The primary health care approach is the central pillar of UNHCR's public health strategy. However, ensuring referrals to higher levels of care for patients with life and limb threatening conditions is important to save lives. Referral to secondary or tertiary level medical care should be in line with country level standard operating procedures.
Secondary and tertiary health services are often costly and UNHCR budgets are likely to be limited. Realistic limits should be set, particularly for costly specialist services.
Relevance for emergency operations
Access to hospital level care (secondary and tertiary) is an important component of comprehensive health care and saves lives. In emergencies, there are often increased health needs, including health emergencies due to disruption of services and the need for referrals to prevent avoidable deaths. This is especially critical for emergency obstetric care.
The Public Health Officer and partners will need to identify appropriate referral facilities including an assessment of their capacity to provide the required services; costs; and any support needed (e.g., equipment, supplies, human resources, ambulances).
In a new onset emergency, prioritization will be needed and will depend on the availability and level of referral facilities.
Typically, initial referral criteria will include:
- Comprehensive emergency obstetric and new-born care (CEmONC)
- Lifesaving medical care (e.g., treatment of severe respiratory infections, blood transfusion)
- Life and limb saving surgical care (e.g., ruptured ectopic pregnancy, appendectomy, amputation)
Public health officers should develop a country standard operating procedure to guide referral care.
This should follow a stepwise process:
- Conduct a situational analysis to determine the health burden and national health policies and system, barriers and options for referral.
- Explore all referral health care modalities such as availability of charitable organizations, other NGOs and visiting specialists.
- Define clear target groups, typically refugees but may include asylum seekers and stateless persons
- Define medical eligibility and ineligibility for assistance which will typically prioritize emergency and lifesaving conditions.
- Set up a referral care committee to support decision making on cases. This will be most relevant in larger referral care programmes with significant budgets.
- Explore all financing options as UNHCR resources are always limited there may be other options such as full inclusion in the national systems, health insurance if existing and cost effective and cash-based interventions amongst others.
- Develop appropriate agreements with partners and service providers. Usually, an NGO partner will manage referrals and a PPA may be needed. The partner should establish contracts if needed with the referral facilities clearly defining the expectations and financial agreements. Ambulance services should be available 24/7.
- Communicating with refugees. Refugees and other key stakeholders (MoH and partners) should be made aware of referral care support available, how to access it and limitations and that their personal data is strictly confidential and treated in line with UNHCR's Data Protection framework.
- Monitoring. A system should be set up to track referrals and expenditure, UNHCR has developed the medical referral database (MRD) that can perform this function.
The structure of the SOP should include at least the following chapters:
- Hospitals selected for referral care
- Types of referral care covered
- Non-referrable medical conditions
- Decision-making processes for referral care
- Mechanisms for engaging other actors in referral care
- Cost settlement
Post emergency phase
The above standards apply both to emergencies and long-term situations.
As the situation stabilizes, a more comprehensive referral care programme can be considered including referral for elective procedures.