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Background and purpose: The process by which family physicians refer patients to specialized levels of the healthcare system is presented. In other words, the referral system can assure us that the clients of health care services are optimally allocated at the specialized level of services. In addition to providing proper time and providing proper health care for health benefits. The referral process is a specialized outpatient consulting process that determines the course and communication of the individual in three levels of the health system to provide the integrity and continuity of services this study aimed to determine the quality of referral and feedback forms in the medical family physician of Mazandaran province in 2019. Materials and methods: This descriptive cross-sectional study was conducted to examine the form of insurance referral of social security insurance by physicians of urban families and feedback from experts. After receiving the code of ethics and obtaining permission from the relevant organization the researcher paid the social security organization 1397 issued by the physicians in the province. The statistical population consisted of all forms of reference and the feedback from experts to the social security insurance organization to get the right According the report of the department of medical record department of the social security insurance organization of Mazandaran province in1397 has been handed over to that organization in a total of 151075 reference sheets completed to obtain the right of the specialists. the collected data were entered into Excel software for statistical analysis was performed in descriptive statistics using central dices (mean, median, mode) and dispersion index(variance, standard deviation, range of changes, coefficients of variation ) for quantitative variables, and index, percentage, and prevalence for qualitative data. The data were analyzed by using SPSS-25 software. Results: The study of 3200 cases of referral and referral forms of family physicians and specialists showed that among the Physicians 2321(72.5) were male and 879(27.5) were female. The patient's records in 586(%18.3) were incomplete. Clinical findings Were found in 98(2.7%) cases and paraclinical findings were incomplete in 22 cases (0.7%) and complete in 171 cases (5.3%). in 884 cases (27.6%) the papers were illegible the cause of referral was written in 560(17.5%). the reason for further referral in 187 cases (5.8%) was written by experts. In addition, 1454 cases (45.4%) of the return sheets completed by specialists were illegible. Conclusion: The results obtained in this study show that the status of the quality of completion of the referral form by the family doctors and also the status of providing feedback by the specialist doctors are not suitable. to improve this situation the implementation of face-to-face and non-face-to-face training programs for both groups and using electronic referral forms can be put on the agenda. [ABSTRACT FROM AUTHOR]

Background and purpose: The process by which family physicians refer patients to specialized levels of the healthcare system is presented. In other words, the referral system can assure us that the clients of health care services are optimally allocated at the specialized level of services. In addition to providing proper time and providing proper health care for health benefits. The referral process is a specialized outpatient consulting process that determines the course and communication of the individual in three levels of the health system to provide the integrity and continuity of services this study aimed to determine the quality of referral and feedback forms in the medical family physician of Mazandaran province in 2019. Materials and methods: This descriptive cross-sectional study was conducted to examine the form of insurance referral of social security insurance by physicians of urban families and feedback from experts. After receiving the code of ethics and obtaining permission from the relevant organization the researcher paid the social security organization 1397 issued by the physicians in the province. The statistical population consisted of all forms of reference and the feedback from experts to the social security insurance organization to get the right According the report of the department of medical record department of the social security insurance organization of Mazandaran province in1397 has been handed over to that organization in a total of 151075 reference sheets completed to obtain the right of the specialists. the collected data were entered into Excel software for statistical analysis was performed in descriptive statistics using central dices (mean, median, mode) and dispersion index(variance, standard deviation, range of changes, coefficients of variation ) for quantitative variables, and index, percentage, and prevalence for qualitative data. The data were analyzed by using spss-25 software. Results: The study of 3200 cases of referral and referral forms of family physicians and specialists showed that among the Physicians 2321(72.5) were male and 879(27.5) were female. The patient's records in 586(%18.3) were incomplete. Clinical findings Were found in 98(2.7%) cases and paraclinical findings were incomplete in 22 cases (0.7%) and complete in 171 cases (5.3%). in 884 cases (27.6%) the papers were illegible the cause of referral was written in 560(17.5%). the reason for further referral in 187 cases (5.8%) was written by experts. In addition, 1454 cases (45.4%) of the return sheets completed by specialists were illegible. Conclusion: The results obtained in this study show that the status of the quality of completion of the referral form by the family doctors and also the status of providing feedback by the specialist doctors are not suitable. to improve this situation the implementation of face-to-face and non-face-to-face training programs for both groups and using electronic referral forms can be put on the agenda.

Abstract Nigeria accounts for 39% of global malaria deaths in children under 5 years of age and the effective management of severe malaria is a health priority. The Annual Nigeria Severe Malaria Stakeholders Workshop, held on the 5–6th of July 2023 in Abuja, Nigeria brought together representatives from 36 States, the Federal Capital Territory, and other key stakeholders to address the management of severe malaria across all levels of the health service. Aims were to provide updates and review progress on severe malaria activities, the burden of disease, commodity logistics management, and pre-referral national policy implementation as well as to disseminate research findings. Two roundtable discussions were conducted to identify the challenges, barriers, and facilitators to the effective management of severe malaria in Nigeria. A key challenge was the limited awareness of updated guidelines and strategic documents among frontline health workers, leading to the misuse of non-recommended medications, like α-β-arteether. Further to this, the need to ensure appropriate treatments during pregnancy and the adoption of the WHO directive on the use of rectal artesunate were highlighted. To address these issues, innovative dissemination channels for guideline awareness were recommended and collaboration with professional organizations to enrich training materials emphasized. Other areas for improvement considered the processes involved in severe malaria management, with insufficient coordination among government agencies, inadequate referral linkages, and inadequate human resources identified as barriers. Recommendations focused on practical measures to minimize wastage of injectable artesunate, enhance data management through scaling up electronic medical records, and strengthen referral systems. The extension of severe malaria surveillance to patients older than 5 years was also proposed. To deliver these changes, actionable plans for sustained recruitment and training are needed, as well as committed advocacy at all levels to ensure timely fund disbursement and institutional support. A key overarching theme from the workshop was that a multifaceted approach was needed to address severe malaria in Nigeria, emphasizing collaborative efforts, evidence-based practices, and strategic resource allocation. With the largest malaria burden globally, the potential impact of addressing the challenges of severe malaria management in Nigeria cannot be understated and must be urgently addressed.

Abstract Background Efficient healthcare delivery and access to specialized care rely heavily on a well-established healthcare sector referral system. However, the referral system faces significant challenges in developing nations like Bangladesh. This study aimed to assess self-referral prevalence among patients attending tertiary care hospitals in Bangladesh and identify the associated factors. Methods This cross-sectional study was conducted at two tertiary care hospital, involving 822 patients visiting their outpatient or inpatient departments. A semi-structured questionnaire was used for data collection. The patients’ mode of referral (self-referral or institutional referral) was considered the outcome variable. Results Approximately 58% of the participants were unaware of the referral system. Of all, 59% (485 out of 822) of patients visiting tertiary care hospitals were self-referred, while 41% were referred by other healthcare facilities. The primary reasons for self-referral were inadequate treatment (28%), inadequate facilities (23%), critical cases (14%), and lack of expert physicians (8%). In contrast, institutional referrals were mainly attributed to inadequate facilities to treat the patient (53%), inadequate treatment (47%), difficult-to-treat cases (44%), and lack of expert physicians (31%) at the time of referral. The private facilities received a higher proportion of self-referred patients compared to government hospitals (68% vs. 56%, p

Nigeria accounts for 39% of global malaria deaths in children under 5 years of age and the effective management of severe malaria is a health priority. The Annual Nigeria Severe Malaria Stakeholders Workshop, held on the 5–6th of July 2023 in Abuja, Nigeria brought together representatives from 36 States, the Federal Capital Territory, and other key stakeholders to address the management of severe malaria across all levels of the health service. Aims were to provide updates and review progress on severe malaria activities, the burden of disease, commodity logistics management, and pre-referral national policy implementation as well as to disseminate research findings. Two roundtable discussions were conducted to identify the challenges, barriers, and facilitators to the effective management of severe malaria in Nigeria. A key challenge was the limited awareness of updated guidelines and strategic documents among frontline health workers, leading to the misuse of non-recommended medications, like α-β-arteether. Further to this, the need to ensure appropriate treatments during pregnancy and the adoption of the WHO directive on the use of rectal artesunate were highlighted. To address these issues, innovative dissemination channels for guideline awareness were recommended and collaboration with professional organizations to enrich training materials emphasized. Other areas for improvement considered the processes involved in severe malaria management, with insufficient coordination among government agencies, inadequate referral linkages, and inadequate human resources identified as barriers. Recommendations focused on practical measures to minimize wastage of injectable artesunate, enhance data management through scaling up electronic medical records, and strengthen referral systems. The extension of severe malaria surveillance to patients older than 5 years was also proposed. To deliver these changes, actionable plans for sustained recruitment and training are needed, as well as committed advocacy at all levels to ensure timely fund disbursement and institutional support. A key overarching theme from the workshop was that a multifaceted approach was needed to address severe malaria in Nigeria, emphasizing collaborative efforts, evidence-based practices, and strategic resource allocation. With the largest malaria burden globally, the potential impact of addressing the challenges of severe malaria management in Nigeria cannot be understated and must be urgently addressed. [ABSTRACT FROM AUTHOR]

