Home Health Systems Strategies to Strengthen Referral From Primary Care to Secondary Care in LMICs

Strategies to Strengthen Referral From Primary Care to Secondary Care in LMICs

by Public Health Update

Strategies to strengthen referral from primary care to secondary care in low- and middle-income countries

The Asia Pacific Observatory on Health Systems and Policies is a collaborative partnership which supports and promotes evidence-based health policy making in the Asia Pacific Region. Based in WHO’s Regional Office for South-East Asia, it brings together governments, international agencies, foundations, civil society and the research community with the aim of linking systematic and scientific analysis of health systems in the Asia Pacific Region with the decision-makers who shape policy and practice.


Primary care is seen as a main way for achieving UHC in many countries. Creating an essential package of services and bringing those services nearer to users are essential to improve coverage. However, just as important are availability of hospital services and integration of the hospital and primary care. 

This policy brief and the accompanying background paper identifies the current challenges that many low- and middle-income countries are grappling with when it comes to delineating services that patients should use at primary or secondary care level and using published documents, identifies three strategies that contribute to better management of referrals: 

  • introduce / enhance gatekeeping role of primary care providers;
  • define clearly package of services that are provided in each level; and
  • link financing and provider payment mechanisms for each level.

The above strategies work best when they are out in place together as a package rather than individually. The brief concludes by identifying an approach to introduce these strategies within the health architecture. 

Conclusion and Recommendation

The extent of and quality of care provided at primary and secondary levels is a key determinant of a number of health system outcomes, including QoC, patient satisfaction, and costs of care. Formal management of the division of services between these levels, and of the process of referral between the primary and secondary levels, can enable better management of demand for care, improve patient care and patient satisfaction, and control costs. This is particularly an issue for countries introducing UHC schemes, which reduce barriers to access to services, and can result in an increase in demand.
Effective management of the division of services and referral between service levels requires balancing across competing outcomes – patient satisfaction, QoC, control of costs, and equity in utilization. While there are effective strategies, the effectiveness of these strategies depends on other aspects of health system function, including financing and workforce allocation to facilities at different levels, incentives generated by payment mechanisms, and the trust and confidence of patients and communities in the services provided.

Approach to addressing referral

  • Identify current problems with the referral system, with a focus on the quality and capacity of services at the primary and secondary levels, distribution of workforce between the levels, and levels of patient satisfaction and confidence in services at each level. There may be different issues in different local contexts, e.g. overuse of hospitals in urban areas, and underuse in rural areas or by disadvantaged groups. Based on this, identify the aims for policy in this area.
  • Identify the key drivers of provider practices and patient behaviour that result in these problems.  In particular, these include the determinants of the services and capacity to provide these services at the primary and secondary levels (e.g. funding and workforce distribution), the determinants of provider behaviour (e.g. payment mechanisms and salary incentives), and the determinants of patient behaviour (e.g. barriers to access, beliefs and expectations, confidence and trust in providers).
  • Where resource redistribution (e.g. from secondary to primary care levels) is a key policy objective, consider defining benefit packages/ packages of services to be provided at each level, as a lever to obtain increased funding, and to determine payment mechanisms, particularly from insurance schemes that provide the appropriate incentives.
  • Where more active demand management is sought, consider a formal gatekeeping role for PHC, while ensuring adequate PHC capacity, appropriate incentives for patients and doctors, and establishing an effective process and mechanism for referral upwards and backwards.

Krishna Hort, Katherine Gilbert, Prabhathi Basnayaka & Peter Leslie Annear. (‎2019)‎. Strategies to strengthen referral from primary care to secondary care in low- and middle-income countries. World Health Organization. Regional Office for South-East Asia. https://apps.who.int/iris/handle/10665/325734. License: CC BY-NC-SA 3.0 IGO


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