Lake State functional referral system Guide

THE REPUBLIC OF SOUTH SUDAN
L A K ES S T A T E
MINISTRY OF HEALTH
EFFECTIVECLOSED LOOP REFERRALSYSTEM
GUIDELINE AND PROTOCOLS
July /2015
LAKES STATE

1
Table of Contents
ACRONYMS.....................................................................................................................................2
Acknowledgments ..............................................................................................................................3
BACKGROUND................................................................................................................................4
INTRODUCTION..............................................................................................................................5
DEFINITIONS............................................................................................................................................................................5
RATIONAL FOR FUNCTIONAL REFERRAL SYSTEM GUIDE.......................................................6
PURPOSE OF EFFECTIVE REFERRAL SYSTEM.............................................................................7
THE REQUIREMENTS FOR AN EFFECTIVE REFERRAL SYSTEM................................................7
ESSENTIAL ELEMENTS OF REFERRAL SYSTEM.........................................................................8
REASONS FOR REFERRAL.............................................................................................................8
LAKE ESTATE REFERRAL MECHANISM:.....................................................................................9
PATIENT TRANSFER .............................................................................................................................................................9
A framework for the referral from PHCC/U, County Hospitals to Rumbek State Hospital Hospital..9
1. Community level...................................................................................................................10
2. Health facility level................................................................................................................10
3. 24-HOUR EMERGENCY CALL CENTER...........................................................................11
FUNCTIONAL CLOSED LOOP REFERRAL SYSTEM MODEL .....................................................11
REFERRAL FEEDBACK MECHANISM.........................................................................................13
ROLE AND RESPONSIBILITY OF ORGANIZATIONS ANDSERVICES PROVIDERS IN THE
REFERRAL SYSTEM .....................................................................................................................14
ROLES AND RESPONSIBILITIES OF THE REFERRING HEALTHPROFESSIONAL.....................................................................14
ROLES AND RESPONSIBILITIES OF THE REFERRAL COORDINATOR......................................................................................14
ROLES AND RESPONSIBILITIES OF THE REFERRING FACILITY..............................................................................................14
ROLES AND RESPONSIBILITIES OF RECEIVING HEALTHPROFESSIONAL.............................................................................15
RESPONSIBILITIES OFTHE RECEIVING FACILITY...................................................................................................................15
Referral tool kits...............................................................................................................................15

2
ACRONYMS
CHD: Community Health Department
HF: Health Facility
IMC: International medical corps
PHCU Primary health care unit
PHCCs: Primary health care center
TBA: Traditional Birth attendants
IMC: International medical corps
SOPs: Standard Operating Procedures
TBA: Traditional Birth Attendants
VHC: Voluntary Health committees
MoH: The Ministry of Health
RSS: Republic of South Sudan
WHO: World Health Organization

3
Acknowledgments
This document was made possible through the support of South Sudan Health pooled Fund
This guide consumed huge amount of work and dedication. Still, implementation would not have
been possible if we did not have a support of many individuals and organizations. Therefore we
would like to extend our sincere gratitude to all of them.
First of all we are thankful to the Director General of the Lakes State Ministry of Health, Dr.
Michael Mading and the Acting Director of Administration and Finance in the Lakes State
Ministry of Health, Dr. Hakim for their support and for providing necessary guidance concerning
the implementation of the guide.
We are also grateful to the different stakeholders and implementing partners in Lakes State for
provision of expertise, and technical support during discussions towards the implementation of
the guide. Without their superior knowledge and experience, the guide would may lacking in
quality, and thus their support has been essential.

4
BACKGROUND
The Ministry of Health (MoH) of the Republic of South Sudan (RSS) operates a decentralized
structure of health services delivery in line with its interim Constitution and the current 11
National Health Policy. The provision of health care services is based on the principle of a
‘Continuum of Care’ as recommended by the World Health Organization (WHO).
In South Sudan this continuum of care is provided through a pyramidal structure with primary
health care services provided through a network of Primary Health Care Units and Primary
Health Care Centers being the lowest level of contact between the community and the health
system.
Primary Health Care Units (PHCUs) provide basic preventive, promotive and curative care while
Primary Health Care Centers (PHCCs) in addition to services offered by PHCUs provide basic
diagnostic laboratory services and maternity care.
The South Sudan health system therefore envisages a three-tier structure of primary, secondary
and tertiary health-care facilities to bring health-care services within the reach of the population.
Primary health care services are provided by the PHCC/PHCUs while the secondary tier services
are provided by the county hospitals. The county hospitals are the first level referral point from
the PHCC/PHCUs and community. Secondary health care is provided by state Hospitals
providing comprehensive specialist services.
Administratively, the Ministry of Health (MoH) oversees the delivery of health services in the
country through the respective State Ministries of Health (SMoH). Each state ministry of health
provides leadership of the health Sector through coordination, personnel management,
monitoring of primary facilities and infrastructure
The State Ministry of health is able to execute its functions through the administration of the
County Health department that is in charge of managing service delivery at county level. The
CHD oversees and coordinates the activities of the PHCC/PHCU, village health committees at
Payam and Boma levels.