Background: Efficient healthcare delivery and access to specialized care rely heavily on a well-established healthcare sector referral system. However, the referral system faces significant challenges in developing nations like Bangladesh. This study aimed to assess self-referral prevalence among patients attending tertiary care hospitals in Bangladesh and identify the associated factors. Methods: This cross-sectional study was conducted at two tertiary care hospital, involving 822 patients visiting their outpatient or inpatient departments. A semi-structured questionnaire was used for data collection. The patients' mode of referral (self-referral or institutional referral) was considered the outcome variable. Results: Approximately 58% of the participants were unaware of the referral system. Of all, 59% (485 out of 822) of patients visiting tertiary care hospitals were self-referred, while 41% were referred by other healthcare facilities. The primary reasons for self-referral were inadequate treatment (28%), inadequate facilities (23%), critical cases (14%), and lack of expert physicians (8%). In contrast, institutional referrals were mainly attributed to inadequate facilities to treat the patient (53%), inadequate treatment (47%), difficult-to-treat cases (44%), and lack of expert physicians (31%) at the time of referral. The private facilities received a higher proportion of self-referred patients compared to government hospitals (68% vs. 56%, p < 0.001). Among patients attending the study sites through institutional referral, approximately 10% were referred from community clinics, 6% from union sub-centers, 25% from upazila health complexes, 22% from district hospitals, 22% from other tertiary care hospitals, and 42% from private clinics. Patients visiting the outpatient department (adjusted odds ratio [aOR] 3.3, 95% confidence interval [CI] 2.28–4.82, p < 0.001), residing in urban areas (aOR 1.29, 95% CI 1.04–1.64, p = 0.007), belonging to middle- and high-income families (aOR 1.34, 95% CI 1.03–1.62, p = 0.014, and aOR 1.98, 95% CI 1.54–2.46, p = 0.005, respectively), and living within 20 km of healthcare facilities (aOR 3.15, 95% CI 2.24–4.44, p-value < 0.001) exhibited a higher tendency for self-referral to tertiary care facilities. Conclusions: A considerable number of patients in Bangladesh, particularly those from affluent urban areas and proximity to healthcare facilities, tend to self-refer to tertiary care centers. Inadequacy of facilities in primary care centers significantly influences patients to opt for self-referral. [ABSTRACT FROM AUTHOR]

BACKGROUND: Preeclampsia continues to be a major cause of maternal and perinatal mortality and morbidity globally. Although pre-referral treatment constitutes a bigger part of the management package for preeclampsia with severity features in low-income settings, little is known regarding the characteristics and challenges of preeclampsia pre-referral and referral management in the Sub-Saharan setting. OBJECTIVE: To determine the characteristics and challenges of pre-referral and referral management of preeclampsia with severity features. STUDY DESIGN: We conducted a mixed method study on the pre-referral management of pregnant women complicated by preeclampsia with severity features in Ethiopia. We prospectively collected data on clinical characteristics, management outcomes, and pre-referral characteristics of pregnant women who are complicated by preeclampsia with severity features. Data were collected using a structured questionnaire. For the qualitative part of our study, we conducted 20–30 minutes of semistructured, qualitative, face-to-face, in-depth interviews with 14 health professionals. Quantitative data were analyzed using SPSS (version 23), and simple descriptive statistics were employed. We used thematic analysis on Open Code 4.03 software to analyze the qualitative data. RESULTS: A total of 261 pregnant women who had preeclampsia with severity features were included in the study, and 14 care providers were interviewed about existing challenges with pre-referral management for patients with preeclampsia with severity features. The mean systolic and diastolic blood pressures were 154.3 mm Hg and 100.3 mm Hg, respectively. The total perinatal mortality was 6.5% (17/261). Three of 261 mothers (1.1%) were complicated by intracranial hemorrhage, and other 1.1% (3/261) of other women developed pulmonary edema. Out of 261 patients, only 41 patients (15.7%) received magnesium sulfate before referral. Similarly, antihypertensive medication was given only to 35 of 261 patients (13.4%) pre-referral. Eight of 261 mothers convulsed (3.1%) during referral. Two of 261 mothers (0.8%) developed pulmonary edema when they arrived at recipient health institutions after referral. Similarly, another 2 of 261 (0.8%) women developed disseminated intravascular coagulation by the time of arrival from the referring health institution. On the basis of qualitative data analysis, 3 overarching themes were recognized: (1) challenges related to patient and family resistance, (2) Challenges related to healthcare providers’ knowledge, skill, and confidence, and (3) health system-related challenges. Low use of magnesium sulfate and antihypertensive drugs, patient misperceptions regarding reasons for referral, providers’ lack of knowledge on the pre-referral management, inadequate communication between referring and recipient health institutions, and nonexistence of uniform preeclampsia pre-referral and referral management protocols among the referring institutions were the identified gaps. CONCLUSION: We found a significant gap in pre-referral management for patients with preeclampsia with severity features. Preeclampsia management policy reforms should include the introduction of adequate patient counseling platforms, increasing community awareness creation, providing in-service training on pre-referral management of preeclampsia for health personnel, ensuring constant availability of anticonvulsant and antihypertensive drugs and uniform implementation of preeclampsia pre-referral management protocols across health institutions.

Objective: To explore the concept of spiritual healing and compare its effects with allopathic medicine in terms of disease conceptualization, treatment approach and patient perception and use in community setting. Methods: A qualitative research design with a grounded theory approach was utilized for this study. Semi-structured interviews and focus group discussions were conducted, and data were analyzed using thematic content analysis technique. Results: The explorative of spiritual healing revealed motivation challenges and treatment frameworks. Healers emphasized skills mastery and adherence to values, employing methods like Ijazas and wazaiif. Patients reported mixed experiences, with some finding benefit while others expressed their doubt. Comparison with allopathic medicine highlighted drawbacks leading to discussion on preference or potential co-existence. Conclusion: In conclusion, spiritual healing offers a unique perspective on healthcare, while challenges exist, including skepticism and the need for integration with allopathic medicine. The field continues to play a pivotal role in addressing social well being. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this study was to determine the maternal mortality ratio at a tertiary care hospital of rural Assam, analyze the epidemiological factors and causes of maternal death, and to suggest recommendations for improvement. Method: This was a 10 year retrospective study from January, 2011 to December, 2020. Total 275 no of maternal deaths were taken for this study. Demographic and other data are collected from bed head tickets, case records, maternal death register and maternal death review register from office of O&G and MRD of Jorhat Medical College And Hospital. The maternal mortality ratio, epidemiological parameters, and causes of maternal mortality were evaluated. Results: In our study, total 275 no of maternal death were found in 69,685 no of live birth with a maternal mortality ratio(MMR) of 394.63 per 1,00,000 live birth. Out of total maternal death most are occurred in below 25 years of age which is 60% (165). Maximum maternal death 132(48%) out of 275 were primigravida. 211(76.7%) cases were found as unbooked. Most women died within 12 hours of admission 191, (69.4%) which suggest that majority of patients arrived at the hospital quite late. Maximum maternal deaths 141(51.2%) occurred in the postpartum period. Leading cause of maternal death in our study is found as eclampsia which is 78 no (28.4%). Conclusion: The majority of maternal deaths may have been avoided with good and proper antenatal care at primary level, early diagnosis and referral, better transportation facilities and better-equipped tertiary care centre. [ABSTRACT FROM AUTHOR]

