Zimbabwe's hospital referral system: does it work?

Background: Anecdotal evidence has suggested inefficiency in the pyramidal health care referral system established in Zimbabwe in 1980, as part of its primary health care (PHC) model. Aim: To assess the functioning of the pyramidal referral system in two rura l districts surrounding Harare, Zimbabwe, with regard to two common indicat or conditions: pneumonia in children and malaria in adults. Methods: For a three-month period, all complete inpatient records with disc harge diagnoses of pneumonia or malaria from three hospitals representing d ifferent levels of care were analyzed (n = 227). Data were collected on dem ographic and patient care variables. The appropriateness of admissions and referrals was determined by an assessment of the severity of illness and 'i ntensiveness' of care required. Data were analyzed for differences among th e three hospitals and between the two indicator conditions. Per night inpat ient bed costs for each hospital were also calculated. Results: For pneumonia in children, 56.8% of patients admitted at the secon dary level, 53.8% of patients at the tertiary level and 57.8% of patients a t the quaternary level were of mild severity. For malaria in adults, 74.0% of patients seen at the secondary level, 81.5% of patients at the tertiary level and 54.3% at the quaternary level were of mild severity. For pneumoni a, there were no differences in severity between the three hospitals wherea s for malaria significant case-mix differences among the hospitals were fou nd. Most patients attending the highest level referral facility were inappr opriate admissions who could have been treated at a lower level of care. Th e majority of patients at all the hospitals studied had used that hospital as their first or second point of contact with the health services. There w ere large variations in the inpatient per night bed costs between the three hospitals. Conclusions: Using the indicator diseases of pneumonia in children and mala ria in adults, this study concluded that this network did not meet design e xpectations as the central level referral hospital cared for a similar case -mix of patients as the district level, but at six times the cost. The appr opriateness of admissions and referrals could be improved by developing or strengthening intermediate level facilities, by changing mechanisms of acce ss to specialist facilities and by training health professionals in communi ty settings.