Medical referral care

Last updated: 08 January 2024

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Key points

A global UNHCR medical referral care guidance document exists and should be used to develop and implement country specific medical referral SOPs at the onset of an emergency
Two types of referrals are made: for (a) emergencies (obstetrical, medical and surgical); and for (b) elective cases for complementary investigations or specialized treatment. During emergency situations emergency life-saving referrals are prioritized
Use national health systems as much as possible
The decision to make a medical referral is always to be made by a medical professional and is based on prognosis, availability of services, and cost
It is essential to monitor referral care, including the reasons for referral, outcomes and costs. The UNHCR medical referral database is available to partners for this purpose

Overview

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.

Main guidance

Emergency Phase

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
Monitoring

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.

Medical Referral Care checklist

Establish a country level medical referral SOP at the onset of an emergency.

Identify and establish an agreement with a referral care partner if needed.

Ensure agreements are established between the partner and referral care service providers where needed and that 24/7 ambulance transfer is available.

Ensure a monitoring system is established to monitor referrals and costs.

Standards

Sphere standards-2018

Health systems standard 1.1: health service delivery

Establish or strengthen triage mechanisms and referral systems.

Implement protocols for triage at healthcare facilities or field locations in conflict situations, so that those requiring immediate attention are identified and quickly treated or stabilized before being referred and transported elsewhere for further care.
Ensure effective referrals between levels of care and services, including protected and safe emergency transport services and between sectors such as nutrition or child protection