STRENGTHENING REFERRAL SYSTEM TO IMPROVE MATERNAL HEALTH The Kenya Red Cross Experience

Introduction A functional referral system is key in reducing maternal mortality. A referral system is defined as a mechanism to enable client’s health needs be comprehensively managed using resources beyond those available where they access care (Kenya Health Sector Referral Strategy). An effective referral system ensures a close relationship between all levels of the health system and helps to ensure people receive the best possible care closest to home. It assists in making cost- effective use of hospitals and primary health care services. A well functioning referral system requires active collaboration and cooperation between the different stakeholders and care providers within a referral network Good morning Ladies and gentlemen, all protocol observed. I will not repeat the statistics that we heard yesterday but I would like to recall Dr. Abdo’s presentation where he mentioned that having a functional referral system is an important action towards reducing maternal mortality. I take this opportunity to congratulate the MOH for recently launching the Kenya Health Sector Referral Strategy and the kenya National Guidelines For patient Referral.

UNDERLYING CAUSES OF MATERNAL DEATHS Three distinct levels of delay which contribute to maternal morbidity and mortality. Delay in deciding to seek appropriate care. This is due to socio cultural barriers, failure to recognize danger signs, failure to perceive severity of illness and cost considerations. Delay in reaching Health facility: this is due to long distances to facility, poor conditions of roads, lack of transportation and cost considerations. Delay in receiving adequate emergency care at facility: this is due to shortage of staff, supplies and basic equipments among others.

FRAMEWORK FOR REFERRAL SYSTEM IN KENYA REFFERAL SERVICE CLIENT MOVEMENT SERVICE/EXPERTISE MOVEMENT SPECIMEN MOVEMENT CLIENT PARAMETERS MOVEMENT

REFFERAL CHAIN AS DEFINED IN REFERRAL STRATEGY National Referral NATIONAL REFERRAL SERVICES County Referral COUNTY REFERRAL SERVICES Primary care PRIMARY CARE SERVICES Community COMMUNITY SERVICES

TYPES OF REFERRALS Emergency referrals Urgent Referrals Non Urgent Referrals These referrals entail Client movement Service/Expertise movement Specimen Movement Movement of client parameters.

MAJOR GAPS IN REFERRAL SYSTEM IN KENYA Kenya Health sector Referral strategy June 2013 – June 2018: Policy and strategic level No transport policy for Health sector No by pass policy No coordination structure for the referral services Lack of quality standards and performance monitoring tools. No policy guidelines on who is responsible for financing Referral services in the Country.

MAJOR GAPS IN REFERRAL SYSTEM IN KENYA Operational level Ineffective networking of the different levels By passing of lower levels of facilities Inappropriate referrals. Inadequately resource facilities according to norms and service standards Lack of effective referral monitoring system. Inadequate communication and transport systems. Ineffective referral and feedback system Lack of referral coordinating forums and review meetings Issues of financing. Lack of integration.

BRIDGING THE GAP – COMMUNITY FACILITY LINKAGE KRCS ROLE BRIDGING THE GAP – COMMUNITY FACILITY LINKAGE

KRCS ROLE KRCS appreciates that a well functioning Referral system must have clear quality standards that are influenced by Health systems determinants: capabilities of lower tiers/levels, availability of specialized personnel, training capacity, organizational and coordination arrangements, cultural issues, political issues and traditions. General determinants: population size and density, terrain and distances between urban centres, pattern and burden of disease, demand for and ability to pay for referral care. The KRCS model of strengthening referrals seeks to address the gaps that exist along the referral chain in the Country.

KRCS SUPPORT TO REFERRAL CHAIN Community based demand creation activities organized around the Community Health strategy. This creates community based referral mechanisms to facilitate linkage with primary care services. Provision of Ambulance services for Client movement from Community to Health facility and from health facility to Health Facility.