Background: Adequate facilities for deliveries and for managing high risk pregnancy cases may not be available at all hospitals along with round the clock working staff. This study was done to identify the types of cases being referred and to study reasons for referral to tertiary care setup for management. Material and Methods: This prospective study was conducted over a period of 3 months in the Department of Obstetrics and Gynaecology, Government Maternity Hospital, Tirupati and included a total of 417 cases who were referred to this tertiary care center for further management. The following variables were analysed like age, birth order, referring facility, reasons for referral. Results: Most of the patients were from rural background. 20-40 years aged women were predominant. Primigravida women were mostly being referred. The maximum number of cases were referred from the nearby area hospitals. Previous history of cesarean section and premature rupture of membranes were the most common reasons for referral. Conclusion: Strengthening of the health care facilities and proper training of the staff so that they can decide when to refer and whom to refer can reduce the maternal mortality and morbidity significantly. [ABSTRACT FROM AUTHOR]

Objective: Liberia experiences an unmet need for cesarean section with about 5% population coverage, lower than 9%–19% coverage associated with improved maternal and newborn outcomes. Delays in the referral process for comprehensive emergency obstetric and newborn care (CEmONC) services due to ineffective communication between a rural health facility (RHF) and a district hospital contribute to the low CS rate. This study examined the association between mobile obstetric emergency system (MORES) implementation and referral time for obstetric emergencies as well as maternal/newborn outcomes. Methods: A pre‐post descriptive analysis was conducted on data collected from 20 rural health facilities (RHFs) and two hospitals in Bong County. Women with referral data from both RHFs and hospitals were matched and information including transfer time, reasons for referral, and maternal and newborn outcomes were extracted. Descriptive analysis and logistic regression models examined the relationship between the intervention's implementation and mode of delivery, maternal outcome, newborn outcome, and transfer time from RHF to district hospital. Ethics approval was obtained from two study centers. Results: Women had higher odds of undergoing a CS at endline (OR: 1.86 95% CI: 0.99–3.46) compared to baseline. Additionally, newborns had lower odds of showing non‐vigorous symptoms (OR: 0.31; 95% CI: 0.14–0.68), defined as a newborn with poor respiratory effort, muscle tone, or heart rate. There was no significant association between the intervention's implementation and transfer time. Conclusion: The MORES intervention is a promising means to increase timely care seeking along the referral pathway which may enhance access to cesarean section as well as improved newborn outcome in low‐ and middle‐income countries. Synopsis: Mobile obstetric emergency system (MORES) is a promising intervention to enhance communication between rural health facilities and hospitals to improve cesarean section rates and newborn outcome. [ABSTRACT FROM AUTHOR]

Background: In the highly competitive landscape of healthcare, nurturing strong relationships between referring healthcare providers and healthcare facilities is essential for maintaining patient loyalty. This study explores the factors influencing referring health care provider engagement and its subsequent impact on the willingness to rerefer to healthcare facilities. Methods: A cross-sectional quantitative survey was conducted with 181 healthcare providers who regularly refer patients to a private hospital in Jakarta. Data were collected through an online structured questionnaire consisting of 29 questions. The following dimensions were covered: specialist characteristics, practice characteristics, healthcare provider–specialist interaction, patient– specialist interaction, returning referral, training opportunity, healthcare provider engagement, and willingness to rerefer to hospital. Results: The study yielded significant findings, with five out of the six antecedents associated with healthcare provider engagement demonstrating statistical significance (p < 0.05). The most significant coefficient value pertaining to healthcare provider engagement was observed in patient–specialist interaction (β = 0.287, p < 0.05). Furthermore, the analysis indicated a substantial and positive correlation between health care provider engagement and willingness to rerefer to the healthcare provider (p < 0.05). Conclusions: Healthcare providers who demonstrate engagement with the hospital are likely willing to rerefer their patients to the hospital. Therefore, to increase the willingness to rerefer patients to the hospital, hospital management should prioritize fostering engagement with healthcare providers, particularly by improving patient and specialist interaction experiences. [ABSTRACT FROM AUTHOR]

Every year millions of people are burned and many of them are transported to specialized burn centers. One of the most important challenges in the face of burn patients in urban areas is deciding about referring patients to specialized burn centers. In this study, correlation between referral distance and mortality rate is investigated. Our cross-sectional analytic study included admission data of 7248 burn patients from Imam Reza Burn Center (Mashhad, Iran) over 9 years. The outcomes of interest were mortality, length of hospital stay, and the Abbreviated Burn Severity Index (ABSI). Also, we measured the distance between the patient referral location to Mashhad. SPSS version 16 was used for data analysis. Overall, 52.7% of admitted patients were referred from hospitals in other cities. The referred group had more severe burn injury (P <.001), higher mortality rate (P <.001), and longer length of hospital stay (P <.001). The referred distance was associated with an increased risk of death (Odds ratio = 1.68, 95% CI, 1.47–1.92), but after controlling the severity of burns, only ABSI was the statistically significant predictor of mortality (Odds ration = 2.17, 95% CI, 2.05–2.28). Therefore, increasing the distance from urban areas to specialized burn center did not increase the mortality rate. After adjusting for ABSI, the mortality rate in referred patients was not related to referral distance. By observing referral points based on available guidelines, distance from a referral burn center does not affect mortality rate independently. Therefore, equipping the existing burn centers instead of building new ones and focusing on improving referral system can be a good strategy in low- and middle-income countries with limited resources. [ABSTRACT FROM AUTHOR]

This article examines the assessment of gynecological procedures and referrals at Malingping Regional General Hospital in Indonesia from 2020 to 2022. The study reveals that ovarian tumors are the most prevalent gynecological condition, comprising 45% of cases. The hospital faces challenges in referring patients, particularly those with cancer, due to long travel distances and waiting times. The research emphasizes the necessity for infrastructure improvements, enhanced services, and health policy changes to ensure better access for regional patients. The document also discusses the management of gynecological cases at Malingping Regional Hospital, where referrals are based on factors such as case complexity, physician confidence, and facility availability. Ovarian tumors are the most common cases, with 80% being benign. However, late-stage diagnoses and limited access to specialized services contribute to high mortality rates. The hospital lacks certain diagnostic tests and specialist departments, necessitating referrals to other hospitals. The government is actively working to enhance access to specialist care and increase the number of hospitals in the area. [Extracted from the article]

Cascading of referrals to health institutions aims to increase the balanced distribution and quality of health services provided. Although health institutions in Turkey are divided into steps in terms of scope, there is no mandatory referral system for patient application. Patients admitted to the neurosurgery outpatient clinic of 3 different hospitals in the first week of September 2023 were analyzed. The patients' complaints, reasons for referral to the outpatient clinic, by whom or by which system, the department to which they should have applied, and the necessity of the operation were examined to evaluate. There were 671 applications made to the neurosurgery outpatient clinic in 3 different health institutions. The average examination time per patient was 6 minutes. Surgical treatment was planned for only 14.8% of the patients. Most patients were referred to physical therapy and neurology departments from neurosurgery. Only 59% of the patients came to the examination by making an appointment, while 41% were examined without an appointment. The ratio of inappropriate admissions to total admissions in these 3 health institutions was 85.1%. Only a minority of patients admitted to the neurosurgery outpatient clinic at a public health institution in Turkey were found to require surgery, while the majority were referred to other outpatient clinics. This study underscores the significance of the referral chain in delivering high-quality health care services, particularly in the field of neurosurgery. [ABSTRACT FROM AUTHOR]

Purpose: To assess the neonatal referral and transport system for gastroschisis patients referred to a tertiary level hospital in Kenya. Methods: This was a prospective cross-sectional study carried out at Kenyatta National Hospital (KNH) which recruited patients with gastroschisis using consecutive sampling approach. Data were collected on pre-, intra-transit factors, time and distance covered. Assessment was done using pre and intra transit factors as per the standard transport protocols in literature. Results: Twenty-nine patients presented with gastroschisis during the eight month study period. Mean age was 7.07 h. There were 16 (55.2%) males and 13 (44.8%) females. Mean birthweight was 2020 g, and a mean gestational age of 36.5 weeks. Mean duration of transit was 5 h. Mean distance from referring facility was 153.1 km. Most affected factors in the pre-transit protocol were lack of monitoring chart (0%), comment on blood investigations (0%), gastric decompression (3.4%), and prenatal obstetric scan (44.8%). For intra-transit scores, most affected were incubator use (0%), bowel monitoring (0%), functioning nasogastric tube (13.8%), and adequate bowel cover (34.5%). Conclusion: This study demonstrates that pre-transit and transit care of neonates with gastroschisis is inadequate in Kenya. Interventions needed, as identified by this study, to promote care of neonates with gastroschisis are advised. [ABSTRACT FROM AUTHOR]

The Sukabumi City Integrated Referral Service System (SLRT) is a program implemented in 2013 to help identify the poor and vulnerable to poverty. Providing information on various social protection and poverty reduction programs to the community. The purpose of this research is to find out how effective the Integrated Service and Referral System is in handling the social welfare problems of the poor in Sukabumi City. This research uses Campbell's theory. This research method uses qualitative methods. Data collection techniques were observation, interviewing, and documentation. Data validation methods used technical triangulation and source triangulation. The data analysis used was from Miles and Huberman, with data reduction, data presentation, and conclusion drawing. The results of this study indicate that the SLRT has been running in accordance with the stipulated law; its implementation has been quite effective in reducing poverty, but outreach to all the people of Sukabumi City is still uneven, and the socialization carried out is still lacking, both offline and online using social media, so that many people are not aware of the SLRT. The SLRT must improve its implementation in accordance with the SLRT General Implementation Guidelines No. 25 of 2017 so that it is more effective.

