ArticleInternational journal of health policy and management2022
Using Network and Complexity Theories to Understand the Functionality of Referral Systems for Surgical Patients in Resource-Limited Settings, the Case of Malawi.
Article in International journal of health policy and management, 2022. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 5 papers.
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Who cites it
5 citing papers in PubMed, 9 citations in OpenAlex.
- Optimizing people's movement across the health system: a scoping review of referral systems within a primary health care approach.Primary health care research & development · 2025Article
- Factors associated with delayed referrals of patients with sepsis from primary to tertiary healthcare in Blantyre, Malawi: a qualitative study.BMC primary care · 2025Article
- Evidence-Informed Surgical Systems Strengthening with Meaningful Stakeholder Involvement in Low-Resource Settings: A Response to Recent Commentaries.International journal of health policy and management · 2024Article
- Understanding networks in low-and middle-income countries' health systems: A scoping review.PLOS global public health · 2023Article
- International Journal of Health Policy and Management (IJHPM): A Decade of Advancing Knowledge and Influencing Global Health Policy (2013-2023).International journal of health policy and management · 2023Article
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Authors and funding
10 authors at 5 institutions in 4 countries.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundA functionally effective referral system that links district level hospitals (DLHs) with referral hospitals (RHs) facilitates surgical patients getting timely access to specialist surgical expertise not available locally. Most published studies from low- and middle-income countries (LMICs) have examined only selected aspects of such referral systems, which are often fragmented. Inadequate understanding of their functionality leads to missed opportunities for improvements. This research aimed to investigate the functionality of the referral system for surgical patients in Malawi, a low-income country.
methodsThis study, conducted in 2017-2019, integrated principles from two theories. We used network theory to explore interprofessional relationships between DLHs and RHs at referral network, member (hospital) and community levels; and used principles from complex adaptive systems (CAS) theory to unpack the mechanisms of network dynamics. The study employed mixed-methods, specifically surveys (n=22 DLHs), interviews with clinicians (n=20), and a database of incoming referrals at two sentinel RHs over a six-month period.
resultsObstacles to referral system functionality in Malawi included weaknesses in formal coordination structures, notably: unclear scope of practice of district surgical teams; lack of referral protocols; lack of referral communication standards; and misaligned organisational practices. Deficiencies in informal relationships included mistrust and uncollaborative operating environments, undermining coordination between DLHs and RHs. Poor system functionality adversely impacted the quality, efficiency and safety of patient referral-related care. Respondents identified aspects of the district-RH relationships, which could be leveraged to build more collaborative and productive inter-professional relationships in the future.
conclusionMulti-level interventions are needed to address failures at both ends of the referral pathway. This study captured new insights into longstanding problems in referral systems in resource-limited settings, contributing to a better understanding of how to build more functional systems to optimise the continuum and quality of surgical care for rural populations in similar settings.
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