Surgical referral systems in low- and middle-income countries: A review of the evidence

Autoři: Chiara Pittalis aff001;  Ruairi Brugha aff001;  Jakub Gajewski aff002
Působiště autorů: Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland aff001;  Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland aff002
Vyšlo v časopise: PLoS ONE 14(9)
Kategorie: Research Article
doi: 10.1371/journal.pone.0223328



Referral networks are critical in the timely delivery of surgical care, particularly for populations residing in rural areas who have limited access to specialist services. However, in low- and middle-income countries (LMICs) referral networks are often undermined by systemic inefficiencies. If equitable access to essential surgical services is to be achieved, sound evidence is needed to ensure efficient patient care pathways. The aim of this scoping review was to investigate current knowledge regarding inter-hospital surgical referral systems in LMICs to identify the main obstacles to their functioning and to critically assess proposed solutions.


MEDLINE, EMBASE and Global Health databases and grey literature were systematically searched to identify relevant studies. The search generated 2261 unique records, of which 14 studies were selected for inclusion in the review. The narrative synthesis of retrieved data is based on a conceptual framework developed though a thematic analysis approach.


Multiple shortages in surgical infrastructure, equipment and personnel, as well as gaps in surgical and decision-making skills of clinicians at sending hospitals, act as obstacles to safe and appropriate referrals. Comprehensive protocols for surgical referrals are lacking in most LMICs and established patient pathways, when in place, are not correctly followed. Interventions to improve coordination and communication between different level facilities may enhance efficiency of referral pathways. Strengthening capacity of referring hospitals to manage more surgical conditions locally could improve outcomes, decrease the need for referral and reduce the burden on tertiary facilities.


The field of surgical referrals is still an uncharted territory and the limited empirical evidence available is of low quality. Developing strategies for assessing functionality and effectiveness of referral systems in surgery is essential to improve access, coverage and quality of services in resource-limited settings, as well as overall health systems performance.

Klíčová slova:

Behavioral and social aspects of health – Communication in health care – Critical care and emergency medicine – Database searching – Equipment – Obstetric procedures – Surgical and invasive medical procedures – Trauma surgery


1. Ministry of Health. Kenya health sector referral strategy. Nairobi; 2014.

2. WHO. Management of health facilities: referral systems [Internet]. World Health Organization; 2010 [cited 2019 Jun 13].

3. Hensher M, Price M, Adomakoh S. Referral hospitals. In: Jamison DT, Breman JG, Measham AR et al, editor. Disease Control Priorities in Developing Countries. 2nd ed. New York: Oxford University Press and The World Bank; 2006.

4. Meara JG, Leather AJM, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386(9993):569–624. doi: 10.1016/S0140-6736(15)60160-X 25924834

5. Khan S, Zafar H, Zafar SN, Haroon N. Inter-facility transfer of surgical emergencies in a developing country: effects on management and surgical outcomes. World J Surg. 2014;38:281–6. doi: 10.1007/s00268-013-2308-y 24178181

6. Shi G, Zhou B, Cai Z, Wu T, Li X, Xu W. Referral by outreach specialist reduces hospitalisation costs of rural patients with digestive tract cancer: a report from medical consortium in China. Rural Remote Health. 2014;14(1):2317.

7. Albutt K, Yorlets RR, Punchak M, Kayima P, Namanya DB, Anderson GA, et al. You pray to your God: a qualitative analysis of challenges in the provision of safe, timely, and affordable surgical care in Uganda. PLoS One. 2018;13(4):e0195986. doi: 10.1371/journal.pone.0195986 29664956

8. Raykar NP, Yorlets RR, Liu C, Goldman R, Greenberg SLM, Kotagal M, et al. The How Project: understanding contextual challenges to global surgical care provision in low-resource settings. BMJ Glob Heal. 2016;1(4):e000075.