Background: Despite the assurance of universal health coverage, large disparities exist in access to surgery in the state of Chiapas. The purpose of this study was to determine the effectiveness of the surgical referral system at hospitals operated by the Ministry of Health in Chiapas. Methods: 13 variables were extracted from surgical referrals data from three public hospitals in Chiapas over a three-year period. Interviews were performed of health care workers involved in the referral system and surgical patients. The quantitative and qualitative data was analyzed convergently and reported using a narrative approach. Findings: In total, only 47.4% of referred patients requiring surgery received an operation. Requiring an elective, gynecological, or orthopedic surgery and each additional surgery cancellation were significantly associated with lower rates of receiving surgery. The impact of gender and surgical specialty, economic fragility of farmers, dependence upon economic resources to access care, pain leading people to seek care, and futility leading patients to abandon the public system were identified as main themes from the mixed methods analysis. Interpretation: Surgical referral patients in Chiapas struggle to navigate an inefficient and expensive system, leading to delayed care and forcing many patients to turn to the private health system. These mixed methods findings provide a detailed view of often overlooked limitations to universal health coverage in Chiapas. Moving forward, this knowledge must be applied to improve referral system coordination and provide hospitals with the necessary workforce, equipment, and protocols to ensure access to guaranteed care. Funding: Harvard University and the Abundance Fund provided funding for this project. Funding sources had no role in the writing of the manuscript or decision to submit it for publication.

Introduction: Silicosis is the most common and oldest occupational lung disease. The disease has been an ancient one and has been recognized in India for the past around 100 years. However, despite its ubiquitous presence among various mine and quarry workers, there is no uniformly available referral system in India in general for workers having occupational dust exposure and respiratory symptoms. The current study involved the clinical assessment of those working in mines and quarries in Jodhpur, Rajasthan, Western India and explore the possibility of development of a referral system for symptomatic mine workers. Materials and Methods: Workers working in mines and quarries in Jodhpur district were clinically screened for symptoms related to silicosis after choosing the quarries randomly. Demographic information and detailed occupational history were recorded using a predesigned questionnaire. Duration of exposure and morbidity/ mortality details related to silicosis in the family were noted in detail. Respiratory symptom score was evaluated using a numeric score. The study was a cross-sectional one, and a 12-point respiratory symptom score based on predesigned questionnaire was constructed using the literature survey of silicosis symptoms. Results: A total of 435 mine/quarries workers (M: F = 432:3) working in sandstone belt of Jodhpur, Rajasthan, Western India were assessed clinically, and details of their symptoms were noted. Demographic information was as followed mean age = 36.44 ± 11.23 years and mean duration of dust exposure = 13.4 ± 9.6 years. A total of 96/435 workers were symptomatic (22%), and salient hypoxia was present in 113/435 (26%). Both groups of these workers were referred to nearby community health centers for further evaluation. Awareness levels among the workers were poor, as only 119/435 (27%) workers had some ideas about the silicosis prevention while working in mines and quarries. Regular wearing of masks while being on the field was observed in only 8% (35/435). Mine Worker Screening Camp approach was used for symptomatic workers and evaluation by a three-member clinical board was done in community health center in the vicinity of mining areas. Those suspected of having silicosis were referred to pneumoconiosis board for further evaluation. Conclusions: High frequency of symptomatic mine workers (22%) exposed chronically to occupational dust was found in sandstone mines and quarries of Jodhpur region. Awareness levels about silicosis prevention were poor. A referral system for those needing further evaluation has been demonstrated. [ABSTRACT FROM AUTHOR]

Background and Aim: Primary levels of health services are designed to provide, maintain and promote the health of healthy young people, while the goal of higher levels is to screen and restore the health of the patients. One of the challenges is the personal culture of some of the health service providers and the recipients of these services. One of the recent reforms in the healthcare system has been the implementation the Health System Reform Plan based on the family physician and the referral system. This study investigated the status of the referral system in the family physician program in Isfahan metropolitan area in 2018. Materials and Methods: This was a qualitative study with a contractual content analysis conducted on a sample of 28 individuals selected by purposeful snowball sampling continued until saturation. Interviews were held with male and female healthcare workers (n = 14), midwives (n = 10), and managers (n = 4). Data analysis was done using the SPSS.25 statistical software. Results: This study succeeded to explain strategies to improve the quality of the referral system and the views of health service personnel and, finally, find the strengths, weaknesses and solutions for improving the referral system. Conclusion: The findings show that the performance of the referral system in the city of Isfahan is in line with the goals. However, visiting referred patients, providing feedback and referral to the laboratory are not as effective as they should be. Therefore, planning is needed to remove obstacles and solve problems such as shortage of human resources, non-human resources and infrastructure, insufficient provision of medicines and job insecurity so that goals can be reached. [ABSTRACT FROM AUTHOR]

Background and Aim: The health system is trying to prevent unnecessary referrals to higher levels by providing tiered services and thus reduce the cost of health care. Therefore, this study was conducted in Zahedan City, Iran with the aim of finding the causes of referrals from level 1 to higher tiers in rural areas. Materials and methods: This cross-sectional study was conducted on 458 rural patients referred to the second level in the rural areas of Zahedan City, Iran. Data were collected from the family health files available in the Sib system and analyzed using the SPSS-16 statistical software, the statistical tests being descriptive statistics (percentage, frequency) and Chi-square test. Results: The highest (57.6%) and lowest (4.1%) proportions of referrals to the second level of service provision were found to have been in 2018 and 2016, respectively. From among the referred patients nearly 50% had been referred due to the need for a higher expertise, thus most referrals (67.2%) were to specialists. Further analysis of the data showed that only in 23.6% of the cases there was a feedback from the higher level to the first level. Conclusion: The findings show that referrals from family physicians to higher levels in the health system requires higher medical expertise and patient insistence. In addition, feedback to the first level of service provision has not received proper attention. Establishing interactions between physicians and other health service levels, refresher training of physicians, emphasizing the importance of providing feedback and promoting the awareness of patients can reduce to a large extent inappropriate referrals. [ABSTRACT FROM AUTHOR]

Objective: To assess the quality of medical call writing in multiple tertiary care hospitals based on a variety of parameters. Method: The cross-sectional study was conducted in 8 tertiary care hospitals across Pakistan from May 27 to June 27, 2021, and comprised residents and consultants aged 25-60 years regardless of gender and specialty. Data was collected using questionnaires related to demographic and professional characteristics, quality of calls received, quality of calls sent, and opinion regarding improvements to the existing system. Data ws analysed using SPSS 22. Results: Of the105 participants, 65(62%) were residents and 40(38%) were consultants. General surgery team received referrals most frequently 26(24.7%). History of the patient along with relevant examination findings were mentioned in 4(3%) and 6(5%), respectively (p=0.6 vs p=0.5). The timeline was mentioned by 10(9.5%), (p=0.09), and it was inconsistent with the clinical relevancy in 13(12.3%) cases (p=0.5). The working diagnosis for which the patient was admitted in a particular service was mentioned in 35(33.3%) of the generated calls (p=0.01). Conclusion: The call referral system deserved more attention in order to improve communication among the physicians. Analysis of the quality of referral letters should be part of initial and continuing medical education. Key Words: Communication, Call system, Electronic medical record, Referral system.

