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Referral Service Barriers in Ethiopia: experiences and perceptions of actors.

Aynalem Hailemichael
Bekele Belayihun
Mengistu Asnake
Kidest Lulu
Binyam Fekadu Desta
Lidya Genene
Amsalu Obssa
Birhanu Bekele
Fantaw Bihonegn
Wondwossen Tebeje
Mesele Damte


Background: Globally, about 2.8 million neonates and 295,000 mothers die annually. Almost two-third of these deaths are reported from Africa and Asia. The causes have been attributed to sepsis, asphyxia, prematurity, hemorrhage, obstructed labor, and hypertension. To save the lives of women and babies, the Ethiopian Ministry of Health developed and implemented a referral system which comprises a network of primary health care facilities, a guiding document, and established tracking mechanisms. However, there is limited information on barriers to effective patient referrals. This study aims to assess referral barriers at primary healthcare entities in four regional states of Ethiopia.
Methods: The study employed a cross-sectional study design with mixed qualitative and quantitative methods. It was conducted in September 2019 in four purposively selected districts with high referral rates in Ethiopia. The quantitative data were collected for a one-month period from all 1,139 referral service beneficiaries or adult care takers in targeted health facilities using exit interviews. In addition, qualitative data was collected from 52 key informants using in-depth interviews. The quantitative data was analyzed using SPSS v20 and is presented using, tables, and figures. Qualitative data were transcribed verbatim were read and reread. Categories and themes that emerged and corresponding codes were labeled using open code software.
Results: Out of 1,139 formally referred patients, 95% reported that no pre-referral communication occurred between referring and receiving facilities. On the qualitative data analysis, five themes emerged as follows: (1) Lack of provider communication skills, (2) lack of governing documents, (3) shortage of human resource, and (4) Lack of essential equipment in ambulance services, and (5) Lack of infrastructure.
Conclusion: This study explored and described several referral service barriers in four regional states of Ethiopia. The referral service barriers were influenced by both individuals and health systems related factors. The investigators recommend implementing performance and quality improvement interventions to strengthen the referral systems. In addition, to address the barriers of referral system, improving the communication skills of health care providers was recommended. Furthermore, providing governing documents including referral protocol, referral service directory, and guidelines can solve some of the referral services barriers. Equipping ambulances with trained providers and lifesaving equipment, enhancing telephone lines and office facilities are recommended. [Ethiop. J. Health Dev. 2021;35(SI-5):55-62]
Keywords: referral, barrier, primary healthcare, experience, Ethiopia