We have shown that paediatric referral rates in this rural Tanzanian setting are extremely low, at less than 1% of cases seen and 8 per 1000 catchment population per year. There may be many reasons for this low referral rate: firstly, that acutely ill children are not brought to health facilities (Figure 1, steps 1 and 2), secondly that health facility staff do not identify children who need referral (step 3), and thirdly that they only refer children who have the financial and social support required to travel to the referral centre (step 4). The high rate of admissions (71%) among the referred patients suggests that the decision to refer is generally appropriate, but that too few children are referred. The low referral rate may contribute to the high infant and child mortality in the area.
As in Kenya , dispensaries bypassed the health centres by sending paediatric referral cases directly to SFDDH. It is likely that in both countries there is little operational difference between dispensaries and health centres, and also that caretakers perceive them to be the same. Investment is needed in district health systems in order to revitalize health centres, so as to increase their capacity to identify, manage and treat a critical number of severe paediatric patients in order to reduce long-distance referrals.
A quarter of the referral cases did not come from the governmental health system. This reflects the relatively high number of mission and private health actors in Kilombero District. However, we also found 5 patients who had been referred by traditional healers. Similar findings were reported in Bagamoyo District on the Tanzanian Coast . These positive results should encourage the district health management team to remain in contact and to work together with the informal and the private health sectors [16, 17].
Accessibility is one of the key features of a well-functioning system of primary health care. We found that over 90% of patients using MCH and OPD services and 75% of admissions came from within 10 km of the hospital. This shows that the Kilombero District referral hospital is mainly used for primary care for those who live within reach. Approximately 75% of the population of the district live further away, and presumably use their local health facilities for primary care, with the drawback of the low number of referrals.
Our hospital study found 235 referred children in a one-year period, whereas the record review would suggest that around 121 children had been referred from public facilities during 1993 (28 times 4.33, the number of weeks in a month) This difference is partly explained by the inclusion of private and mission referrals in the former work, and may also be due to the one-year time difference and to our sampling scheme of the first week in every month. Whatever the reason, the findings suggest that most patients who are referred do arrive at hospital. However, almost half had a delay of 2 or more days. Once a child is referred, the mother is likely to need the approval of her husband or other family members before she can travel, and she may also need to raise money for the journey [18, 19]. Many of the villages in Kilombero district are difficult to reach, particularly during the rainy season, due to the poor state of the roads and the lack of public transport.
Anaemia and malaria were the main causes of referral. This is not unexpected, particularly in an area with intense perennial malaria transmission and where malaria and anaemia are the major causes of admission the paediatric ward of SFDDH [20, 21]. However, cases reaching the district hospital are only the tip of the iceberg, as over half of child deaths occur at home (Armstrong Schellenberg, unpublished observations).
The low number of paediatric referral cases found in this study (0.6%) are in contrast with the high proportion of children (7 % to 16%) referred by health workers using IMCI guidelines . Full implementation of the IMCI guidelines could lead to an increase in the number of paediatric referral cases who would have difficulties in reaching the district hospital due to the poor road conditions and the lack of transport. In remote areas, the IMCI guidelines may need to be locally adapted to reduce the number of children referred. This step may need availability of more sophisticated treatments at peripheral level accompanied by the respective training, monitoring and supervision.