Closing the gap towards a successful referral system, a case study of a tertiary teaching and referral hospital, Kenya: pre-post intervention study design

Background Inappropriate utilization of higher level health facilities and ineffective management of the referral processes is characterized by self-referrals and frequent bypassing of nearest health facilities coupled with low formal referral mechanisms. This leads to unnecessary congestion at a high-cost health facility and compromises the ability and capacity of Kenyatta National Hospital to function as a referral facility as envisioned by Kenya Health Sector Referral Implementation Guidelines of 2014, Kenya 201 constitution and Kenyatta National Hospital legal statue of 1987. The purpose of this study was to analyse the effect of enforcement of national referral guidelines on health facility referrals to Kenyatta National Hospital. Methods This was a pre-post intervention test study design. The study was conducted amongst the orthopedic health facility referrals in 2021 with 222 and 246 before and after enforcement of the national referral guidelines respectively. This was done in Orthopedic Department at Kenyatta National Hospital. The variables collected were the healthy facility, location of health facility, health facility tier, type of health facility (government or private) and facility related factors associated with healthy facility orthopedic referrals to Kenyatta National Hospital. Data collection was done through data abstraction. Data was analyzed using frequency distribution, pearson chi-square test and logistic regression. Results Nairobi County and its environs constituted over four-fifth of all health facility referrals to Kenyatta National Hospital. Enforcement of the national referral guidelines was significant reduction in health facilities levels 2 and 3 referring patients directly to Kenyatta National Hospital after enforcement of national referral guidelines (p=0.002). About 43 health facilities ceased referring patients to Kenyatta National Hospital with over two-thirds of these health facilities being private facilities. The major facility and patient factors that were associated with health facility referrals to Kenyatta National Hospital were human resource capacity and availability and patient’s preference. Conclusion Enforcement of the national referral guidelines significantly reduced the lower tiers health facilities referring to Kenyatta National Hospital. We recommend having written standard operating procedures on referrals based on the national referral guidelines with continued enforcement of the same to sustain the gains made.