Barriers to referral in Swaziland: perceptions from providers and clients of a system under stress


Author(s): Macintyre K, Littrell M, Hotchkiss D, Mndzebele S, Nkambule R, Malima B, Gumbi S, Dhlamini T, Brown L, and Kemerer V

Year: 2011

World Med Health Pol 2011. 3(4):Article 5. 

In Swaziland, where one in four adults is HIV positive, identifying and addressing barriers to a strong referral system is critical to ensure continuity of care for HIV-positive individuals. This study examines the referral system from the perspectives of health providers, community health workers, traditional healers, clients seeking facility-based care, and managers of private health organizations. Structured and semi-structured questionnaires were administered to 52 senior providers, 161 providers, and 307 clients in 52 health facilities. In 82 randomly selected communities, 81 traditional healers and 247 community health workers also participated. Staff from private health agencies providing HIV-related care were also interviewed.

Referral is commonly understood as sending clients to seek care at higher-level facilities and is an individualized process dependent on various factors. Providers sending clients rarely hear back on any regular basis about those clients. Referrals and linkages for certain services, including nutrition support, psychosocial support, palliative care and home-based care, are particularly weak. Many providers recommended that referral protocols with improved communication tools are needed and said referred clients should be given priority at referral-receiving sites. Policy recommendations include: referral form redesign; formalizing or reforming the referral protocol; strengthening communication and linkages between community- and facility-based providers; and improving patient flow at referral sites.