Development of an indicator to measure emergency interfacility referral readiness for maternal and newborn care at national and sub-national levels

Emergency referral systems are vital to robust and resilient health systems, however, referral system strengthening efforts have been fragmented, often narrowly focused and lacking a clear measurement approach. We aimed to design a comprehensive standardized indicator to assess health facility readiness to refer emergency obstetric and newborn cases to a receiving health facility to improve the quality of referrals. We first developed an overarching emergency referral system monitoring framework. Through literature review and content analysis, we defined key dimensions for measurement. We mapped existing indicators to the monitoring framework’s dimensions and developed a tool to collect inputs for the emergency referral readiness indicator. We repeatedly sought consultation and feedback from stakeholders throughout the 2.5-year process and piloted the tool in Senegal and Mozambique. We consolidated feedback, adjusted and finalized the indicator. The final health facility assessment tool includes 123 questions across six dimensions. The dimensions include (1) Transportation readiness, (2) Referral efficiency and coordination of care, (3) Care during transport, (4) Financial accessibility of referral, (5) Family-centered referral, and (6) Inter-facility relational dynamics. Health facility responses can be scored by level of readiness (essential, improved or advanced) or by dimension. The pilot study showed that the tool was practical and effective. Referral system strengthening efforts can benefit from the emergency interfacility referral readiness indicator put forward in this work. It considers the complexity of the referral system, yet offers a standardized approach to identify gaps in referral systems, focus efforts, and track progress over time.