Barriers to Referral in Swaziland: Perceptions from Providers and Clients of a System under Stress

Date01 December 2011
DOIhttp://doi.org/10.2202/1948-4682.1183
Published date01 December 2011
Volume 3, Issue 4 • 2011 • Article 5
Barriers to Referral in Swaziland: Perceptions from Providers
and Clients of a System under Stress
Kate CE Macintyre, Tulane University of Louisiana
Megan Littrell, Tulane University of Louisiana
David R. Hotchkiss, Tulane University of Louisiana
Sibongile Mndzebele, Ministry of Health
Rejoice Nkambule, Ministry of Health
Batsile Malima
Sikhomba Gumbi, REDI
Thembeyena Dhlamini, REDI
Lisanne Brown, Louisiana Public Health Institute
Verne Kemerer, UNAIDS
Macintyre, Kate CE; Littrell, Megan; Hotchkiss, David R.; Mndzebele, Sibongile; Nkambule,
Rejoice; Malima, Batsile; Gumbi, Sikhomba; Dhlamini, Thembeyena; Brown, Lisanne; and Kemerer,
Verne (2011) "Barriers to Referral in Swaziland: Perceptions from Providers and Clients of a System
under Stress," World Medical & Health Policy: Vol. 3: Iss. 4, Article 5.
Available at: http://www.psocommons.org/wmhp/vol3/iss4/art5
DOI: 10.2202/1948-4682.1183
©2011 Policy Studies Organization
Barriers to Referral in Swaziland:
Perceptions from Providers and Clients of a
System under Stress
Kate CE Macintyre, Tulane University of Louisiana
Megan Littrell, Tulane University of Louisiana
David R. Hotchkiss, Tulane University of Louisiana
Sibongile Mndzebele, Ministry of Health
Rejoice Nkambule, Ministry of Health
Batsile Malima
Sikhomba Gumbi, REDI
Thembeyena Dhlamini, REDI
Lisanne Brown, Louisiana Public Health Institute
Verne Kemerer, UNAIDS
Abstract
In Swaziland, where one in four adults is HIV positive, identifying and addressing barriers
to a strong referral system is critical to ensure continuity of care for HIV positive individuals.
This study examines the referral system from the perspectives of health providers, community
health workers, traditional healers, clients seeking facility-based care, and managers of private
health organizations. Structured and semi-structured questionnaires were administered to 52 senior
providers, 161 providers, and 307 clients in 52 health facilities. In 82 randomly selected
communities, 81 traditional healers and 247 CHWs also participated. Staff from private health
agencies providing HIV-related care were also interviewed.
Referral is commonly understood as sending clients to seek care at higher level facilities
and is an individualized process dependent on various factors. Providers sending clients rarely
hear back on any regular basis about those clients. Referrals and linkages for certain services
are particularly weak including nutrition support, psychosocial support, palliative care and home-
based care. Many providers recommended that referral protocols with improved communication
tools are needed and said referred clients should be given priority at referral-receiving sites. Policy
recommendations include: referral form redesign; formalizing or reforming the referral protocol;
strengthening communication and linkages between community- and facility-based providers; and
improving patient-flow at referral sites.
KEYWORDS: referral, HIV and AIDS, treatment and care, barriers
Author Notes: This research was made possible by support for MEASURE Evaluation from the
U.S. Agency for International Development (USAID) under the terms of Cooperative Agreement
GPO-A-00-03-00003-00. This study was advised by Dr. C. Mabuza (Director of Health Services,
MOHSW), Beatrice Dlamini and Velephi Okello (SNAP), Sibongile Mndzebele (MOHSW M&E);
George Bicego and Peter Vranken of CDC/GAP, Swaziland; and the Swaziland Referral Technical
Working Group. The opinions expressed are those of the authors and do not necessarily reflect
the views of USAID or CDC, or the United States Government or the Government of Swaziland.
Conflicts of interest: None declared. Corresponding author: Kate CE Macintyre, Tulane University
of Louisiana. Email: kmacint@tulane.edu

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