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INTRODUCTION
A referral may be for temporary, permanent or partial transfer of responsibility for the care of a
patient. A referral system entails the interrelationships and coordination of patient care services
from one health care facility to another. The referral process begins by the referring health
professional communicating to the receiving health professional or specialist relevant patient
information. The receiving health professional communicates back to the referring health
professional with information and plan for continuum of care thereby completing the referral
process.
Referral can be vertical as in the hierarchical arrangement of the health services from the lower
end of the health tier system to the higher ones. It also can be horizontal between similar levels
of facilities in the interest of patients for cost, location and other reasons. Referrals can also be
diagonal when a lower level health facility directly refers patients to a state hospital facility
without necessarily passing through the hierarchical system.
In an effort to ensure effective deliver of referral health care services and strengthen the referral
chain with primary health care facilities and county hospitals, Health Pooled Fund (HPF), in
collaboration with the MOH, has proposed a strategy to support the State Ministries of Health
(SMOH) and state-level hospitals. This includes the following: supporting delivery of services
including comprehensive emergency obstetric and neonatal care, trauma care, general surgery,
gynecology, pediatrics, and internal medicine; ensuring an effective referral system; and
strengthen the management and administration of the State Hospitals
DEFINITIONS
A referral: can be defined as a process in which a health worker at a one level of the health
system, having insufficient resources (drugs, equipment, skills) to manage a clinical condition,
seeks the assistance of a better or differently resourced facility at the same or higher level to
assist in, or take over the management of, the client’s case.
Referring unit is a health facility that initiates the referral process. A facility can be both a
referring and receiving unit depending on circumstances.

6
Receiving unit is a health facility that receives patients or clients from referring units and
ensures that required care is given to the client and returns the patient with feedback.
Community to facility referral: traditional birth attendants or community health workers refer
clients to PHCU health facilities.
Facility to facility referral: Clients can be referred between health facilities through standard
referral slip for services not rendered in their facility and for further care and support.
Successful referral: can be defined as a process in which if the referred client received the
service for which he/she referred and confirmed through referral feedback loop system
A referral loop: is the complete cycle/link between the initiating and receivng faciltiy.
Servcie directory is: a lists of all organizations providing specialist care. Such a directory can
facilitate the search for the most appropriate service provider for a particular referral. In such
setting, it is important to keep the contact information up-to-date.
Counter-Referral or Return-Referral: Is the process of re-directing the referred patient back to
the originating unit once the reason for referral has been resolved.
Level 1 Hospital (County hospital): A Level 1 Hospital also known as a County Hospital or
general hospital is a registered health care facility, public or private, for profit or not for profit,
which provides curative, preventive, promotive and rehabilitative care, through outpatient,
inpatient, and community health services.
Level 2 Hospital (State hospital): A State hospital is the referral hospital for the state health
system and renders services at a general specialist level. It receives referrals from county
hospitals as well as PHCC and provides specialist services. State hospitals also serve as a
platform for training of health workers and research.
Level 3 Hospital (Teaching hospital): Level 3 hospitals also known as teaching or National
Referral hospitals provide comprehensive specialist services as tertiary care. These hospitals
should have highly specialized staff and technical equipment—for example, cardiology,
intensive care unit, and specialized imaging units.
RATIONAL FOR FUNCTIONAL REFERRALSYSTEM GUIDE
One of the objectives of the Health Pooled Fund project is strengthening the State Hospitals
referral and linkage system through implementing bi-directional successful effective referral

