Building Resilient Patient Referral Systems in Rural Districts: A Qualitative Study in Ghana

Health system resilience partly depends on robust primary health care systems that are well-linked through functional referral systems. The study explored how referral system challenges are addressed in a poor rural Bongo district to support maternal and newborn care in Ghana. Bongo district was purposively selected for the study. Data were collected from purposefully sampled district, sub-district and facility level health managers, frontline staff and community-level opinion leaders using interviews and focus group discussions. A 3-week participant observation was also conducted in the Bongo-Soe health centre. The data were transcribed and uploaded onto NVivo11 where codes and themes were generated. The findings revealed an integrated referral system, supported by a teleconsultation system which enabled free phone calls between the staff. However, there were some challenges that needed to be resolved to increase the referral system’s robustness. Referral transportation challenges included lack of ambulance services, poor road network, and inability to pay transportation cost. Again, inadequate staffing and patients resisting referrals threatened the functioning of the referral system. Improving referral systems and ensuring viable ambulance services are essential for achieving health systems resilience in poor rural areas. It requires cross-sectoral action beyond the health sector to other sectors. The findings of the study will contribute to building a resilient patient referral system in rural areas, especially for maternal and newborn care. In addition, it adds to existing knowledge on referral systems in Ghana.