Status of Referrals in Three Districts in Ghana. Analysis of Referral Pathways for Children under Five

摘要

Integrated Management of Childhood Illness (IMCI) is a strategy that has been adopted by most African and Latin American countries to reduce infant and child mortality and morbidity. Key to this strategy is the timely and appropriate treatment of severely ill children, which often requires referral to higher levels of care. In many countries and settings culturally specific behavioral and systemic factors determine if a sick child reaches the referral care site. Objectives: This research tested a Rapid Referral Assessment (RRA) methodology in three districts in Ghana - Atwima, Gomoa, and Yendi. The RRA provided national- and district-level managers information to rapidly assess the status of and constraints to referral of severely ill children from first-level care to secondary and tertiary levels. Methods: Data came from medical record reviews at 39 health facilities and interviews of 161 caretakers and 40 health providers. Prevalence estimates looked at referral care patterns of caretakers and providers, referral and counter-referral relationships, frequency of self-referral to upper levels of care, and barriers to compliance with referral. The effects of illness classification, the use of referral slips, caretaker perceptions and constraints, and geographical access were considered. Results: The overall referral rate was 0.9%. Fifty-five percent of referred cases complied with the referral recommendation and arrived at the next level of care. Eighty-six percent of those who complied with referral did so the same day. Only 24% of cases were admitted to the inpatient ward at the referral site. Conclusions: National Health Management Information System (NHMIS) data from 2001 cite 1,861,810 outpatient visits for children less than five years of age. If a 10% approximate referral rate is used, there should be approximately 186,181 referrals in a one-year period. This study found a referral rate of 0.9%, which would amount to 16,756 referrals or 169,425 missed referrals. This study found a compliance rate of 55%, which would imply 9,215 cases actually arriving at the hospital. If one applies an approximate 5% mortality rate for referrals that don't arrive at the referral site, potentially thousands of children would not survive. The results of this assessment are being used by the Ghana Health Service (GHS) to design interventions to improve referral care of severely ill children.