A qualitative assessment of the referral system at district level in Zimbabwe: implications on efficiency and effective delivery of health services

OBJECTIVE

To qualitatively assess the referral system at district level from the consumers' point of view and assess implications it had on efficiency and effectiveness of service delivery.

DESIGN

Descriptive study.

SETTING

Districts of Tsholotsho and Murewa.

SUBJECTS

Subjects of the study included community members, ward health team members outpatient department (OPD).

MAIN OUTCOME MEASURES

The nature and magnitude of the problem; health seeking behaviour; the perceived role of a hospital versus a health centre; knowledge on the referral system; user fees and the referral system and communication between the service and the community; and perceptions on the referral system.

RESULTS

The community does not know the functional differences between a hospital and a clinic. What is clearly known is the physical differences that exist between the two. That is one of the reasons why the choice of a point of entry into the health care delivery system is not always correct. People do understand the mechanics of referring a patient to higher levels of care but they were not happy with the high hospital charges. Although the majority are eligible for free treatment the issues of high transport and other indirect costs were mentioned. There is no effective communication system between the service and the users. This manifested itself through the lack of knowledge or the existence and role of ward health teams or clinic committees. This lack of communication seems to be a major determinant in the failures of many a good policy. The impact of the new fee structure of January 1994 was minimal at district level because the communities felt that although referred patients do not pay hospital consultation fees, once admitted the patient still has to pay or at least prove that he/she is eligible for free services. The inconvenience of proving eligibility for free care still exists.

CONCLUSION

In general, the community did not fully comprehend the purposes and intentions of the new user fees policy of January 1994 which was meant to rationalise the referral system. Generally, communities are seldom consulted in time to ensure effective policy implementation and realisation of the intended impact. Impressions generated on the impact of the problem of the referral system on resource use at hospital level show that it has been considerable, although this study did not quantify it. Unnecessary overloading of referral centres negatively affected the care of referral cases, which actually required hospital care, due to competition with primary care cases.

Use of mental health institutions in Zimbabwe and factors affecting length of stay of patients

OBJECTIVE

To explore the functioning of mental health care institutions and the factors contributing to prolonged length of stay of in-patients.

DESIGN

The study was a descriptive type which employed convenient and stratified simple random sampling procedure to select the institutions and the study subjects. Patients were categorized according to diagnostic grouping and sample sizes were calculated in proportion to ward size and sex. Data was collected through face to face interviewing, administration of the questionnaire, completion of a checklist, observation of hospital records and patient activities as well as studying of patient case notes.

SETTING

The study was done at Ngomahuru and Ingutsheni in Masvingo and Bulawayo respectively.

SUBJECTS

The subjects of the study comprised patients and selected health cadres.

MAIN OUTCOME MEASURES

Length of stay of inpatients by diagnostic grouping and factors contributing to prolonged stay of in-patients.

RESULTS

The two institutions were functioning as both homes and hospitals with more patients needing more social than medical care. Factors affecting length of stay included destitution, lack of community based rehabilitation therapy facilities, poor follow up after discharge and institutionalization of patients.

CONCLUSIONS

Mental health care institutions are experiencing prolonged stay of patients of years or a life time. This has implications on costs and quality of services provided in feeding, clothing and caring for them medically. There is need to consider alternative cost effective, and efficient options of care.