision and monitoring

n      Technical support from the DGHS.

n      Preparation of the document about the piloting findings.

n      Dissemination of piloting findings among the service provider for necessary correction and finalization.

n      Preparation of the proposed final draft and approval of the ministry.

n      Rollout of approved referral system.

n      The whole approach will be like operational research.


   Intuitional referral


  First Referral System ( UHC)

u    Feedback of referral can be given in any designed format.

u    HFWC  / SC will use specific referral form for referral.

u    MO in charge of HFWC will be the authorized person for referral of patient to UHC but in absence of MO, SACMO/MA & FWV can refer patient.


  Second Referral System ( District Hospital)

u    Contact of the referred patient will be RMO (office hours) and EMO after office hours.

u    For recording of the referred patient register will be maintained in the indoor, outdoor, and emergency.

u    The referral will be 2 way: Upward and downward. RMO will be authorized person to refer patients from outdoor, indoor and emergency. In addition to that EMO will be also authorized person to refer patient from emergency

u    C.A. / Indoor medical officer (IMO) will be also the authorized persons under the guidance of specialist for referring patient from indoor.

u    For upward and downward referral the authority will use the specific form.


  3rd Referral System ( 3rd Referral System)

      Tertiary referral center

      Contact of referred patient will be RP, RS in the Office hour and EMO after office hours.

      The referral will be two way, upward and downward.

      For recording of referred patient register will be maintained in outdoor, indoor and emergency.

      For upward / downward referral from emergency the authorized person will be EMO

      From the OPD in case of upward / downward referral the authorized person will be RP, RS.

      From the indoor in case of upward / downward referral the authorized person will be CA under the guidance of unit head.



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