9. WHO. Hospitals and health for all. Geneva: World Health Organization; 1987.

10. Jiskoot P. On-the-job training of clinical officers in Malawi. Malawi Med J. 2008;20(3):74–7. 19537402

11. Simba DO, Mbembati NAA, Museru LM, Lema LEK. Referral pattern of patients received at the National Referral Hospital: challenges in low income countries. East Afr J Public Health. 2008;5(1):6–9. 18669115

12. Cornelissen D, Mwapasa G, Gajewski J, McCauley T, Borgstein E, Brugha R, et al. The cost of providing district-level surgery in Malawi. World J Surg. 2018;42(1):46–53. doi: 10.1007/s00268-017-4166-5 28791448

13. Goodman DM, Srofenyoh EK, Olufolabi AJ, Kim SM, Owen MD. The third delay: understanding waiting time for obstetric referrals at a large regional hospital in Ghana. BMC Pregnancy Childbirth. 2017;17(1):216. doi: 10.1186/s12884-017-1407-4 28693518

14. den Hollander D, Albert M, Strand A, Hardcastle T. Epidemiology and referral patterns of burns admitted to the Burns Centre at Inkosi Albert Luthuli Central Hospital, Durban. Burns. 2014;40(6):1201–8. doi: 10.1016/j.burns.2013.12.018 24439933

15. Fleming M, King C, Rajeev S, Baruwal A, Schwarz D, Schwarz R, et al. Surgical referral coordination from a first-level hospital: a prospective case study from rural Nepal. BMC Health Serv Res. 2017;17(1):676. doi: 10.1186/s12913-017-2624-2 28946885

16. Rudge MVC, Maestá I, Moura PMSS, Rudge CVC, Morceli G, Costa RAA, et al. The safe motherhood referral system to reduce cesarean sections and perinatal mortality—a cross-sectional study [1995–2006]. Reprod Health. 2011;8(1):34.

17. Petticrew M, Roberts H. Systematic reviews in the social sciences: a practical guide. Oxford: Blackwell Publishing; 2006.

18. Peters M, Godfrey C, McInerney P, Baldini Soares C, Khalil H, Parker D. Scoping reviews. In: Aromataris E, Munn Z, editors. Joanna Briggs Institute Reviewer’s Manual [Internet]. The Joanna Briggs Institute; 2017.

19. Higgins J, Green S. Cochrane handbook for systematic reviews of interventions. Version 5.1.0 [updated March 2011]. The Cochrane Collaboration; 2011.

20. Joanna Briggs Institute. Critical appraisal tools [Internet]. [cited 2018 Jun 15].

21. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JPA, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med. 2009;6(7):e1000100. doi: 10.1371/journal.pmed.1000100 19621070

22. Tricco A, Lillie E, Zarin W, O’Brien K, Colquhoun H, Levac D, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2008;

23. World Bank. World Bank country and lending groups [Internet]. [cited 2018 May 15].

24. Canadian Agency for Drugs and Technology in Health. Grey matters: a practical tool for searching health related grey literature. Ottawa: CADTH; 2015.

25. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101.

26. Anderson LM, Petticrew M, Rehfuess E, Armstrong R, Ueffing E, Baker P, et al. Using logic models to capture complexity in systematic reviews. Res Synth Methods. 2011;2(1):33–42. doi: 10.1002/jrsm.32 26061598

27. Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc Sci Med. 1994;38(8):1091–110. doi: 10.1016/0277-9536(94)90226-7 8042057

28. Atkins D, Best D, Briss PA, Eccles M, Falck-Ytter Y, Flottorp S, et al. Grading quality of evidence and strength of recommendations. BMJ. 2004;328(7454):1490. doi: 10.1136/bmj.328.7454.1490 15205295

29. Joanna Briggs Institute. Supporting document for the Joanna Briggs Institute levels of evidence and grades of recommendations [Internet]. The Joanna Briggs Institute Levels of Evidence and Grades of Recommendations Working Party; 2014 [cited 2019 Jun 17].

30. Siraj S, Bawar S. An audit of obstetric referrals from district level hospitals to tertiary level hospitals of KPK. J Postgrad Med Inst. 2016;30(2).