7
from community to PHCU/PHCCs and county hospital and then to Rumbek State Hospital and
beyond.
The Health Pooled Found have an interest on effective functional referral system to enhance the
accessibility and utilization of health service for the general population specifically for mothers
suffering with pregnancies and birth related complications . The presence or absence of effective
functional referral system can determine the uptake of the health services and ensure continuum
of care, if an appropriate level of care is made available when it is needed (taking geographical
factors, time, affordability and emergency services into consideration);
The referral guide helps to:
 Increases the efficiency and effectiveness of the referral system
 Ensure continuum of health and Social service
 Promotes cooperation between the partners who are working in the referral network
PURPOSE OF EFFECTIVE REFERRALSYSTEM
 For continuity of treatment and care
 To save life in emergency situation
 For a specific treatment, procedure and care
 For further medical management
 For quality service.
 Maximize limited resources.
THE REQUIREMENTS FOR AN EFFECTIVE REFERRALSYSTEM
• There should be referral guideline and referral protocol.
• Service providers should be skilled in knowing what, when, where and how to refer.
• There should be standard treatment protocols and SOPs at each health facility level,
according to their competencies.
• Accessibility of services should be facilitated in terms of logistic, through the availability
of adequate transport and communication means, whose use should be regulated.
• Receiving facilities should be equipped to receive referrals and to provide the expected
care
• The system should be able to monitor, supervise and evaluate the quality of care, referral
practices

8
• There should be enough permanently available resources to ensure the referral system
being free of charge for patients
ESSENTIALELEMENTSOF REFERRALSYSTEM
1. A structured health system, constituted by different service providers organized along
a hierarchical line according to the kind of assistance they can offer and which all
together ensure compressive health care service in defined geographical area
2. Clients
3. Standard Referral Guidelines
4. Standard harmonized referral forms
5. Referral directory
Contents of Referral directory
 Name of Organization
 Organization Address/Location and phone number
 Services Provided
 Hours of service
 Contact person
6. Focal person/liaison officer at service provider facility
7. Feedback loop
8. Documentation
9. Logistic and related material/financial resources (transport means, communication
means)
REASONS FOR REFERRAL
The criteria for referral should be medical, objective and in the best interest of the patient or
client. The following are considered good reasons for referrals:
 When a patient needs an expert advice as determined by the attending health professional
 When technical examination is required that is not available at the referring facility
 When a technical intervention that is beyond the capabilities of the facility is required
 When patients require inpatient care that cannot be given at the referring facility
 When the referring facility cannot no more accept patients due to shortage of beds and
unavailability of professionals
 When the patient/client needs social support

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LAKE ESTATE REFERRALMECHANISM:
The recommended referral plan for South Sudan is such that: the Level 1 (county) hospitals
provide general in-patient services and accept referrals from the Primary Health Care Units and
Centres (primary level). Level 2 (State) hospitals receive patients referred from county hospitals
and provide general specialist services. Teaching hospitals (tertiary level) in the major urban
centres serve as national referral facilities and provide specialist and sub-specialist services.
In lake state, Rumbek state hospital receives all referrals from county hospitals and dirctly from
PHCC/Us when required, and state hospital referr upward to Juba Teaching hospital.
PATIENT TRANSFER
A framework for the referral from PHCC/U, County Hospitals to Rumbek State Hospital Hospital
This referral model is designed to adress the referral challenges as proposed by the SMoH. This
framework emphasises the referral coordination mechanism for maternal and child referral-this is
in response to high maternal mortality rates recorded in South Sudan. That said, this model can
always be adapted to suit the coordination of referral of any other cases not necessarily maternal
and child health related. This should be done in consideration of the criteria describe earlier.
South Sudan has one of the world’s highest MMR in the world with most of the maternal deaths
occuring due to pregnancy and childbirth related complications. These deaths are largely
preventable through timely identification, early referral and access of quality/adequate medical
interventions. Like in most developing countries, maternal deaths are majorly due to delays at
three levels i.e. Level 1 delay- The delay in decision to seek care, Level 2 delay-Delay in
reaching care and Level 3 delay- Delay in receiving adequate health care.
In order to save the lives of pregnant women and the unborn/new-borns, it is important to
develop an effective referral mechanism that adequately addresses the 3 delays identified above.
The referral system should be efficient, sustainable and customized to the community contexts.
The success of the referral system is soley anchored on commitment from all levels-MoH/SMoH,
CHD, NGOs and the community.
This referral system will be implemented jointly by the SMoH, CHD , County hospital, PHHC
and PHCUs with the collaboration of the community as described here below.