Hospital congestion, delayed discharge, and bypassing primary care facilities are challenges facing the Iranian health‐care sector. We conducted a case study at the Sheikh al‐Rais Specialty Clinic, Tabriz, Iran, to find plausible, practical policy options for designing and implementing a referral system to reduce and regulate referral volumes to this clinic. We first reviewed the evidence on existing options of hospital congestion and unnecessary referral reduction by conducting a scoping literature review and then supplemented the findings with 18 semistructured interviews. We examined the perspectives of service users and experts in the field. Six practical policy options were identified: institutionalization of the referral system and family physician program, reinforcing gatekeeping system, use of telemedicine, utilization of educational algorithms, implementation of electronic health records, and establishing specialized clinics in different city areas. Local context adaptation, ensuring the availability of resources, political support, and feasibility are critical factors for successful policy implementation. Key points: Improving documentation using electronic health records, integrating electronic ‎health records with referral systems, controlling and reducing the demand for unnecessary ‎referrals through screening mechanisms, and the ability to refer patients to the most appropriate ‎level of referral are crucial.The workload in (sub‐) specialized university clinics can be reduced by ‎implementing the proposed policy options.Establishing an electronic health record system is pivotal in providing advanced and qualified health‐care services. [ABSTRACT FROM AUTHOR]

Primary care has been viewed as a means to ensure equitable access to care, enhance efficiency within healthcare systems, and improve health service quality. In recent decades, Iraq has transformed its compromised health system, shifting the healthcare model from hospital-based to primary care through primary health centers (PHCs) and referral mechanisms. Based on an extensive literature review, this qualitative paper explores the healthcare utilization of PHCs in different regions of Iraq. It also identifies some barriers to PHC use and recommends evidence-based approaches for improving PHCs' performance. Some reported challenges to better utilizing PHCs were the poor quality of services, patient dissatisfaction, long walking distance to a health center, and limited availability and affordability of the medications. If Iraq is to use primary care as a tool in achieving sustainable development goals (SDGs), collaborative efforts addressing the facility-related factors should be a priority. [ABSTRACT FROM AUTHOR]

Introduction: The present study qualitatively investigated the main components that should be considered for the implementation of the referral system in Bojnord city. Methods: In this study, data were collected through doing interviews with experts, and finally, the importance of all the extracted components was evaluated using a researcher-made questionnaire. Also, the exploratory factor analysis method was used to classify the components in main sets. Kolmogorov-Smirnov, one-sample t-test, performed in Excel and SPSS software, was used for statistical analysis. Results: The most frequent noted components by the experts included "empowerment (knowledge, skill, psychological) of human resources involved in the referral system", "paying attention to the motivation of human resources involved in the referral system", and "developing suitable processes for the referral system and re-engineering the processes to meet the conditions". Finally, the main requirements in the referral system of Bojnord city were divided into three categories included organizational and management, manpower, and technology-based requirements. Conclusion: Briefly, some components may lead to improvement of the referral system, which can be categorized into organizational and management, manpower, and technology-based requirements. Detailed planning to improve the referral system can lead to the improvement of the health system.

As per the goals of the family physician program, it is essential to pay attention to the effectiveness and performance of FPP. Although the implementation of the FPP program is an important development in the discussion of rural health insurance and the provision of health services and referral systems in the country, the evidence suggests that by identifying challenges and taking appropriate action, this plan can be improved. This study aimed to investigate the challenges of rural Family Physician Policy (FPP) in northern Iran. This study comprised a mixed method. The former intended to identify the challenges of rural FFP using the narrative review method. To achieve a comprehensive list of challenges, a narrative review and content analysis were performed and semi-structured interviews were held with key stakeholders of FPP in the north of Iran, including physicians, managers, and policymakers. Identified challenges were categorized into eight categories including the weakness of the health insurance system, low comprehensiveness of executive guidelines, inappropriate recruitment and maintenance of human resources, weakness of cultural context, low efficacy of health information management system, poor educational effectiveness, inappropriate motivational mechanisms, and weakness of the referral system. As per the quantitative findings, "weakness of the referral system" and "inappropriate recruitment and maintenance of human resources" had the lowest and highest weaknesses, respectively. To address existing challenges in the rural FPP, a comprehensive plan of action should be developed with an emphasis on human resource management, health information management system, comprehensive rural health insurance, and legislation. [ABSTRACT FROM AUTHOR]

Objective (s): One of the important factors for the implementation of primary health care is the referral system. The aim of this study was to analyze of electronic referral system agenda setting based on Kingdon's multiple streams framework in Golestan province. Methods: A qualitative study was conducted in 2020 based on Kingdan (2003) model in Golestan province. Data were collected using two methods of document review and in-depth individual interviews with 26 individual interviews. Purposeful sampling and analysis of documents were performed by content analysis and interviews were analyzed by framework analysis. Results: The Problem stream was the weakening of the general practitioner and the non-referral of patients, the increase in the payment of people and insurance organizations, and the absence of some specialist physicians. The Policy stream included the obligation to implement the family physician program and referral system in upstream laws and documents, the implementation of the rural family physician program and referral system in 2005, and the urban family physician program in Fars and Mazandaran provinces. The Politic stream included launching a lean system at Golestan University of Medical Sciences, passing a law allocating one percent of value-added resources to the prevention and treatment of villagers within the referral system, and charismatic policymakers and committed executives. Conclusion: Despite the problems caused by the non-implementation of the referral system and the enforcement of laws due to conflicts of interest and insufficient funding for policy implementation in this area, the intersection of three currents of problem, policy, and political determination led to the opening of the window of e-referral policy and system in Golestan province.

Background: The overall quality of care may be hampered by poorly written referrals. Referral letters should be detailed to elicit prompt response by the invited unit. This will enhance ideal management of cases that are referred. Aim: The aim of the study is to determine the quality (content and usefulness) of referral letters received from inpatient clinical wards of University of Nigeria Teaching Hospital (UNTH), Ituku/Ozalla by hematology department of the hospital. Materials and Methods: This was a retrospective study of all referral letters received in hematology department of the hospital over a 1-year period (January to December, 2019) using a validated questionnaire. Results: A total of 231 referral letters were received and evaluated. The median age of the patients was 35 (range: 20–59) years with male-to-female ratio of 1:1.3. Initial statement identifying the reason for the referral was observed in 88.7% (n = 205). Majority (176/213, 82.5%) of the referrals did not include the results of investigations the patients did before the referral. Less than a quarter of the referrals (41/231, 19.3%) contained information on the treatment given to the patient. More than one-tenth (24/231), 11.3%) of the referrals were unhelpful while 13.6% (n = 29) were helpful. Conclusion: The referrals sent to the hematology department were deficient in quality. These deficiencies could be ameliorated by tutoring the younger doctors on the content of an ideal referral letter. Furthermore, a well-structured “referral form” with prompts for easy filling could be designed by hospitals as a guide to physicians for writing appropriate referral letter.

Abstract Background This study looks at the factors that can shape patients’ choice of healthcare providers. Understanding this process can help with making high quality healthcare more accessible for all. We focus on distance, patient’s health status, (perceived) quality of healthcare facility, and referrals to investigate how these factors compete in shaping patients’ choice of hospitals. Methods This study was carried out in Managua, the capital of Nicaragua. Utilizing an exit-survey, patients were interviewed across five public hospitals in 2017 and then six in 2019 when a new highly-equipped hospital was added to the system. We used a multinomial logit model to investigate patients’ preference of a specific hospital over the rest within each wave. Results Our results show that being referred to a hospital is the strongest predictor and in some cases, it can increase the relative risk ratio of choosing a facility by a factor of 49 (p

Abstract Background The family physician program was launched in 2005 in rural areas of Iran and then piloted in 2012 in the cities of Fars and Mazandaran provinces due to insufficient health coverage in these cities. However, despite its pivotal role in the health system, this program has not progressed according to the policies. This study aimed to explain the underlying factors and challenges of implementing the urban family physician program in Iran. Methods This qualitative study was conducted on 44 policy-makers and managers at national and provincial levels selected via snowball and purposive sampling with maximum variation. The data were managed in MAXQDA 2020 and analyzed by directed content analysis. A triangulation method was adopted for this purpose. Results A total of 10 categories, 18 sub-categories, and 29 codes were formed. Most challenges related to underlying factors included precipitancy, economic sanctions, belief in traditional medicine, belief in the expertise of previous physicians, and global ranking of countries. For program implementation, most challenges included a diversity of insurance organizations, budget allocation, referral system, electronic file, educational system, and culture building. Conclusions The major challenges pertaining to underlying factors included international pressure for reforms and precipitancy in program implementation due to management changes. The challenges associated with program implementation included budget provision and interaction with insurance organizations. Therefore, to expand this program to other provinces in Iran, the identified factors should be carefully considered so that sufficient confidence and commitment can be guaranteed for all stakeholders.