Provision of Ambulance Services

Ambulance Referral Statistics No. of Calls May-14 Jun-14 Jul-14 TOTAL POP KISII 331 372 375 1,078 1,152,282 KAKAMEGA 547 492 542 1,581 1,660,651 BOMET 410 393 424 1,227 730,129 GARISSA 107 121 149 377 623,060 MANDERA   69 115 184 1,025,756

Ambulance Referral Statistics   KISII KAKAMEGA BOMET GARISSA MANDERA MATERNITY 422 498 311 80 63 MEDICAL 457 784 686 206 87 CARDIAC 58 62 28 30 8 TRAUMA 141 237 202 61 26 TOTAL 1,078 1,581 1,227 377 184

KRCS SUPPORT TO REFERRAL CHAIN Provision of vehicles and other logistics for expertise movement during medical outreaches

KRCS SUPPORT TO REFERRAL CHAIN Construction/ equipping of health centres and dispensaries to ensure that they can provide appropriate services. This enables management of the referrals from communities and also facilitates referrals to nearest County Referral. Equipping and upgrading of hospitals to ensure service provision for the referrals from the health centres. Dadaab Level 5 Hospital

KRCS REFFERAL MODELS Community led Patient/Client led Reverse referral

COMMUNITY LED REFERRAL FACILITY PRECONDITIONS Functional Ambulatory system. Functional health facility Quality of care PRECONDITION Decision making Knowledge /awareness perception Ambulance HEALTH FACILITY HOUSE HOLD CHEW/HW CHW FEEDBACK DETERMINANTS HRH adequacy and know how Attitude Quality of care DETERMINANTS Male involvement Social support cost FUNCTIONAL HEALTH CARE SYSTEM,COMMUNITY EMPOWERMENT AND INVOLVEMENT

LESSONS FROM COMMUNITY LED MODEL From January to May 2014, 760 mothers have been referred under this model in Isiolo and Garissa Counties. This model enhances follow-up of the mother pre during and post the referral. This model ensures early identification of danger signs by the trained CHVs with support from the CHEWs. It enhances community ownership.

PATIENT/CLIENT LED REFERRAL PRECONDITIONS Functional Ambulatory system. Functional health facility Quality of care PRECONDITION Decision making Knowledge /awareness perception HEALTH FACILITY Ambulance CLIENT CAREGIVER DETERMINANTS HRH adequacy and know how Attitude Quality of care DETERMINANTS Male involvement Social support cost FUNCTIONAL HEALTH CARE SYSTEM

LESSONS FROM PATIENT/CLIENT LED MODEL From January to May 2014, 1,747 mothers have been referred under this model in Isiolo and Garissa Counties. Creates good networks for inter hospital transfers.

FUNCTIONAL HEALTH CARE SYSTEM,COMMUNITY EMPOWERMENT AND INVOLVEMENT REVERSE REFERRAL FACILITY COMMUNITY PRECONDITIONS Functional Ambulatory system. Functional health facility Quality of care PRECONDITION Decision making Knowledge /awareness perception Ambulance HOUSE HOLD HEALTH FACILITY CHEW/HW CHW DETERMINANTS HRH adequacy and know how Attitude Quality of care DETERMINANTS Male involvement Social support cost FEEDBACK FUNCTIONAL HEALTH CARE SYSTEM,COMMUNITY EMPOWERMENT AND INVOLVEMENT

LESSONS FROM REVERSE REFERRALTHIS MODEL Workable model for the hard to reach areas and areas with low facility coverage.

Key components for effective referral CONCLUSION Key components for effective referral Functional Community health strategy Ambulatory services Functional health facilities. Important to note that Community Facility linkages are key in the Kenyan context for improved referrals in context of maternal health

Need for coordination across the different parts of the health system CONCLUSION There is need to align the health system with the needs of the population looking at the geography and income distribution (Arid and Semi Arid Lands, Hard to reach areas, terrain, conflict areas etc) Need for coordination across the different parts of the health system

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