Research BMJ Glob Health: first published as 10.1136/bmjgh-2019-001568 on 17 August 2019. Downloaded from Referral transit time between sending and first-line receiving health facilities: a geographical analysis in Tanzania Michelle M Schmitz, 1 Florina Serbanescu,1 George E Arnott,1 Michelle Dynes,1 Paul Chaote,2 Abdulaziz Ally Msuya,3 Yi No Chen1 To cite: Schmitz MM, ABSTRACT Summary box Serbanescu F, Arnott GE, Background Timely, high-quality obstetric services et al. Referral transit time are vital to reduce maternal and perinatal mortality. We What is already known? between sending and first- spatially modelled referral pathways between sending line receiving health facilities: Strengthening obstetric inter-facility referral sys- and receiving health facilities in Kigoma Region, Tanzania, ► a geographical analysis in tems in developing countries, including reducing de- identifying communication and transportation delays to Tanzania. BMJ Global Health lays due to inadequate transportation and unreliable timely care and inefficient links within the referral system. 2019;4:e001568. doi:10.1136/ communication, increases access to timely, appro- Methods We linked sending and receiving facilities to bmjgh-2019-001568 priate obstetric and neonatal care. form facility pairs, based on information from a 2016 Handling editor Seye Abimbola Health Facility Assessment. We used an AccessMod cost- What are the new findings? friction surface model, incorporating road classifications ► About 57.8% of facility pairs in Kigoma did not refer Additional material is ► and speed limits, to estimate direct travel time between to facilities providing higher levels of care. published online only. To facilities in each pair. We adjusted for transportation view please visit the journal ► When accounting for communication and transpor- online (http:// dx. doi. org/ 10. and communications delays to create a total travel time, tation delays, only 47.5% of the facility pairs have 1136bmjgh- 2019- 001568) simulating the effects of documented barriers in this an estimated overall referral transit times below 2 referral system. hours. Results More than half of the facility pairs (57.8%) did not Received 19 March 2019 refer patients to facilities with higher levels of emergency What do the new findings imply? Revised 21 May 2019 obstetric care. The median direct travel time was 25.9 min ► Interventions for reducing referral transit times Accepted 8 June 2019 (range: 4.4–356.6), while the median total time was in Kigoma could include increasing the number 106.7 min (22.9–371.6) at the moderate adjustment level. of ambulances, developing an ambulance dis- patch system and improving radio and ambulance Total travel times for 30.7% of facility pairs exceeded http://gh.bmj.com/ 2 hours. All facility pairs required some adjustments for communications. transportation and communication delays, with 94.0% of ► Combining cost-friction surface modelling with field- facility pairs’ total times increasing. work data provides stakeholders with a better un- Conclusion Half of all referral pairs in Kigoma Region derstanding of their healthcare referral system. have travel time delays nearly exceeding 1 hour, and facility pairs referring to facilities providing higher levels of care also have large travel time delays. Combining on September 30, 2021 by guest. Protected copyright. care facilities to obtain emergency obstetric cost-friction surface modelling estimates with documented © Author(s) (or their transportation and communications barriers provides a and neonatal care (EmONC) at higher-level employer(s)) 2019. Re-use more realistic assessment of the effects of inter-facility facilities if life-threatening complications permitted under CC BY-NC. No occur.9 Within the Three Delays Model commercial re-use. See rights delays on referral networks, and can inform decision- and permissions. Published by making and potential solutions in referral systems within of maternal mortality, the efficiency of a BMJ. resource-constrained settings. referral system affects the third delay (delay 1Division of Reproductive Health, in receiving appropriate care on arrival to Centers for Disease Control and a health facility, including time to travel Prevention, Atlanta, Georgia, between facilities if the appropriate level of USA INTRODUCTION care is not available at the initial facility).10 2Kigoma Regional Medical Office, Kigoma, Tanzania, United Almost 99% of all maternal deaths, and most Efforts to improve referral systems contribute Republic of perinatal deaths, occur in low- and middle-in- to two of the United Nation’s Sustainability 1–6 3AMCA Inter-Consult Ltd, Dar come countries. Strengthening the Development Goals: Goal 3 (ensuring healthy es Salaam, Tanzania, United