Objective="Scope and quality of First Referral Units."
Details for Reform Option "Organisation of the referral system, Kharar Hospital, Punjab"
The patient referral system in Punjab is disorganised and haphazard. A patient has to go through certain administrative procedures and queue up for his or her turn when he or she goes for treatment to, say, a Primary Health Centre (PHC). When he is referred to another facility, for example, a district level hospital, the patient has to follow the same procedure all over again. And again, after treatment at the big hospital, when he goes back to the PHC for follow-up checks, he has to stand in queue and go over the whole process yet another time. This causes great inconvenience to patients. Lack of organisation in the patient referral system also creates excessive patient load on Community Health Centres and District Hospitals.
The Punjab Health Systems Corporation (PHSC) was set up as part of a World Bank project in 1995 to revamp the delivery of the secondary level government healthcare system. (See PROD entry No 145: Punjab Health Systems Corporation, Punjab). Systematising the practice of referring patients to a higher facility and back was one of the crucial reforms brought about by PHSC. A case study of Kharar Hospital highlights the difference this reform has made.
Kharar Hospital was functioning as a 30-bed hospital with a trauma unit. After being taken over by PHSC, in October 1996, it was upgraded to a 50-bed hospital. Until then patient referral was being done on the normal Out Patient Department (OPD) slip.
PHSC took the following steps to rationalise the referral system:
Zoning: Units referring cases to district Civil Hospitals were grouped into zones on the basis of rural roads leading to the district town. Thus the Civil Hospital has patients referred from 22 subsidiary dispensaries, one Primary Health Centre (PHC) and one Community Health Centre (CHC). Though patients coming from other zones are not refused primary treatment, they are referred back to their particular administrative zone for follow-up. Grouping into zones helps referring units as it leaves no room for confusion regarding where to send patients for treatment.
Referral cards: Referral is a two-way process—one, when a patient is referred to a higher facility and two, when he or she is referred back, after treatment, to the original facility for follow-up. Colour-coded referral cards, according to the type of health facility, were introduced, where CHCs and PHCs refer on blue cards to sub-divisional hospitals, which in turn refer on a green card to the district hospital. Referral of patients from the district hospital is on a white card. The card serves as an OPD ticket. No fee is charged from a patient with a referral card; it gives the patient direct access to the concerned speciality, bypassing the OPD queue. The patient is also provided feedback cards so that the referring doctor gets information with regard to improvements made by the patient.
Mismatching in the posting of specialists minimised: The government system of posting is often irrational whereby specialists, like a surgeon or an ophthalmologist, is sent to a PHC while a general physician is posted in a CHC or a district hospital where there is demand for the specialist’s skills. PHSC corrected this anomaly with internal re-arrangements (deputation) within a district so as to make the specialist available at the referral unit.
Besides creating a new system, other changes were introduced to the hospital to strengthen the referral system:
Infrastructure: Only one Operation Theatre (OT) was functiong till PHSC took over Kharar Hospital in 1996. In the process of strengthening infrastructure, this was converted into a labour room and three new OTs were constructed, one each for Gynae, Surgery and Ophthalmology. Four new wards were also added—two emergency and two male wards.
Equipment: were made available according to norm and in working condition. Maintenance of the equipment was done through annual maintenance contract; 15% of the user charge was earmarked for repair and maintenance.
Ambulance service: Two ambulances were made available round-the-clock; recurring cost of running the ambulances was met by levying a nominal user charge at the rate of INR 3.50 per kilometre.
Laboratory test facility: Laboratory has been provided with semiautomatic analyser and range of tests to be conducted increased according to norms for the facility.
Blood Bank: Blood bank services were revived after a gap of 4 years, in 2000, as per guidelines with a capacity of 50 units of whole blood per month.
Workforce: Vacant posts in the non-clinical services were filled by contractual appointments. At present, there is no vacant post in the hospital.
Though no proper study has been conducted to evaluate the refurbished referral system, the patient certainly stands to gain. Healthcare providers are also able to utilise a particular health facility according to its strength.
Capital cost was needed basically to strengthen infrastructure and to revive the blood bank. Recurring cost of laboratory tests, ambulance, etc are taken care of by revenue collected from user charges.
Kharar Hospital, Punjab.
Approximately one year
Early diagnosis and referral: Improved laboratory facilities help determine the kind of treatment required and the new organised system makes quick referral possible.F
Faster: Referred patients are given due care and privilege of bypassing the formalities for consultation.
Follow-up: System of back referral gives the opportunity to treating physician to follow up on their patients.
Rational utilisation: A proper referral system prevents both over and under utilisation of the health facilities.
Unwillingness of doctors to comply with internal deputation.
Who needs to be consulted
State Government, Tertiary care hospital.
Only in the initial phase clinical and para-clinical staff needs orientation training to follow the defined referral norms in favour of patients.
Chances of Replication
Replicable. Internal deputation of specialists, colour coded referral cards and strengthening of the services at the first referral unit makes the referral system efficient.
A strong and efficient referral system depends, to a large extent, on simultaneous upgradation of facilities. Along with making referrals more systematic it is important to strengthen services at the health centres.
Dr. Anuradha Davey, Research Consultant, National Institute of Medical Statistics, May, 2006.