Exploring Health Workers' Perspectives on Referral System Challenges in Nigeria

Referral, the transfer of care for a patient from one health worker or facility to another by request, is imperative for patients to access different tiers of care. The Nigerian referral system is faced with challenges, but there is limited understanding of the challenges. Addressing this gap may help the Nigerian government, health service managers and other stakeholders to plan appropriate actions for improving the referral system. Health workers are key actors in the referral system who can offer in-depth information on the challenges in the referral system. A wide range of 46 Nigerian health workers participated in this online qualitative survey. Participants were selected from social media using purposive sampling between February and April 2023. Responding to five open-ended questions, participants described challenges in the referral system and highlighted solutions. Thematic analysis was performed on the data. Findings reveal that health workers face infrastructure challenges. These include a lack of ambulances, long distances between health facilities that make and receive referrals, and the limited physical space to accommodate patients in health facilities receiving referrals. Health workers face challenges of a communication gap between health facilities that make and receive referrals, as well as a lack of specialist care. In addition, health workers face challenges of two patient-related factors. The first is patients' lack of funds to access health services in health facilities receiving referrals, which is linked to increased morbidity and mortality that places work pressure on health workers. The second is the challenge of convincing patients of the reasons for referrals, which is a result of patients' false beliefs about referrals. Health workers also describe the challenges patients face in the referral system. According to health workers, patients face the challenge of long waiting times in health facilities receiving referrals. Just as health workers, patients face infrastructure challenges. These include a lack of ambulances and a lack of bed spaces to accommodate patients and caregivers in health facilities receiving referrals. Health workers report that patients also face challenges of lack of funds to access specialist care, anxiety about referrals and poor directions on how to navigate the health facilities receiving referrals. To address the challenges, health workers recommend infrastructure improvements. These include the availability of ambulances and spacious health facilities. Finally, health workers recommend improved communication between health facilities that make and receive referrals, employment of more medical specialists, health insurance and health education. The study provides comprehensive information on actions to take to strengthen the referral system in Nigeria.