After analyzing the determinants and perspectives of the stakeholders involved, five major themes were extracted from the qualitative data and a conceptual framework of the referral system was generated. The themes were “Referral Policy, Roles and Responsibilities, Implementation, Barriers and Facilitators, Monitoring, Evaluation and Feedback.” (as shown in figure 1)
Referral policy
Interviews mainly from the policy makers and administrators revealed that most of them weren’t aware of the referral guidelines released by the state of Madhya Pradesh in February 2021. All of them agreed on the fact that there is a need for a uniform national referral policy to ensure a holistic approach towards the delivery of healthcare services.
The subthemes for the theme ‘Referral policy’ were categorized into existence of a referral policy, reasons for not having referral policy, views on referral, understanding referral and importance of universal referral policy (as shown in figure 2).
Some of the verbatims of the participants were:
“So, there is no written order as such for practicing referral, how each patient is supposed to go to another hospital. There is no order” …. (Doctor of Medicine from SHC)
“Universal referral policy advantage is that any patient won’t have any problem, any delay, reach right centre at the right time” …… (Administrator of SHC)
Roles and responsibilities
Many of the administrators had said that there was no written order on referral policy and hence their hospital staff hadn’t been trained for it. The doctors also expressed that they were neither assigned any specific roles and responsibilities nor trained to ensure smooth referral mechanisms.
The subthemes for the second theme ‘Roles and responsibilities’ were categorized into role in referral policy making, duties/ responsibilities and mechanisms to ensure smooth referral (as shown in figure 3). Some of the verbatims were:
“……I give my technical inputs to the department based on the ground realities, based on the new innovations, or best practices as adopted by the other states in the country…” (policymaker in DHS)
“Pre communicated/ pre informed so staff is prepared to receive, ensuring patient stability
during transport in ambulance and prevent patient deterioration” ….(doctor in THC)
Implementation
Most of the doctors mentioned that they referred patients based on their necessity with a referral slip, in the format that is available in the hospital and would document the same in the referral registers in the ward or OPDs after counselling or clear communication as to seriousness of the condition of the patient. They sometimes give in to the demands of the patients as well.
The subthemes for the third theme ‘Implementation’ were categorized into training, maintenance of referral record, designated referral point, patient beliefs and choices, factors influencing successful referral and types of referrals (as shown in figure 4).
The verbatims were:
” the patient goes there and does it all in own… So there should be some person for help. Some referral officer… referral handling officer. Something like some destination should be met there, and that person should be there” …. (Administrator or in-charge of SHC)
“Timely and appropriate referral will increase treatment outcomes, patient satisfaction, improve quality of work for doctors and generate robust epidemiological data”…… (doctor in THC)
“Patient referred to government hospital but sometimes patient go to private hospital” ... (doctor in PHC)
Barriers & Facilitators
Policymakers, administrators, and doctors briefed that patients are referred only when certain necessary services were not available in the designated hospitals like, required investigations, OT services, lack of super specialty doctors or any staff, medicines, etc. Patients had elaborated on the cumbersome procedures in certain hospitals and their preference with respect to distance from their residence, waiting time, comfort and trust levels with the doctors and hospital services, cost of treatment, etc. as determinants in seeking healthcare in a particular hospital.
The subthemes for the fourth theme ‘Barriers & Facilitators’ were categorized into factors affecting referral, reasons for referral, facility factors, patient factors, illness characteristics and doctor factors (as shown in figure 5).
The verbatims were:
"It's nearby.... free medicines….old hospital… more crowds... government hospital.... Fast service"…. (patients from PHC and SHC)
“BPL patients for cost of treatment…where beneficiary schemes like Ayushman Bharat (AB PM-JAY) and other grants are available” …. (administrator or in-charge of THC)
“They may not be having proper infrastructure, proper staff for that…. equipment may not be available…. no expert or no specialist” …. (Policymaker in DME)
Monitoring, feedback and evaluation
Many stakeholders had agreed that a uniform referral policy if implemented, would decrease duplication of resources, increase patient satisfaction, compliance, treatment adherence, and thus improve patient health outcomes. They also emphasized that there needs to be a monitoring and feedback mechanism to evaluate and ensure the appropriateness of referral and prevent unnecessary referrals.
The subthemes for the fifth theme ‘Monitoring, feedback and evaluation’ were categorized into appropriateness of referral, effects / outcomes of referral, prevent unnecessary referrals and average referral percentage (as shown in figure 6).
The verbatims were:
“Backward and forward chain to be coordinated by outside/ third party level” …. (administrator or in-charge of THC)
“…of course, increase patient satisfaction, compliance, treatment adherence, improve outcomes…. comfort near home….no disturbance to livelihood…..”(doctor in THC)