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Paediatric referrals in rural Tanzania: the Kilombero District Study - a case series
Fidel Font1, Llorens Quinto, Honoraty Masanja
1Unidad de Epidemiologia y Bioestadistica, Hospital Clinic i Provincial, Villarroel 170, 08036 Barcelona, Spain. font@ifrc.org
Insights
Referral rates for children in Tanzania are low, with few children receiving higher care despite appropriate admissions. The Integrated Management of Childhood Illness strategy may need adaptation for remote areas.
Area of Science:
- Public Health
- Pediatrics
- Health Services Research
Background:
- Referral systems are crucial for primary care and the Integrated Management of Childhood Illness (IMCI) strategy.
- Understanding referral patterns from primary facilities and to referral hospitals is essential for optimizing child healthcare.
Purpose of the Study:
- To investigate referral rates, delays, and appropriateness of pediatric referrals in Kilombero District, Tanzania.
- To evaluate the effectiveness of the referral process within the IMCI framework.
Main Methods:
- Retrospective review of patient records from primary facilities (1993).
- Prospective study interviewing mothers/carers of children under five at a referral hospital (August 1994 - July 1995).
- Data collected on demographics, diagnoses, referral status, and admission to the pediatric ward.
Main Results:
- Only 0.6% of children from primary facilities were referred; 7.8 cases per 1000 under-fives were referred annually.
- Severe malaria and anemia were leading diagnoses (70% of referrals); 71% of referred children were admitted.
- Significant delays were observed, with 48% of referrals taking 2+ days to reach the hospital.
Conclusions:
- The high admission rate suggests appropriate referral decisions, but the overall low referral rate indicates underutilization of the system.
- Adaptations to the IMCI strategy are needed for sparsely populated areas with transport challenges to improve peripheral management and reduce unnecessary referrals.
Abstract:
BACKGROUND: Referral is a critical part of appropriate primary care and of the Integrated Management of Childhood Illness (IMCI) strategy. We set out to study referrals from the aspect both of primary level facilities and the referral hospital in Kilombero District, southern Tanzania. Through record review and a separate prospective study we estimate referral rates, report on delays in reaching referral care and summarise the appropriateness of pediatric referral cases in terms of admission to the pediatric ward at a district hospital METHODS: A sample of patient records from primary level government health facilities throughout 1993 were summarised by age, diagnosis, whether a new case or a reattendance, and whether or not they were referred. From August 1994 to July 1995, mothers or carers of all sick children less than five years old attending the Maternal and Child Health (MCH) clinic or outpatient department (OPD) of SFDDH were interviewed using a standard questionnaire recording age, sex, diagnosis, place of residence, whether the child was admitted to the paediatric ward, and whether the child was referred. RESULTS: From record review, only 0.6% of children from primary level government facilities were referred to a higher level of care. At the referral hospital, 7.8 cases per thousand under five catchment population had been referred annually. The hospital MCH clinic and OPD were generally used by children who lived nearby: 91% (n = 7,166) of sick children and 75% (n = 607) of admissions came from within 10 km. Of 235 referred children, the majority (62%) had come from dispensaries. Almost half of the referrals (48%) took 2 or more days to arrive at the hospital. Severe malaria and anaemia were the leading diagnoses in referred children, together accounting for a total of 70% of all the referrals. Most referred children (167/235, 71%) were admitted to the hospital paediatric ward. CONCLUSIONS: The high admission rate among referrals suggests that the decision to refer is generally appropriate, but the low referral rate suggests that too few children are referred. Our findings suggest that the IMCI strategy may need to be adapted in sparsely-populated areas with limited transport, so that more children may be managed at peripheral level and fewer children need referral.