Health Policy and Planning, Vol 13, 359-370, Copyright © 1998 by Oxford University Press
D Sanders, J Kravitz, S Lewin and M McKee
Background. Anecdotal evidence has suggested
inefficiency in the pyramidal health care referral system established in
Zimbabwe in 1980, as part of its primary health care (PHC)
model.Aim. To assess the functioning of the pyramidal
referral system in two rural districts surrounding Harare, Zimbabwe, with
regard to two common indicator conditions: pneumonia in children and
malaria in adults.Methods. For a three-month period,
all complete inpatient records with discharge diagnoses of pneumonia or
malaria from three hospitals representing different levels of care were
analyzed (n=227). Data were collected on demographic and patient care
variables. The appropriateness of admissions and referrals was determined
by an assessment of the severity of illness and 'intensiveness' of care
required. Data were analyzed for differences among the three hospitals and
between the two indicator conditions. Per night inpatient bed costs for
each hospital were also calculated.Results. For
pneumonia in children, 56.8% of patients admitted at the secondary level,
81/5% of patients at the tertiary level and 54.3% at the quaternary level
were of mild severity. For pneumonia, there were no differences in severity
between the three hospitals whereas for malaria significant case-mix
differences among the hospitals were found. Most patients attending the
highest level referral facility were inappropriate admissions who could
have been treated at a lower level of care. The majority of patients at all
the hospitals studied had used that hospital as their first or second point
of contact with the health services. There were large variations in the
inpatient per night bed costs between the three
hospitals.Conclusions. Using the indicator diseases of
pneumonia in children and malaria in adults, this study concluded that this
network did not meet design expectations as the central level referral
hospital cared for a similar case-mix of patients as the district level,
but at six times the cost. The appropriateness of admissions and referrals
could be improved by developing or strengthening intermediate level
facilities, by changing mechanisms of access to specialist facilities and
by training health professionals in community settings.
ARTICLES
Zimbabwe's hospital referral system: does it work?
Public Health Programme, University of the Western Cape, Belville, South Africa; Dept of Public Health and Preventive Medicine, Oregon Health Sciences University, Portland, OR, USA; Centre for Epidemiological Research in Southern Africa, Medical Research Council of South Africa, Tygerberg, South Africa; Health Services Research Unit, Dept of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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