Abstract Background Over ten years on from a randomised controlled trial and subsequent national roll-out, the National Exercise Referral Scheme (NERS) continues to be routinely delivered in primary care across Wales, UK. Few studies have revisited effective interventions years into their delivery in routine practice to understand how implementation, and perceived effects, have been maintained over time. This study explores perceptions and experiences of referral to NERS among referrers, scheme deliverers and patients. Methods Individual, semi-structured interviews were conducted with 50 stakeholders: scheme referrers (n = 9); scheme deliverers (n = 22); and referred patients (n = 19). Convenience sampling techniques were used to recruit scheme referrers and purposive sampling to recruit scheme deliverers and patients. Thematic analysis was employed. Results Analyses resulted in five key themes; referrer characteristics, geographical disparities in referral and scheme access, reinforcements for awareness of the scheme, patient characteristics and processes and context underpinning a referral. Overall there was a high concordance of views between all three stakeholder groups and barriers and facilitators were found to be entwined within and across themes. Referral barriers persisting since the earlier trial included a lack of consultation time and a lack of referral feedback. Newly identified barriers included a lack of scheme awareness and a referral system perceived to be time intensive and disjointed. Key referral facilitators included patient self-referrals, a growing scheme reputation and promotional activities of scheme deliverers. Conclusions Findings provide evidence that could inform the further development of NERS and wider exercise referral schemes to ensure the referral process is timely, efficient and equitable.

Background: With government's proposal of the Healthy China Strategy, universal health has become the focus of increasing attention in China. As a special group, children's health is the basis and start of the national health. The construction of children's healthcare system should be given the priority. This study applied the concept of health equal benefits and conducted a systematic and in‐depth theoretical and empirical research on the children's healthcare system in Beijing, aiming at proposing relevant countermeasures and suggestions such as constructing the path of children's health care system in China. Methods: This study adopted the way of questionnaire on children's basic information, health status, health service demand, insured situation and system satisfaction and then analysed the children's health, healthcare, satisfaction influence factors and their healthcare needs based on a survey in Beijing China. Methods such as descriptive statistics, analysis of variance and logistic regression are adopted to analyse the correlation between factors affecting children's health. Results: The findings show that overall health of the children in Beijing was better. However, there are still problems such as insufficient resource coverage and incorrect cognition in some groups. Their mental health and support need to be put emphasis on. The popularization of medical insurance policies for urban and rural residents in Beijing needs to be further improved. The burden of seeing a doctor is slightly lower than before, and the contribution to protecting children's health is not strong enough. Conclusions: Through the survey of children in Beijing, it can be seen that there are still some problems existing in the healthcare system of children in China from the perspective of equal benefit. This study draws policy attention to the issues of financing, service contents, targets, service level and the degree of social recognition. [ABSTRACT FROM AUTHOR]

Introduction: The present study qualitatively investigated the main components that should be considered for the implementation of the referral system in Bojnord city. Methods: In this study, data were collected through doing interviews with experts, and finally, the importance of all the extracted components was evaluated using a researcher-made questionnaire. Also, the exploratory factor analysis method was used to classify the components in main sets. Kolmogorov-Smirnov, one-sample t-test, performed in Excel and SPSS software, was used for statistical analysis. Results: The most frequent noted components by the experts included "empowerment (knowledge, skill, psychological) of human resources involved in the referral system", "paying attention to the motivation of human resources involved in the referral system", and "developing suitable processes for the referral system and re-engineering the processes to meet the conditions". Finally, the main requirements in the referral system of Bojnord city were divided into three categories included organizational and management, manpower, and technology-based requirements. Conclusion: Briefly, some components may lead to improvement of the referral system, which can be categorized into organizational and management, manpower, and technology-based requirements. Detailed planning to improve the referral system can lead to the improvement of the health system. [ABSTRACT FROM AUTHOR]

Aims: This review aims to map the needs and challenges in the application of teledentistry and online referral system encountered by dental health care professionals in Indonesian primary health care centers (puskesmas) to provide safe dental health service to the population during the COVID-19 pandemic. Materials and Methods: Literature search was undertaken of both in Indonesian and overseas context related to teledentistry. Narrative review of the literature was written to present the challenges, solutions, and application of teledentistry at Puskesmas to optimize oral health services during the COVID-19 pandemic. Results: Online referral system and teledentistry are options to help dental health service delivery in the pandemic era. While it has been adopted in many private clinics, there are many challenges to adopt it at the puskesmas level due to a lack of infrastructure, human resources, and budget allocation. While the Indonesian government has plans to support the digitization in the education and health sector, this pandemic shall pose an opportunity for Indonesian health department to develop and facilitate the use of teledentistry and online referral system. During this situation, health cadres can bridge the relationship between Puskesmas and the poor community through the help of teledentistry. Conclusions: The government commitment in applying online referral system and teledentistry in Puskesmas is needed. Dental education institutions can help to supply human resources, who are capable of developing and carrying out the most suitable teledentistry application for all stakeholders. [ABSTRACT FROM AUTHOR]

Expensive medical treatment (Kanbing Gui in Chinese) is not only an economic problem, but also a major concern of livelihood. To realize the strategy of Healthy China, it is urgent for China to address the "Kanbing Gui". As the core mechanism about medical resource allocation, the referral system plays a significant role in optimizing resource allocation. However, since the implementation of the new health system reform, the structural imbalance and low efficiency of resource allocation in China' s healthcare system have not been improved effectively, and the problem of "Kanbing Gui" still exists. The referral system, as a basic institution, can reduce medical costs to the greatest extent, but few studies have investigated expensive medical treatment from the imbalance of resource allocation in the referral system. In this paper, first of all, the current referral system in China and its structure of resource allocation characterized by the "inverted pyramid" are described in a theoretical way. Then, the mechanism related to the impact of resource imbalance on the "Kanbing Gui" in the referral system is explained from the aspects of factors' scale effect and transaction cost effect. Finally, based on the sample data of 30 provincial regions in China from 2010 to 2019, this paper empirically examines the imbalance of resource allocation in the referral system from the three aspects of human, material and financial resources. Also, it tests the influence of referral system on "Kanbing Gui" and its heterogeneous shock. There are two main findings: Firstly, the imbalance of resource allocation in the referral system significantly aggravates the problem of "Kanbing Gui" at the individual and national levels. Secondly, the Cost Disease caused by the imbalance of resource allocation has emerged in the eastern and western regions, but has not yet appeared in the central region. Compared with the existing research, this paper makes expansions in the following two aspects. Firstly, it theoretically illustrates the internal inconsistency between the structural features of resource allocation and the rational structure of medical services demand in China' s referral system. Also, it explores the internal mechanism of "Kanbing Gui" caused by structural imbalance of medical resource allocation. Secondly, the problem of "Kanbing Gui" is investigated from the imbalance of resource allocation. The referral system is widely used to optimize resource allocation and reduce medical costs in various countries and regions around the world. Due to the poor performance of referral system in China, it is worth studying whether it has the opposite effect on the problem of "Kanbing Gui". This study, to some extent, also reveals the mechanism that the current referral system affects the "Kanbing Gui", which might be helpful to analyze the reasons why the referral system is difficult to implement. In addition, it can provide an enlightenment about the urgent issue of "Kanbing Gui". Optimizing medical resource allocation and reducing medical costs are the foundation of establishing an integrated healthcare system and implementing the strategy of Healthy China. [ABSTRACT FROM AUTHOR]

Abstract Background Low and middle income countries has recently implemented various reforms toward Universal Health Coverage (UHC). This study aims to assess the impact of Family Physician Plan (FPP) and Health Transformation Plan (HTP) on hospitalization rate in Iran. Methods We conducted an Interrupted Time Series (ITS) design. The data was monthly hospitalization of Mazandaran province over a period of 7 years. Segmented regression analysis was applied in R version 3.6.1. Results A decreasing trend by − 0.056 for every month was found after implementation of Family Physician Plan, but this was not significant. Significant level change was appeared at the beginning of Health Transformation Plan and average of hospitalization rate increased by 1.04 (P

