A qualitative assessment of the referral system at district level in Zimbabwe: implications on efficiency and effective delivery of health services

This exploratory study describes the nature and magnitude of the problem of health referrals, health-seeking behavior, perceptions, and knowledge at the district level in Zimbabwe. Data were obtained from focus groups with 159 persons in Tsholotsho and 132 persons in Murewa; from discussions with health personnel from the 6 health centers in Murewa and the 2 rural hospitals in Tsholotsho; and from records among a systematic sample of 400 new outpatients during October 1993 and March 1994 in Murewa district. Findings indicate that 71.8% in outpatient departments at Murewa Hospital had no access to a health center. 24.3% by-passed the health center for treatment at the hospital. 3.8% were referred by health centers. The absolute number of referrals did not change during 1991-93. However, the number directly accessing services from outside the district rose. Focus group participants reported their intention to use the nearest clinic for an illness. In Tsholotsho, people initially used the village community worker/headman. If illness was perceived as serious, patients would go to a hospital. For minor illness, people used traditional herbal remedies. If illness did not change after remedies, the clinic was consulted. Some illnesses were perceived as outside the realm of medicine. Most distinguished between a health center and a hospital, but were unaware of the important, superior functions of the health center. Most did not understand the logic behind the referral system, but appreciated referrals and not the cost of hospital treatment or transportation. The community was unaware of Ward Health Teams. Many did not understand the new fee policy introduced in 1994.