Factors affecting unsuccessful referral by the lady health workers in Karachi, Pakistan

Abstract

The Government of Pakistan initiated the National Program for Family Planning and Primary Health Care (PHC) in 1994.1 The primary objective of this program was to improve the health status of the people by training Lady Health Workers (LHWs) to provide PHC at the grass roots level. To date, the program has recruited about 70,000 workers. LHWs are trained to provide essential maternal and child heath and family planning services, management of common ailments and provision of family planning material and health education. In addition, they collect information regarding basic health indices and utilization of services, which is aggregated at the national level and form an important part of national health statistics. LHWs are based at First Level Care Facilities (FLCFs). Being an outreach worker, they make at least one visit per household per month. Each LHW is responsible for at least 100 households or a population of 1000, whichever comes first. It has been estimated that LHWs coverage of services to 'eligible individuals' ranges from 32.5% to 49% in various provinces of the country.2 This figure is expected to rise as the government is planning to expand the coverage by increasing the number of LHWs.3 Thus the LHWs are becoming an increasingly important source of health delivery within the community. The FLCFs constitute an integral part of the district health system. Ideally, FLCFs should act as a filter to prevent crowding of patients at district tertiary care hospitals and other Higher Level Care Facilities (HLCFs) for conditions that can be managed at lower levels. However, simultaneously there must also exist a referral system for those who cannot be dealt with at the FLCF. This referral should be such that there is continuity of individual care and information flow in a way that is acceptable to the health worker and the individual patient.4 One of the important functions of the LHW is referral of patients to the appropriate health facility. Referral has been defined as a process in which the treating physician at a lower level of the health service seeks the assistance of a trained person with better resources/facilities at higher level, to guide him in managing or take over management.5 Successful referral means that a patient who has been referred for whatever reason, reaches the referred health facility in an appropriate time period irrespective of the treatment outcome. However, a significant proportion of patients comprise of those who are referred, but who, for whatever reason, do not comply. These non-attenders are defined as 'unsuccessful referrals'. Unsuccessful referrals are wasteful with regards to limited resources.6 Patients do not receive necessary medical care. On the contrary many may visit at later dates with complications that are expensive and are difficult to treat.7-9 In Pakistan, an estimated 44% of patients presenting at the FLCF are subsequently referred to the HLCFs.10 However, due to various reasons not all these referred patients attend the referral sites, constituting referral failure. Referral failure rates vary widely all across the world from 12% in the British National Health Services (NHS)6 to 31% in South Western Uganda.11 There is no data pertaining to referral pattern from the grass root level in Pakistan. Furthermore, this topic has never been researched systematically in the developing countries. Therefore, we conducted a study with the objectives: 1) to estimate the proportion of patients referred to various health care facilities and 2) to identify the factors associated with unsuccessful patient referral in Karachi.