Abstract Background Weak referral systems remain a major concern influencing timely access to the appropriate level of care during obstetric emergencies, particularly for Low-and Middle-Income Countries, including Ghana. It is a serious factor threatening the achievement of the maternal health Sustainable Development Goal. The objective of this study is to establish process details of emergency obstetric referral systems across different levels of public healthcare facilities to deepen understanding of systemic barriers and preliminary solutions in an urban district, using Ablekuma in Accra, Ghana as a case study. Methods The study is an analytical cross-sectional study. Nine [1] targeted interviews were carried out for a three-week period in June and July 2019 after informed written consent with two [2] Obstetrics & Gynaecology consultants, two [2] Residents, one family physician, and four [3] Midwives managing emergency obstetric referral across different levels of facilities. Purposeful sampling technique was used to collect data that included a narration of the referral process, and challenges experienced with each step. Qualitative data was transcribed, coded by topics and thematically analysed. Transcribed narratives were used to draft a process map and analyze the defects within the emergency obstetric referral system. Results Out of the 34 main activities in the referral process within the facilities, the study identified that 24 (70%) had a range of barriers in relation to communication, transport system, resources (space, equipment and physical structures), staffing (numbers and attitude), Healthcare providers (HCP) knowledge and compliance to referral policy and guideline, and financing for referral. These findings have implication on delay in accessing care. HCP suggested that strengthening communication and coordination, reviewing referral policy, training of all stakeholders and provision of essential resources would be beneficial. Conclusion Our findings clearly establish that the emergency obstetric referral system between a typical teaching hospital in an urban district of Accra-Ghana and peripheral referral facilities, is functioning far below optimum levels. This suggests that the formulation and implementation of policies should be focused around structural and process improvement interventions, strengthening collaborations, communication and transport along the referral pathway. These suggestions are likely to ensure that women receive timely and quality care.

Background: The public sector of the health care system provides justice and access for all people who need more specialized services through the referral system. If the challenges of the referral system are not identified and addressed promptly, the system will not be efficient and effective. The purpose of this study was to rank the reasons for non-referral of outpatient level 1 to level 2 in the electronic referral system of Golestan province in 2019. Methods: In this descriptive and cross-sectional study, 431 outpatients participated from the pilot hospitals of the e-referral system in Golestan province, who did not refer to the level 2 specialist despite that an appointment was set by the system. The participants were selected using a stratified random sampling method. Data were collected using a questionnaire and analyzed by descriptive statistics and Friedman test in SPSS 23 software. Results: The most important reasons for patients who were not referred from level 1 to level 2 in the electronic referral system included the presence of a trusted and familiar physician, inability to pay the visit of a specialist, and high cost of transportation from home to the designated specialist, respectively. The gender of the specialist physician and lack of guidance on referral to the specialist physician were indicated by the referral center. Patients ranked the reasons of not referring to the specialist differently (P < 0.001). Conclusions: The current status can be improved by increasing the public confidence in specialized physicians working in the electronic referral system and making the specialized services free for the poor patients. Furthermore, raising the patientchr('39')s awareness about using Level 2 specialized services through the mass media can help patients to benefit from these services.

Abstract Background Between the years 2000 and 2017, the global maternal mortality rate dropped by 38% however, 94% of maternal deaths still emanated from low-to middle-income countries. Rural women are at a significantly higher risk of dying from pregnancy when compared to their urban counterparts. Early detection of complications and prompt referral to higher levels of care can reduce the associated maternal and perinatal mortality. This study aimed to determine the maternal and perinatal outcomes of pregnancy-related referrals from rural health facilities to central hospitals in Harare, Zimbabwe. Methods A prospective descriptive study was conducted using a sample of 206 patients. All mothers who were referred from rural healthcare facilities were recruited for participation. Data were extracted from patient notes using a structured questionnaire and missing information was obtained from the mother after she had recovered. Bivariate analysis was done using IBM SPSS. Results The average age of study participants was 27.4 ± 7.7 years. 87.4% had booked for antenatal care and 81.6% presented to the tertiary facility with their referral notes. The major reasons for referring patients were previous cesarean section (20.4%) and hypertensive disorders in pregnancy (18.4%). There were nine maternal deaths thus a case fatality rate of 4.4% while the perinatal mortality rate was 151/1000 live births. Young mothers were at a higher risk of having adverse perinatal outcomes while primiparous mothers were more likely to have a blood transfusion. Mothers who traveled for > 100 km to the tertiary facility and those who did not attend any antenatal visit were more likely to need blood transfusion. Delivering at the rural health facility was significantly associated with receiving a blood transfusion at the tertiary facility. Mothers who did not attend antenatal visits were more likely to have negative perinatal outcomes. Conclusion The proportion of obstetric patients being referred from rural facilities to tertiary institutions for complications reveals how primary and secondary healthcare facilities in Zimbabwe are falling short of offering the services they should be offering. Equipping these facilities with skilled human resources as well as contemporary equipment could help decongest the central hospitals consequently reducing the adverse maternal and perinatal outcomes.

As per the goals of the family physician program, it is essential to pay attention to the effectiveness and performance of FPP. Although the implementation of the FPP program is an important development in the discussion of rural health insurance and the provision of health services and referral systems in the country, the evidence suggests that by identifying challenges and taking appropriate action, this plan can be improved. This study aimed to investigate the challenges of rural Family Physician Policy (FPP) in northern Iran. This study comprised a mixed method. The former intended to identify the challenges of rural FFP using the narrative review method. To achieve a comprehensive list of challenges, a narrative review and content analysis were performed and semi-structured interviews were held with key stakeholders of FPP in the north of Iran, including physicians, managers, and policymakers. Identified challenges were categorized into eight categories including the weakness of the health insurance system, low comprehensiveness of executive guidelines, inappropriate recruitment and maintenance of human resources, weakness of cultural context, low efficacy of health information management system, poor educational effectiveness, inappropriate motivational mechanisms, and weakness of the referral system. As per the quantitative findings, “weakness of the referral system” and “inappropriate recruitment and maintenance of human resources” had the lowest and highest weaknesses, respectively. To address existing challenges in the rural FPP, a comprehensive plan of action should be developed with an emphasis on human resource management, health information management system, comprehensive rural health insurance, and legislation.

During the outbreak of epidemics such as coronavirus disease (COVID-19), the local hospitals often withstand a sharp increase of patient influx, which renders the healthcare system on the verge of collapse. To alleviate the situation, the effective allocation of scarce medical resources during the pandemic plays a vital role. The essence of the healthcare system in time of emergency is to stay functional, and to be able to diagnose and hospitalize as many patients as possible. Fangcang shelter hospital, as a novel way to temporarily increase the capacity of the local healthcare system, is proven to be effective against the COVID-19 pandemic. To improve the performance of the healthcare system with Fangcang, many practical factors need to be taken into account, such as the patient deterioration during waiting to be admitted, the referral mechanism according to the severity of the patients, and the selective admission regulations. To address the high volatility and time-varying feature of the COVID-19, a multistage and multi-type medical service network model is established, and a dynamic allocation strategy of the medical resources at each stage is proposed based on a stochastic optimization problem, which is then solved via the fluid queueing approximation. Combined with the real data collected from Wuhan, it is revealed that the proposed algorithm could help with the allocation of medical resources during the outbreak of epidemics. Even with limited medical resources available, the method could still maintain a guaranteed service level while keeping the healthcare system operational. Furthermore, the simulation analysis validates that our method can effectively allocate medical resources at each stage, so as to stabilize the system performance and fulfill the medical demand for multiple types of patients. Note to Practitioners—To fend off the outbreak of epidemics, the lessons have to be learned from the past. The successful control of the spread of COVID-19 in Wuhan (China) is a classical example of applying modern medical practices and management tools. In the present article, the treating procedure of COVID-19 in Wuhan is modeled as a multistage decision problem, which includes the screening with nucleic acid testing, the further testing, the treatment of patients with mild/severe symptoms, or even critical patients. The introduction of Fangcang shelter hospital is crucial for winning the battle against COVID-19. The current study attempts to determine the timing of introducing the Fangcang shelter hospital during the outbreak of a major epidemic, and helps allocate the medical resources needed to contain the spread of the virus. It is discovered that the actual number of beds in the Fangcang shelter hospital is far more than what is necessary, and it would be better to have built the Fangcang some time in advance. In the meantime, the number of designated hospitals for COVID-19 is in line with the results obtained via the optimal staffing strategy proposed here, but it is also noticeable that these hospitals should be released of duty sooner to fight against not only COVID-19 but also other diseases in reality. [ABSTRACT FROM AUTHOR]

