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BMJ 2015; 351 doi: (Published 14 October 2015) Cite this as: BMJ 2015;351:h5489

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Operationalizing an effective referral system in India

The health care system in India is plagued by overcrowding, lack of specialist doctors, paramedics and an effective referral system. There is a provision for referral of patients from subcentres, primary health centres, community health centres to subdistrict or district level and then to tertiary health facilities in medical college hospitals, superspeciality hospitals and research institutes under the public health care in India. The actual practice of referral is entirely different than that is laid down in principle. Any one can go to any level of health care system without any referral. This poses a burden on the secondary and tertiary level hospitals or health settings where a large number of patients with minor ailments throng the out patient departments (OPD) and increases the bulk of patients who can be easily tacked at the lower level health care settings.

A study by Pothuraju et al (1) reported the five common systems involved with disorders in the OPD as follows:
Diseases of respiratory system - ICD code J00-J99 - 12.7%,
Infectious and parasitic diseases - ICD Code A00-B99 - 8.2%,
Diseases of musculoskeletal system - ICD Code M00-M99 - 5.8%,
Diseases of digestive system - ICD Code K00-K99 - 5.7%,
Diseases of skin and subcutaneous tissues - ICD Code L00-L99 - 5.4 percent,
In another 33 %, the treatment was provided based on symptoms and signs (ICD Code R00-R99). Another study from a tertiary care hospital in Geater NOIDA, Uttar Pradesh (2) also reported the common morbidity as follows: among males , upper respiratory infection (URI), low backache (LBA), lower respiratory infection (LRI), acid peptic disease (APD), intestinal parasitosis (IP), bronchial asthma (BA), scabies, malaria and anaemia was 12.6%, 9.1%, 7.2%, 7.0%, 7.0%, 6.9%, 3.7%, 2.6%, and 0.4% respectively. In females, the figures were 7.6%, 18.3%, 3.7%, 13.6%, 4.4%, 2.4%, 2.2%, 1.5% and 3.2% respectively and 8.7% for Pelvic Inflammatory Disease (PID).

This shows that more than 50% morbidity could have been seen at the level of primary health centre and the serious ones could have been referred to the tertiary care hospitals.

The problems in implementing a successful referral system in India are : (1) non availability of adequate trained manpower, infrastructure (laboratory facilities, drug supplies, equipments, furniture etc.) in the primary health care settings, (2) lack of strict regulation on the referral system, (3) lack of strict regulation in avoiding minor cases coming directly to secondary or tertiary care hospitals, (4) non-availability of universal health card indicating the health facility for initial screening. This problem can be solved by demarcating the areas for health facility for each citizen using either the aadhar card (digitized identity card) or universal health card and making a strict regulation that only those seen in the designated health centres would be considered for health services once referred. This will lessen the burden in the tertiary health facilities and the health care providers can dedicate their time and energy in taking care of those referred with quality service provision.

1. Potharaju HR, Kabra SG. Prescription audit of outpatient attendees of secondary level government hospitals in Maharashtra. Indian Journal of Pharmacology.2011: 43( 2):150-156.
2. Sharma M, Agrawal D, Kumar D, Goel N. Morbidity Profile And Drug Distribution Pattern At A Newly Established Tertiary Care Hospital. The Internet Journal of Health. 2008;9(2):1-7.

Competing interests: No competing interests

15 October 2015
Mongjam Meghachandra Singh
Reeta Devi
Maulana Azad Medical College, New Delhi
Professor, Department of Community Medicine, Maulana Azad Medical College, New Delhi; co-author: Assistant Professor, School of Health Sciences, Indira Gandhi National Open University, New Delhi