district-level referral system is a key govern- lives and promoting well-being) and Goal 9 Republic of ment strategy to improve maternal health in (building resilient infrastructure).11 The time- 7 8 Correspondence to Tanzania. liness of a referral process may be affected by Michelle M Schmitz; An inter-facility first-line obstetric referral the quality of the communication network MSchmitz1@ cdc. gov system allows patients delivering at primary among facilities, transportation resources, Schmitz MM, et al. BMJ Global Health 2019;4:e001568. doi:10.1136/bmjgh-2019-001568 1 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2019-001568 on 17 August 2019. Downloaded from and road conditions.12 Understanding the current use and existing gaps of the emergency referral system is key to expanding coverage of high-quality intrapartum services. Geographic information systems (GIS) and spatial analyses can play an important role in assessing esti- mated physical access, distance and travel time to both obstetric care and EmONC facilities.13–15 To our knowl- edge, only one study in sub-Saharan Africa has conducted spatial analyses on obstetric care referrals, taking into account existing transport and communication factors.16 Research related to developing and evaluating strategies for locally appropriate transport, communication and referral systems for obstetric emergencies has been iden- tified as a high priority by the public health and medical community and policymakers.17 We describe observed inter-facility referral patterns found in Kigoma Region overall, and by facility type or EmONC level. We assess if these pairs transported patients to higher levels of care and consider the effect of travel delays due to transportation and communication barriers on the referral network. These observations will guide regional and programmatic efforts in improving the efficiency and effectiveness of the regional referral network. METHODS Study site Kigoma Region is a remote region in the western part Figure 1 Contextual map of Kigoma Region, Tanzania. of Tanzania bordering Lake Tanganyika and Burundi (figure 1). In 2012, the region had a total population of 2 Hospitals, typically referral centres for dispensaries and 127 930—of which 22% were women of reproductive age health centres, provide outpatient and inpatient care in (aged 15–49 years)—and was predominantly rural (83% various wards (eg, obstetric/gynaecological, surgical). http://gh.bmj.com/ 18 of the total population). Obstetric healthcare services are provided by the govern- More than one-quarter of Kigoma Region (27%) is ment (92.5%) and by faith-based and voluntary organi- arable/grazing land, with the remainder either as forests sations (7.5%).23 The health system is decentralised, and or bodies of water. Paved primary roads exist between district health offices (DHOs) provided administrative the main towns of Kigoma, Ujiji, Manyovu, Uvinza and and management support to facilities. Kasulu; remaining roads are packed dirt. Additionally, on September 30, 2021 by guest. Protected copyright. many communities along Lake Tanganyika are isolated Data source: Health Facility Assessment from roads, relying on boat transportation.19 We based our analyses on the 2016 Health Facility Assess- Compared with Tanzania as a whole, women in Kigoma ment (HFA) conducted in Kigoma Region by the Centers have a higher total fertility rate (6.5 births per woman for Disease Control and Prevention, AMCA Interconsult, vs 5.4 per woman), lower contraceptive use (27% vs and the Tanzanian MoH.23 The HFA assessed 174 facili- 34%) and a lower proportion of facility deliveries (60% ties providing delivery services, including all six hospitals, vs 63%).20 21 The Tanzanian Ministry of Health, Commu- all 25 health centres (excluding a health centre located nity Development, Gender, Elderly and Children—or the in a refugee camp), and 143 dispensaries (ie, 88% of all MoH—has identified Kigoma as a high-priority region dispensaries providing routine obstetric care). The HFA for health systems strengthening efforts to improve collected information on each facility’s geographical reproductive, maternal and newborn health outcomes.8 location, self-reported inter-facility referral networks for Most healthcare services in Tanzania are provided in obstetric cases, observable transportation resources (eg, public-sector health facilities: dispensaries, health centres presence of functional vehicles, drivers, fuel and vehicle and hospitals.22 Dispensaries provide primary outpatient maintenance) and communication capacity (eg, mobile care, including maternal and child health services, for phones, radios, landline telephones) for both facilities their catchment areas. Health centres, usually the first