31. Sani R, Nameoua B, Yahaya A, Hassane I, Adamou R, Hsia RY, et al. The impact of launching surgery at the district level in Niger. World J Surg. 2009;33(10):2063–8. doi: 10.1007/s00268-009-0160-x 19653031

32. Gyedu A, Baah EG, Boakye G, Ohene-Yeboah M, Otupiri E, Stewart BT. Quality of referrals for elective surgery at a tertiary care hospital in a developing country: an opportunity for improving timely access to and cost-effectiveness of surgical care. Int J Surg. 2015;15:74–8. doi: 10.1016/j.ijsu.2015.01.033 25659222

33. Crandon IW, Harding HE, Williams EW, Cawich SO. Inter-hospital transfer of trauma patients in a developing country: A prospective descriptive study. Int J Surg. 2008;6(5):387–91. doi: 10.1016/j.ijsu.2008.07.004 18789880

34. Lee WS. Pre-admission consultation and late referral in infants with neonatal cholestasis. J Paediatr Child Health. 2008;44(1–2):57–61. doi: 10.1111/j.1440-1754.2007.01170.x 17640283

35. Nkurunziza T, Toma G, Odhiambo J, Maine R, Riviello R, Gupta N, et al. Referral patterns and predictors of referral delays for patients with traumatic injuries in rural Rwanda. Surgery. 2016;160(6):1636–44. doi: 10.1016/j.surg.2016.08.006 27743716

36. Hsia RY, Mbembati NA, Macfarlane S, Kruk ME. Access to emergency and surgical care in sub-Saharan Africa: the infrastructure gap. Health Policy Plan. 2012;27(3):234–44. doi: 10.1093/heapol/czr023 21441566

37. Kruk ME, Wladis A, Mbembati N, Ndao-Brumblay SK, Hsia RY, Galukande M, et al. Human resource and funding constraints for essential surgery in district hospitals in Africa: a retrospective cross-sectional survey. PLoS Med. 2010;7(3):e1000242. doi: 10.1371/journal.pmed.1000242 20231869

38. Ajiko MM, Davé D, Feldhaus I, Smith R, Juillard C. Patterns of surgical presentation at an African regional referral hospital: surveillance as a step towards improving access to care using operative and inpatient records as. Eur J Trauma Emerg Surg. 2017;43:265–72. doi: 10.1007/s00068-016-0644-y 26869519

39. Abdullah F, Choo S, Hesse AAJJ, Abantanga F, Sory E, Osen H, et al. Assessment of surgical and obstetrical care at 10 district hospitals in Ghana using on-site interviews. J Surg Res. 2011;171(2):461–6. doi: 10.1016/j.jss.2010.04.016 20691981

40. Bowman K, Jovic G, Rangel S, Berry W, Gawande A. Pediatric emergency and essential surgical care in Zambian hospitals: a nationwide study. J Pediatr Surg. 2013;48(6):1363–70. doi: 10.1016/j.jpedsurg.2013.03.045 23845631

41. Gajewski J, Bijlmakers L, Mwapasa G, Borgstein E, Pittalis C, Brugha R. “I think we are going to leave these cases”. Obstacles to surgery in rural Malawi: a qualitative study of provider perspectives. Trop Med Int Heal. 2018;23(10):1141–7.

42. Directorate of Health Services Kerala. Referral guidelines for the common conditions for institutions under DME & DHS in Kerala. Kerala: Government of Kerala; 2012.

43. Ministry of Public Health & Sanitation. Clinical guidelines for management and referral of common conditions at levels 4–6: hospitals. Nairobi: World Health Organization; 2009.

44. Ministry of Health. Zambia national maternal and neonatal services referral guidelines. Lusaka: Ministry of Health; 2018.

45. Gajewski J, Mweemba C, Cheelo M, McCauley T, Kachimba J, Borgstein E, et al. Non-physician clinicians in rural Africa: lessons from the Medical Licentiate programme in Zambia. Hum Resour Health. 2017;15(1):53. doi: 10.1186/s12960-017-0233-0 28830528

46. Gajewski J, Conroy R, Bijlmakers L, Mwapasa G, McCauley T, Borgstein E, et al. Quality of surgery in Malawi: comparison of patient-reported outcomes after hernia surgery between district and central hospitals. World J Surg. 2018;42(6):1610–6. doi: 10.1007/s00268-017-4385-9 29209733

47. World Health Organization. Strengthening health systems to improve health outcomes: WHO’s framework for action. Geneva: World Health Organization; 2007.

Článek vyšel v časopise


2019 Číslo 9