Transcript Slide 1

STRENGTHENING REFERRAL SYSTEM
TO IMPROVE MATERNAL HEALTH
The Kenya Red Cross Experience
Introduction

A functional referral system is key in reducing maternal mortality.

A referral system is defined as a mechanism to enable client’s health
needs be comprehensively managed using resources beyond those
available where they access care (Kenya Health Sector Referral
Strategy).
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An effective referral system ensures a close relationship between all
levels of the health system and helps to ensure people receive the best
possible care closest to home.

It assists in making cost- effective use of hospitals and primary health
care services.
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A well functioning referral system requires active collaboration and
cooperation between the different stakeholders and care providers
within a referral network
UNDERLYING CAUSES OF MATERNAL DEATHS

Three distinct levels of delay which contribute to maternal
morbidity and mortality.
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Delay in deciding to seek appropriate care. This is due
to socio cultural barriers, failure to recognize danger
signs, failure to perceive severity of illness and cost
considerations.
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Delay in reaching Health facility: this is due to long
distances to facility, poor conditions of roads, lack of
transportation and cost considerations.

Delay in receiving adequate emergency care at
facility: this is due to shortage of staff, supplies and basic
equipments among others.
FRAMEWORK FOR REFERRAL SYSTEM IN KENYA
REFFERAL SERVICE
CLIENT MOVEMENT
SERVICE/EXPERTISE
MOVEMENT
SPECIMEN MOVEMENT
CLIENT PARAMETERS
MOVEMENT
REFFERAL CHAIN AS DEFINED IN REFERRAL STRATEGY
National Referral
NATIONAL REFERRAL SERVICES
County Referral
COUNTY REFERRAL SERVICES
Primary care
PRIMARY CARE SERVICES
Community
COMMUNITY SERVICES
TYPES OF REFERRALS
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Emergency referrals
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Urgent Referrals
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Non Urgent Referrals
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These referrals entail
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Client movement
Service/Expertise movement
Specimen Movement
Movement of client parameters.
MAJOR GAPS IN REFERRAL SYSTEM IN KENYA
Kenya Health sector Referral strategy June 2013 – June 2018:
Policy and strategic level
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No transport policy for Health sector
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No by pass policy
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No coordination structure for the referral services
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Lack of quality standards and performance monitoring tools.
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No policy guidelines on who is responsible for financing Referral
services in the Country.
MAJOR GAPS IN REFERRAL SYSTEM IN KENYA
Operational level
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Ineffective networking of the different levels
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By passing of lower levels of facilities
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Inappropriate referrals.
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Inadequately resource facilities according to norms and service standards
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Lack of effective referral monitoring system.
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Inadequate communication and transport systems.
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Ineffective referral and feedback system
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Lack of referral coordinating forums and review meetings
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Issues of financing.
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Lack of integration.
KRCS ROLE
BRIDGING THE GAP – COMMUNITY FACILITY LINKAGE
KRCS ROLE
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KRCS appreciates that a well functioning Referral system must have
clear quality standards that are influenced by
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Health systems determinants: capabilities of lower tiers/levels,
availability of specialized personnel, training capacity, organizational and
coordination arrangements, cultural issues, political issues and
traditions.
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General determinants: population size and density, terrain and distances
between urban centres, pattern and burden of disease, demand for and
ability to pay for referral care.
The KRCS model of strengthening referrals seeks to address the gaps
that exist along the referral chain in the Country.