Primary healthcare will not be effective unless there is a proper referral system. In contrast, comparing the performance of healthcare systems provides an opportunity for policy makers to determine the status of the country's healthcare system compared with their international counterparts. Therefore, we ranked the countries in terms of indicators affected by the referral system. This study was conducted in 2020. In the first phase, which was to determine the indicators affected by a country's referral system, data were collected by the Delphi method, and therefore, 13 indicators with a content validity ratio equal to or greater than 0.42 were selected. In the second phase, the data of 13 indicators selected in the first phase were extracted from the 2018 and 2019 World Health Organization reports. The weight of the indicators was calculated based on the Decision-Making Trial and Evaluation Laboratory method–based Analytic Network Process (DANP) and Shannon's entropy, and the VIekriterijumsko KOmpromisno Rangiranje (VIKOR) method was used to rank the countries. SPSS 24 and Excel 2013 software were used for data analysis. Switzerland, Germany, and Sweden ranked first, second, and third, respectively. In all the 3 countries, there are no mandatory gatekeeping systems. Physicians, especially general practitioners, are the core of primary healthcare, and in all the 3 countries, there is a uniform and coherent health financing system that is either based on mandatory health insurance (Switzerland and Germany) or taxes (Sweden). India had the lowest ranking. It seems that the study of the health system of the countries that have obtained higher rankings can indicate their efforts in establishing a gatekeeping system, family physician program, and appropriate financing system. Therefore, other countries can study successful countries and copy them as a model to improve their health system. • The researchers used few indicators to rank the countries. • The decision-making trial and evaluation laboratory method–based analytic network process and Shannon's entropy were used to weigh the indicators affected by the referral system, and Vlsekriterijumska Optimizacija I Kompromisno Resenje was used to rank the countries. • Policy makers can take high-ranking countries as a model to improve their health system. [ABSTRACT FROM AUTHOR]

Background: Nowadays, prosthodontic patients are inquisitive about the various treatments available in the dental clinic. Several Prosthodontics services are obtainable depending on the extent of the damaged teeth, the number and position of remaining teeth, restoration of partially and completely edentulous arch, patient general health and preference. The rehabilitation can be either fixed or removable prosthesis, implant system or obturators. This study aims to assess the prosthodontic awareness and treatment services provided by the general dentist and specialists practicing in Ha’il. Methods: This observational study had a cross- section design. Nonprobability sampling technique was employed that produced information from 106 respondents working in various dental centers of Hail city, utilizing questionnaire survey. Collected data were analyzed using SPSS Version 23. The Fisher Exact test was utilized to check the significant differences between variables. Results: A total of 106 respondents most of them worked in the academic institution 41.3% and government clinic 39.4%. Overwhelming response from general practitioner 82.1% and 17.9% for specialist were recorded. Majority of the dentists were worked with Fixed Prosthodontics 93.4%, Removable 61.3%, then the Implant and Maxillofacial Prosthodontics. Dentist who referred patient to specialist at least 1-5 times per month 48.1% was the highest among the referral system. Significant difference were present between specialty and patient referral or implant prosthodontics with P values of 0.036, and 0.0001 respectively. Conclusions: Different Prosthodontic services are available in Ha’il, the most popular is Fixed prosthesis over the removable and implant supported prosthesis. General practitioners and specialists are doing referral system to the prosthodontist. Moreover, the awareness about prosthodontics and CAD/CAM technology are evident, but less in clinical skills. Enhancement of Prosthodontics skills among the dentists by attending training courses or higher studies related to Prosthodontic rehabilitation are recommended.

Objective: The purpose of this study was to assess patients’ perception on tiered maternal referral system (during pregnancy, delivery, and postpartum) in a hospital of West Sumatra of Indonesia. Materials and Methods: The design was a cross-sectional interview survey. A convenient sampling technique was used to recruit 134 sample. Our study was approved by the Committee of the Research Ethics of the Faculty of Medicine, Andalas University number 002/KEP/FK/2018. An interview guideline was prepared and translated into Bahasa Indonesia. There were two interviewers recruited and trained to collect information for the study. Each interview took approximately 12 minutes and were recorded using mobile phone. Data from the interviews were analysed by using QSR NVIVO 10 and MS Excel 2010. Results: The vast majority of the respondents reported that there was sufficient understanding of the services and the structure of the overall tiered referral system. The complaints addressed the issue of administrative procedure, accessibility, and equity, waiting time and card activation, ease of obtaining referral letter in the primary level of healthcare, and transport duration when the patient has to be referred to advance level of healthcare. Conclusion: The functional use of electronic referral system is an urge for solution. Future studies on patients’ perception and assessment toward healthcare providers’ opinion should be carried out to increase the service quality.

In recent decades, bold steps taken by the government of Nepal to liberalise its abortion law and increase the affordability and accessibility of safe abortion and family planning have contributed to significant improvements in maternal mortality and other sexual and reproductive health (SRH) outcomes. The Trump administration’s Global Gag Rule (GGR) – which prohibits foreign non-governmental organisations (NGOs) from receiving US global health assistance unless they certify that they will not use funding from any source to engage in service delivery, counselling, referral, or advocacy related to abortion – threatens this progress. This paper examines the impact of the GGR on civil society, NGOs, and SRH service delivery in Nepal. We conducted 205 semi-structured in-depth interviews in 2 phases (August–September 2018, and June–September 2019), and across 22 districts. Interview participants included NGO programme managers, government employees, facility managers and service providers in the NGO and private sectors, and service providers in public sector facilities. This large, two-phased study complements existing anecdotal research by capturing impacts of the GGR as they evolved over the course of a year, and by surfacing pathways through which this policy affects SRH outcomes. We found that low policy awareness and a considerable chilling effect cut across levels of the Nepali health system and exacerbated impacts caused by routine implementation of the GGR, undermining the ecology of SRH service delivery in Nepal as well as national sovereignty.

Background: The Family Physician Program, one of the most important efforts of the Iran health system to establish a referral system, was developed and implemented in several provinces, but it faced challenges due to several reasons that prevented the programchr('39')s progress. So This study was conducted to analyze the family physician program to identify the causes and challenges of the program failure. Materials & Methods: This retrospective study of policy analysis is a qualitative study with Purposive sampling. Semi-open interviews and document analysis were used for data collection. Data analysis was performed through thematic analysis in the policy triangle framework using MAXQDA software. Results: According to the study framework, the challenges of the Family Physician Program in the context are conflict of interest, dependency of plans to oneself, instability in management and plans, insufficient attention to culture, resources, and infrastructure. In terms of content include disproportionate executive approach, Lack of localization, selection of inappropriate tools, insufficient transparency, and ambiguity in goals, tasks, and responsibilities; The challenges of the process were examined based on the policy cycle. Conclusion: The implementation of the family physician program is influenced by cultural, social, political, managerial, and economic factors. As the Ministry of Health officials has re-introduced this crucial program, reviewing the content and methods of program implementation seems necessary.

Background and Aim: Referral system is one of the principles and foundations of primary health care services. One of the most important challenges and problems of the referral system is the lack of knowledge of people and patients of its nature, services and benefits. The purpose of this study was to identify the factors affecting the acceptance of the referral system by patients. Materials and Methods: This was a qualitative study conducted in 2021 using the framework (structural) analysis method. The participants were 18 experts in the field of referral system and 14 patients referred to the outpatient and inpatient wards of Imam Khomeini Hospital Complex in Tehran selected by purposive sampling. Data were collected by Semi-structured interviews and analyzed using the MAXQDA. Results: Based on the findings in this study, Factors influencing the acceptance of the referral system by patients were found to be the following: (1). Factors related to the stewardship and governance of the health system (responsibility and accountability, appropriate levels of health services, patient-centered care, and rules and regulations); (2). Factors related to the health services access (financial, physical and cultural); (3). Factors related to service providers (trusting healthcare staff, professional skills of service providers, and their behavioral and communication skills); (4). Factors related to the service delivery process (quality of service delivery, attention to patients' wants and needs, use of technology in service delivery, monitoring service delivery, and service coverage); (5). factors related to the recipients of the services (satisfaction, education, awareness and communication). Conclusion: Considering the importance and key role of patients in the success of the referral system, health planners and policy makers should pay special attention to the factors identified in this study. [ABSTRACT FROM AUTHOR]