Effective Referral System for the Utilization of Critical Maternal and Newborn Health at

Rural Health Centers of Ethiopia

APHA 143rd Annual Conference

Chicago, Illinois

Low utilization of services andlimited health system capacity

• Ethiopia has one of the highest maternal and neonatal mortality in the world

• Access and utilization of proven interventions to reduce both maternal and newborn deaths is low

• Multiple factors contribute to low utilization– Socio-cultural factors– limited number of skilled staff, well equipped and well

functioning facilities – low quality of care– weak referral system

Background

The Government of Ethiopia is increasing access to health care through:

• Health Extension Flagship Program• Organizing primary health care units (PHCU) structure

and strengthening the referral and support network• Accelerated expansion of health centers• Expanding access to BEmONC services at health

centers • Provision of ambulances to woredas to mitigate

transportation barriers

Government commitment and action

Background

Background JSI/L10K’s Presence in Ethiopia

• Implements community-based RMNCH strategies– CBDDM and family

conversation– Participatory community

quality improvement (PCQI)– Family planning– Effective referral solutions

• To demonstrate innovative approaches to strengthening referral systems and refining those approaches for adoption and scaling across the country

– iCCM/CBNC

The Referral Linkage

Health center

Communities

Referral Hospital

Referral

Referral

Re

ferr

al

Referring unit Transport Receiving unit

Innovation: The 3-step model for improving referral

• Assets: eg. Public transport• Main barriers• Low health care seeking behavior • Absence of referral protocols & job aids• Low quality of services

Mapping of referral resources

-Desk review

-In-depth interviews

-FGD

• Introduce referral protocols & job aids• Build capacity of referral sites• Improve care-seeking• Performance review and supervision

Participatory Design of innovations

-Consultative workshop

-Joint action plan

• HFs assigned liaison officer to coordinate referrals

• Communication and transport arrangement

• Active collaboration among referral levels

Active management of referrals

Methods• Registers and tools introduced to record the

performance of the referral system• Before and after cross-sectional facility surveys

(health center and referral hospitals) was used to measure the effectiveness of the intervention– Baseline: March 2013– Follow-up: December 2014

• Data– Service statistics, six months retrospective– Interview – Records review

Methods..

• Data from referral hospitals were limited to cases referred from the intervention health centers.

• Facility registers were reviewed to capture the required data and patient records were used to retrieve missing data.

• Descriptive and t-statistics were done to assess statistically significant differences in the outcome measures using Stata version 12.1.

Slip Ambulance Advance call

Escorting Feedback Mean

71

55

0

35

0

32

8881

25

69

27

58

Baseline Follow-up

%

P-Value < 0.001

Functioning referral system

Adherence to specific referral protocols among maternal referrals out from the health center to hospital

Mean percentage score of maturity index

Baseline Follow-up

41

88

%

P-Value < 0.001

Functioning referral system…

Functioning referral system

20

40

60

80

100

Ad

he

ren

ce to

re

fera

l pro

toco

l sco

re

70 80 90 100Maturity index score

Association between adherence to referral protocoland maturity index

P-value < 0.05

Increased utilization of emergency care

Skilled delivery

Baseline Follow-up

30

46

%

P-value < 0.01

Met need for EmONC

Baseline Follow-up

26

38

P-value < 0.01

Challenges

• Two-way communication though improving was a challenge

• Lack of ambulance back home service• Efficient use of ambulance for obstetric and newborn

emergencies;

Lessons learned

Engaging stakeholders across each level of the referral system created an awareness of the challenges and a greater sense of commitment to jointly address them

Consultative and monthly and quarter review meetings created a platform for building relationships across each level of the referral system

Utilization of lifesaving obstetric interventions has improved following the implementation of the effective referral solutions.

Thank you!!

Maturity index

• It is implementation of core mechanisms to strengthen the management of the referral system including– Assignment of referral focal person/liaison officer at health

center and hospital– Communication system to allow for calling ahead prior to

referral– Dissemination of ambulance call numbers to communities– Development of standard protocols for who to refer, when

and where– Distribution and training in the use of standard protocols– Referral-in and referral-out registers existing and being used – Referral slips (standardized and in place at health posts and

health centers)– Regular meetings to address referral-related issues in each

PHCU network