KRCS SUPPORT TO REFERRAL CHAIN
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Community based demand creation activities organized around the
Community Health strategy. This creates community based referral
mechanisms to facilitate linkage with primary care services.
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Provision of Ambulance services for Client movement from Community
to Health facility and from health facility to Health Facility.
Ambulance services
Provision of Ambulance Services
Ambulance Referral Statistics
No. of Calls May-14
Jun-14
Jul-14
TOTAL
POP
KISII
331
372
375
1,078
1,152,282
KAKAMEGA
547
492
542
1,581
1,660,651
BOMET
410
393
424
1,227
730,129
GARISSA
107
121
149
377
623,060
69
115
184
1,025,756
MANDERA
Ambulance Referral Statistics
KISII
KAKAMEGA
MATERNITY
422
498
311
80
63
MEDICAL
457
784
686
206
87
CARDIAC
58
62
28
30
8
TRAUMA
141
237
202
61
26
1,078
1,581
1,227
377
184
TOTAL
BOMET GARISSA MANDERA
KRCS SUPPORT TO REFERRAL CHAIN
Provision of vehicles and other logistics for expertise movement during
medical outreaches
KRCS SUPPORT TO REFERRAL CHAIN
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Construction/ equipping of health centres and dispensaries to ensure
that they can provide appropriate services. This enables management
of the referrals from communities and also facilitates referrals to nearest
County Referral.
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Equipping and upgrading of hospitals to ensure service provision for the
referrals from the health centres.
Dadaab Level 5 Hospital
KRCS REFFERAL MODELS
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Community led
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Patient/Client led
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Reverse referral
COMMUNITY LED REFERRAL
COMMUNITY
FACILITY
PRECONDITIONS
•Functional Ambulatory
system.
•Functional health facility
•Quality of care
PRECONDITION
•Decision making
•Knowledge
/awareness
•perception
HOUSE HOLD
DETERMINANTS
•Male involvement
•Social support
•cost
Ambulance
CHW
CHEW
/HW
FEEDBACK
HEALTH
FACILITY
DETERMINANTS
•HRH adequacy and
know how
•Attitude
•Quality of care
FUNCTIONAL HEALTH CARE SYSTEM,COMMUNITY EMPOWERMENT AND INVOLVEMENT
LESSONS FROM COMMUNITY LED MODEL
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From January to May 2014, 760 mothers have been referred under this
model in Isiolo and Garissa Counties.
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This model enhances follow-up of the mother pre during and post the
referral.
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This model ensures early identification of danger signs by the trained
CHVs with support from the CHEWs.
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It enhances community ownership.
PATIENT/CLIENT LED REFERRAL
PRECONDITIONS
•Functional Ambulatory
system.
•Functional health facility
•Quality of care
PRECONDITION
•Decision making
•Knowledge
/awareness
•perception
CLIENT
CARE
GIVER
Ambulance
HEALTH
FACILITY
DETERMINANTS
•HRH adequacy and
know how
•Attitude
•Quality of care
DETERMINANTS
•Male involvement
•Social support
•cost
FUNCTIONAL HEALTH CARE SYSTEM
LESSONS FROM PATIENT/CLIENT LED MODEL
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From January to May 2014, 1,747 mothers have been referred under
this model in Isiolo and Garissa Counties.
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Creates good networks for inter hospital transfers.
REVERSE REFERRAL
FACILITY
COMMUNITY
PRECONDITIONS
•Functional Ambulatory
system.
•Functional health facility
•Quality of care
PRECONDITION
•Decision making
•Knowledge
/awareness
•perception
HEALTH
FACILITY
DETERMINANTS
•Male involvement
•Social support
•cost
Ambulance
HOUSE HOLD
CHEW
/HW
CHW
FEEDBACK
DETERMINANTS
•HRH adequacy and
know how
•Attitude
•Quality of care
FUNCTIONAL HEALTH CARE SYSTEM,COMMUNITY EMPOWERMENT AND INVOLVEMENT
LESSONS FROM REVERSE REFERRALTHIS
MODEL
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Workable model for the hard to reach areas and areas with low
facility coverage.
CONCLUSION
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Key components for effective referral
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Functional Community health strategy
Ambulatory services
Functional health facilities.
Important to note that Community Facility
linkages are key in the Kenyan context for
improved referrals in context of maternal health
CONCLUSION
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There is need to align the health system with the
needs of the population looking at the geography
and income distribution (Arid and Semi Arid
Lands, Hard to reach areas, terrain, conflict
areas etc)
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Need for coordination across the different parts
of the health system
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