Give Celso, Ndima Sozinho, Steege Rosalind, Ormel Hermen, McCollum Rosalind, Theobald Sally, Taegtmeyer Miriam, Kok Maryse, Sidat Mohsin
Department of Community Health, Faculty of Medicine, University Eduardo Mondlane, Av, Salvador Allende no.702, Maputo, Mozambique.
Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK.
BMC Health Serv Res. 2019 Apr 29;19(1):263. doi: 10.1186/s12913-019-4076-3.
Effective referral systems from the community to the health care facility are essential to save lives and ensure quality and a continuum of care. The effectiveness of referral systems in Mozambique depends on multiple factors that involve three main stakeholders: clients/community members; community health workers (CHWs); and facility-based health care workers. Each stakeholder is dependent on the other and could form either a barrier or a facilitator of referral within the complex health system of Mozambique.
This qualitative study, aiming to explore barriers and enablers of referral within the lens of complex adaptive health systems, employed 22 in-depth interviews with CHWs, their supervisors and community leaders and 8 focus group discussion with 63 community members. Interviews were recorded, transcribed and read for identification of themes and sub-themes related to barriers and enablers of client referrals. Data analysis was supported by the use of NVivo (v10). Results were summarized in narratives, reviewed, discussed and adjusted.
All stakeholders acknowledged the centrality of the referral system in a continuum of quality care. CHWs and community members identified similar enablers and barriers to uptake of referral. A major common facilitator was the existence of referral slips to expedite treatment upon reaching the health facility. A common barrier was the failure for referred clients to receive preferential treatment at the facility, despite the presence of a referral slip. Long distances and opportunity and transport costs were presented as barriers to accessibility and affordability of referral services at the health facility level. Supervisors identified barriers related to use of referral data, rather than uptake of referral. Supervisors and CHWs perceived the lack of feedback as a barrier to a functional referral system.
The barriers and enablers of referral systems shape both healthcare system functionality and community perceptions of care. Addressing common barriers to and strengthening the efficiency of referral systems have the potential to improve health at community level. Improved communication and feedback between involved stakeholders - especially strengthening the intermediate role of CHWs - and active community engagement will be key to stimulate better use of referral services and healthcare facilities.
从社区到医疗机构的有效转诊系统对于挽救生命、确保医疗质量和提供连续护理至关重要。莫桑比克转诊系统的有效性取决于多个因素，涉及三个主要利益相关者：客户/社区成员；社区卫生工作者；以及医疗机构的医护人员。在莫桑比克复杂的卫生系统中，每个利益相关者都相互依赖，可能成为转诊的障碍或促进因素。
这项定性研究旨在从复杂适应性卫生系统的角度探讨转诊的障碍和促进因素，对社区卫生工作者、他们的主管和社区领袖进行了22次深入访谈，并与63名社区成员进行了8次焦点小组讨论。访谈进行了录音、转录和阅读，以确定与客户转诊的障碍和促进因素相关的主题和子主题。数据分析得到了NVivo（v10）软件的支持。结果以叙述形式总结、审查、讨论和调整。
所有利益相关者都承认转诊系统在连续优质护理中的核心地位。社区卫生工作者和社区成员确定了类似的转诊促成因素和障碍。一个主要的共同促进因素是存在转诊单，以便在到达医疗机构时加快治疗。一个常见的障碍是，尽管有转诊单，但被转诊的客户在医疗机构未能得到优先治疗。长距离以及机会和交通成本被认为是在医疗机构层面获得转诊服务的可及性和可承受性的障碍。主管们确定了与转诊数据使用相关的障碍，而不是转诊的接受情况。主管们和社区卫生工作者认为缺乏反馈是功能性转诊系统的一个障碍。
转诊系统的障碍和促进因素塑造了医疗系统的功能以及社区对护理的认知。解决转诊系统的常见障碍并提高其效率有可能改善社区层面的健康状况。改善相关利益者之间的沟通和反馈——特别是加强社区卫生工作者的中间作用——以及社区的积极参与将是促进更好地利用转诊服务和医疗设施的关键。
