A Better Way to Refer—and to Be Referred

Magdalena Vendura neatly writes down the details in her files—full names, addresses, telephone numbers, HIV statuses. It’s the kind of information her clients can only give to someone they trust completely, someone they know to be discreet. Clients in the Kavango region of Namibia tend to guard their HIV statuses closely. Stigma and shame still surround the virus in the city of Rundu, where senior HIV counselor Magdalena and her colleagues are busy at work in the New Start Center.

Many clients love New Start Centers. The small, government-run facilities are scattered throughout Namibia and offer family planning, HIV testing and counseling, and other services. Clients like that the wait times are shorter than in busy local hospitals. They also like the privacy. At a hospital, for instance, clients are more likely to run into neighbors. Many worry they’ll be spotted heading to the part of the hospital everyone knows is reserved for HIV services. The centers, on the other hand, are so anonymous that until last year, the Rundu New Start Center didn’t even take down clients’ names.

HIV care is complex and in high demand in Namibia, where the prevalence rate among adults is 13.4%. Many of Magdalena’s clients need care beyond what New Start offers. That’s why referrals to other hospitals and clinics are a vital part of her work.

It’s frustrating for Namibian health workers like Magdalena that they’ve never had a way to be sure that clients they refer elsewhere actually make it to their appointments. For example, Magdalena may counsel a pregnant, HIV-positive woman and refer her to a neighboring hospital for services that will help her to prevent passing the virus to her baby. Six months later, though, Magdalena and her colleagues won’t necessarily know whether the mother got those services—or whether there is a baby out there who now needs HIV care.

But now, thanks to a new referral system designed by IntraHealth International and Namibia’s Ministry of Health and Social Services, Magdalena has data that show whether her clients get the care they need. She has information that helps the New Start Center measure how effective its referral services are, lets staff know when clients may need additional help, and ensures more people get the care and services they need.

A new direction

As part of its new bi-directional referral system, IntraHealth designed a referral form—a stack of which are bound into a booklet, in triplicate—that health workers can use to record key details of a client’s health history and services. When Magdalena refers a client, she fills out a form and tears two copies out of the book, leaving a carbon copy behind for the center’s records. One copy goes in the client’s file. The original goes with the client. When the client arrives at his or her appointment, a health worker at the new facility can see all of the key details recorded on the form and tears off a section of it to stow in a locked box. At the end of the week, a staff member from Rundu’s New Start Center treks out to the facilities to collect all the slips so they can be compared to those recorded in the booklet.

Then Magdalena picks up the phone. She goes down the list and calls the clients whose referral slips did not make it back to the center. “We noticed you weren’t able to make it to your appointment,” she tells them. “Is there any problem? Can we help?”

Sometimes clients simply haven’t gotten around to it yet. But often—particularly with those who have only recently learned they are HIV-positive—clients admit they are too worried, scared, or ashamed to go to the hospital for care.

“Come back in and see us again,” Magdalena tells them. “We’ll talk more.” They often do, and after more counseling, many find the courage they need to seek further treatment.

IntraHealth worked with the ministry to test the bi-directional referral system for six months in 55 health facilities in the Kavango, Oshikoto, Oshana, and Khomas regions. They found that the system did help health workers to follow up with their clients, though a lack of phones and limited communications infrastructure in some areas mean that not all had the same successes as the Rundu New Start Center. The paper-based forms present another challenge—some facilities ran out and had no way of ordering more.

But the pilot’s successes are encouraging, says IntraHealth’s Dr. Alexis Ntumba. “Referrals are not new in Namibia, but there have been many challenges for the system,” he says. “It lacks standard procedures between public facilities and we have inconsistent communication and tracking between different providers and facilities. Also, different facilities use different forms—some more detailed than others—and that affects the continuum of care for clients. It means we can’t ensure that clients who are referred actually reach their destinations and benefit from the services.”

Staff at many of the facilities involved in the pilot liked the consistency the forms offered. And even after the pilot was over, Rundu’s New Start staff continued to use the basic principles and practices they learned during the study.

IntraHealth is now working to scale up the bi-directional referral system and streamline its design. Dr. Ntumba and his team are working with the ministry to update the forms, prevent booklet shortages, and add a mobile phone component that will help save time (no more running back and forth between facilities to collect slips). The paper referral slips, though, are here to stay—having a form gives clients peace of mind and reassurance when it comes to visiting health facilities that are new to them.

Greater trust, better care

When the Rundu New Start Center staff started taking down their clients’ names and addresses, they worried clients would object (though Magdalena and her colleagues keep the center records secure and confidential). But they found that clients were happy to give their information—and that it helped form a deeper sense of trust in the health workers.

“In that way, clients came to be more open,” says Josef Kanema, HIV counselor and acting site manager at the New Start Center. Clients no longer felt they were adrift after being referred away from the health center. And they liked that the staff could get to know their individual situations well and were willing to keep helping them beyond their initial testing and counseling appointments.

Now clients will even call the center ahead of time when they don’t make it to their appointments, just to let staff know not to worry or to say that they’re having problems getting there. Some clients even stop to chat about their referral appointments when they see staff members on the street.

“We hadn’t seen that before the bi-directional study,” Josef says. “For me, these are the real success stories.”

This work was performed under the IntraHealth project Namibia Capacity Building for Country Owned HIV/AIDS Services, which is funded by the US Agency for International Development.

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