10
1. Community level
a) Identification, registration and linking :each pregnant woman to a focal TBAs member in the
community. Each TBAs shall follow-up and monitor estimated 15-20 pregnant women in their
respective villages. During the ANC process, the pregnant women will be linked to TBAs in
their area for emergencies. This is a process that is cheap to implement by the CHD and their
respective supporting partners.
b) The TBA shall be the focal point for the pregnant women : the pregnant can report to the
TBAs for assistance in emergency so that the referral process can be initiated as early as
possible. Where there are no networks avalable,a VHF radio is to be installed at the facility to
aid timely communication. Where possible, the TBAs should be supported/provided with
alternative means of transport such as a bicycle which can be used to initiate the referral process
from the community to the nearby PHCU/PHCC or BEmONC centre. Whenever faced with an
emergency, the TBAs will call the nearest health facility and immediately start the patient
transfer process to meet the health facility team along the way. This kiss-movement approach
will directly reduce the referral time by about 30%.
2. Health facility level
a) Service delivery :The health facilities should be staffed and equipped to provide BEmONC
and stabilization services in emergencies. This will reduce the risk of death and morbidity during
transportation over long distances to CEmONC centre when required. The health workers will
also accompany the patient during transit/referral
b) Training:The health workers and TBAs should be extensively trained on the referral
protocol, early identification of risk factors and danger signs and referral
c) Communication. The county hospital, PHCCs should be have a cell phone or VHF radio to
communicate with the Rumbek sate hospital call center. The telephone numbers of the call center
and services directory shuld be provided to refering health facilities .
The transport will be free of charge and available 24/7 the Ambulance use will be regulated and
exclusively dedicated to referral
d) Documentation and feedback. The receiving health facilities will document the case details
including outcome and share this feedback with the referring centre. At county level and facility
level, it is recommended that a monthly review meeting be conducted to evaluate the referral

11
system. At State level, there will be a quarterly referral coordination meeting to assess progress
of implemenation of the referral system and continue improving the quality of service.
3. 24-HOUR EMERGENCY CALL CENTER
A core component of the referral system will be a 24-hour call center located at Rumbek State
Hospital, which will serve as a referral service for patients who are in need of a higher level of
care. The number for the call center will be available to the PHCC/PHCUs and county hospitals.
The call center will be staffed by a health worker who is trained in basic obstetric and newborn
care and can advise the caller on whether or not to refer the patient to the next level of care. The
call center will also be a mechanism to support tracking the number of referrals taking place and
will report these numbers to the CHD and the SMOH. An additional responsibility of the call
center will be to track the operating status of the county hospitals in the state. For example, the
call center operator can contact the hospitals on daily basis to determine their bed availability,
whether they have a working ambulance, etc. This way, when a PHCC/PHCU or county hospital
contacts the call center, they will be provided accurate information on the availability of higher-
level health services in the area. The call center will also be equipped with a high frequency (HF)
radio so that it can communicate with key primary health facilities, county hospitals and
ambulances across the state, which will also be equipped with base and mobile HF radios.

12
FUNCTIONALCLOSED LOOP REFERRALSYSTEM MODEL
Village B -TBA
Village A –TBA
PHCU A
-Safe and clean
delivery
-onsite VHF radio,
cell phone,
motorcycle
Rumbek State Hospital
• All general services
• Radio call center
7/24 hours
• Ambulance 7/24
PHCU B
-qualified staff
-BEmONC,
stabilization
-onsite VHF radio,
cell phone,
motorcycle
County Hospital B
-qualified staff
-BEmONC, stabilization
-onsite VHF radio, cell
phone, motorcycle
County Hospital B
-qualified staff
-BEmONC,
stabilization
-onsite VHF radio,
cell phone,
motorcycle
PHCC
-qualified staff
-BEmONC,
stabilization
-onsite VHF radio,
cell phone,
motorcycle

13
REFERRALFEEDBACKMECHANISM
Village-A
CVD a
Rumbek State Hospital
PHCU-
A
Village-B
CVD b
PHCU-
B
County hospital County hospital
PHCC

