A Qualitative Study of Referral Practices of the Public Healthcare System in Bhopal District of Madhya Pradesh

Background - Referral system is backbone of any healthcare delivery system. Referral defined as the handover of patients from doctor to doctor or from one team to another has been identified as a high-risk area as patient valuable information can be lost or not quantified or recorded properly during the transit. Many referrals are regarded as unnecessary, meaning that the problem could be handled by the General Practitioner (GP). Improving the quality of the referral process is important to facilitate timely access to speciality care. Objectives - To understand the perceptions, attitude, behaviour, challenges and facilitators of referral policy, practices and pattern from all the stake holders involved in the referral process, i.e., the health policy makers, healthcare providers and users from primary care to higher levels of health care facilities in the public health system of Bhopal district in Madhya Pradesh. Materials and Methods - 24 in-depth interviews of the health policy or decision makers of the state, doctors, and administrators/ in-charges of the public health system in Bhopal by purposive sampling and exit interviews of a quota sampling of 63 patients were conducted. Thematic framework analysis was done manually and a conceptual framework for the referral system was generated. Results - Five major themes conceptualised for the continuous process of the referral system were referral policy, roles and responsibilities, implementation, barriers and facilitators, monitoring, feedback and evaluation. Conclusion - The implementation of the referral policy regarding the maintenance of the referral registers, issuing of referral slips, etc were not up to the required standards. There is a need for a uniform state referral policy and the establishment of a GP system to ensure continuity of care.