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ROLE AND RESPONSIBILITYOF ORGANIZATIONS AND SERVICES
PROVIDERS IN THE REFERRALSYSTEM
Roles and responsibilities ofthe referring health professional
 Should know what, whom, when and where to refer
 Should fill the referral form with all the necessary information and attach relevant
documents
 Should explain to the patient the rationale or reasons for referral, the means of
transportation, the preparation, the expected indirect costs he/she might have to afford
during his/her stay in the other facility, and possible outcome of referral
 Should be available to answer queries from the referral coordinator or receiving facility
about the referral if necessary
 Should properly document stamped referral for monitoring
Roles and responsibilities ofthe referral coordinator
 Responsible to properly record and document for both in and out referrals
 Facilitates scheduling based on the level of priority for consultation, i.e. emergency,
urgent and routine cases
 Utilizes the following communication methods: VHF radio, telephone and email if
available
 Ensures the availability of service or professionals at the receiving health facility before
referral
 Facilitates transportation for emergency cases
Roles and responsibilities ofthe referring facility
 Performs a situation analysis regarding the process of referral in the facility
 Ensures that staff are well aware of the referral system
 Ensures continuous supply of standardized referral forms are available
 Keeps directory of health services and facilities in the defined geographic area
 Ensures proper recording of all referral activities
 Provides transportation in emergency conditions

15
 Assigns referral coordinator with clear roles and responsibilities
Roles and responsibilities ofreceiving healthprofessional
 Responds promptly to consultation requests
 Reports in detail all pertinent findings and recommendations to the referring health
worker and may outline opinion to the patient (feedback with all required information
and recommendation)
 Communicate with the patient or family
 Does not attempt by word or deed to undermine the role of the referring health worker
Responsibilities ofthe receiving facility
 Conducts situation analysis of the current referral process to identify gaps and strengths
 Assigns referral coordinator with clear roles and responsibilities
 Devises follow up plans and ensures the plans are communicated to the referring facility
/professional
 Ensures staff at points of entry clearly understand the referral process
 Provides continuing education about the referral process to staff and the community
 Ensures referred patients are seen by appropriate professionals
 Ensures that all prescheduled referrals are attended without undue delay
Referraltool kits
1. Referralslip
2. Referralfeedback collection box
3. Referralservice directory
4. Referralregistration book

16
Referred to____________________________________________________________________
Name:_______________________________________________________________________
Age_____________________Sex_____________________Addressess
(Resident)_____________
C/C:__________________________________________________________________________
____________________________________________________________________________
Physical Examination –findings:_____________________________________
Labresults_____________________________________________________________________
_____________________________________________________________________________
Diagnosis:_____________________________________________________________________
_____________________________________________________________________________
TreatmentGiven:________________________________________________________________
_____________________________________________________________________________
Reason for
referral_______________________________________________________________
_____________________________________________________________________________
Referred
by:________________________________DD/MM/YY___________________________
Signature___________________________________________
REFERRAL FEEDBACK (section B)
Name: _______________________________________________________________________
Age_____________________Sex_______________Addressess (Resident)
__________________
Name of Facility:
________________________________________________________________
Type of health service/care/support provided:
___________________________________________
____________________________________________________________________________
Feedback______________________________________________________________________
_____________________________________________________________________________
Name of service
provider____________________________Signature:______________________
Date /Month/Year _________________________
………………………………………………………………………………………………………………………………………………

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LAKE ESTATE MINISTRY OF HEALTH REFERRAL DIRECTORY
Name of the health facility_______________________________________________________
Physical address:
______________________________________________________________________________
______________________________________________________________________________
__________________________________________________________________
Telephone: _______________________________________
Contact person:
__________________________________________________________________________
Mobile phone:
__________________________________________________________________________
Available services:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
________________________________

REFERRAL IN REGISTRATION BOOK
Name of the facility: ____________________________________________________________________________________________________
State : ______________________________________________________County ___________________________________________________
Date Name of the
patient
Card
No
Age Sex Referred from
(name of
facility)
Referred for Diagnosis Service
provided
(Write Yes or
No)
Feedback
provided
(Write Yes
or No)
Remark

REFERENCES
1. An Electronic Patient Referral Application: A Case Study from Zambia Niamh Darcy,
Chris Kelley, Eileen Reynolds, Gordon Cressman, and Perry Killam, March 2010
Research Report
2. Rapid Assessment of Referral Care Systems A Guide for Program Managers:JSI/USAID
3. The Health Referral System In Indonesia
4. Tools for Establishing Referral Network for Comprehensive HIV care in low –Resource
Setting

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