A Referral Card

By Irin Akhter, Farzana Islam, Sumona Siddiqua, Sushama Kanan, Malabika Sarker and Sabina Faiz Rashid

In Bangladesh, there are two types of close-to-community (CTC) providers: formal and informal. Formal CTC providers are the staff of the non-government organizations (NGOs) and government, whereas the informal CTC providers are drug sellers, homeopaths, traditional birth attendants (TBA), and other traditional practitioners. Both types of CTC providers play a key role as negotiators between communities and health systems to provide sexual and reproductive health services to women of Bangladesh and often act as a bridge between them in various contexts. Informal providers often maintain an informal personal link to the formal health sector and make referrals, when required. It is usually based on personal relationships with formal CTC providers in the organizations, rather than a formal structured process.

Reaching out and linking in

In Bangladesh, REACHOUT aims to understand and strengthen the role of CTC providers involve in menstrual regulation (MR) services in two implementing partner organizations, Marie Stopes Bangladesh (MSB) and Reproductive Health Services Training & Education Programme (RHSTEP). MR is a procedure to safely remove risk of pregnancy up to 10 weeks by paramedic or nurse and up to 12 weeks by doctor after a missed menstrual period. MSB is a large international organization and organization RHSTEP is a locally renowned NGO working closely with the government. Both the organizations provide MR services to the poor women; and largely depend on their CTC providers to promote their services in the community and increase service uptake through referrals.

Through the initial context analysis REACHOUT Bangladesh identified that there are no formal links between formal and informal providers and the client referral process faces many challenges. Poor instruction on the referral process, limited referral and interaction between formal and informal providers have negative impact on the health of poor people, especially MR clients.

To minimize the gap between formal and informal providers the following interventions were carried out through two quality improvement cycles (QICs):

Facilitative referral training for both formal and informal CTC providers to strengthen their capacity of referral. Facilitative referral is a process where a CTC provider provides continuous assistance and all necessary information of the service to the client
A revised referral card for both organizations to implement effective referral

Why revise the referral card?

The existing referral card was a one page paper printed on both sides. One side has address and the service hours of the clinic. The other side has the available health services of the respective clinic. It had no provision to document the information of the client and the referrer and had no way to track the referrer.

To revise the referral card REACHOUT Bangladesh applied a participatory approach and discussion with different level of staff from the partner organizations.

CTC providers were asked to list out the information they would want to see in a referral card and to draw a draft referral card during their first facilitative referral training
The draft including the information was shared with CTC providers’ supervisors and they gave feedback on the draft
Researchers designed a referral card addressing all the suggestions and feedbacks from the CTC providers and their supervisors
The research team met the higher authority of both partner organisations separately and shared the newly designed referral card mentioning how they have addressed CTC providers’ and their supervisors’ feedback
The higher authority of the partner organisations approved the design and the concept of the revised referral card
Final proof reading and editing was done involving the clinic managers of the intervention areas
REACHOUT Bangladesh financially supported the printing of the revised card and distributed it among the partner organisations
CTC providers were trained on how to use the referral card in the facilitative referral training

What is the difference?

The revised referral card has two parts with the same serial number printed on both. One part is for the referrer to keep with himself/herself and another part is handed over to the client to carry it to the clinic while accessing services.

The referral card has referrer’s name, referrer’s cell number, date of the referral, due date by which the client has to visit the clinic for the service considering her last menstrual period (LMP), the address of the clinic, and the service hours of the clinic. The client’s name and client’s cell number is printed only in the referrer’s part to track the client and to maintain client’s confidentiality.

Appreciation from providers and supervisors

“This referral card is like an ID card…it is good, if client show this card she gets the benefit and she is satisfied. This referral card is better than the previous slip. It is a document that I can send with the patient to the clinic. If the patient takes the service or not I will know that... If I give this referral card to the patient, she will be happy because I told her if you show this card you will have the treatment quickly and you don't have to face any problem.”

34-year-old pharmacist in an in-depth interview

The formal and informal CTC providers and supervisors of formal CTC providers appreciated the revised referral card as it helps them:

To keep records and to track the referred clients and the referrer
To ensure that the referral fee is paid to the referrer as they also keep a part which is a proof of their work
The referral card is itself documentary evidence of the referral system
The address printed on the referral card helps the client to get to the appropriate clinic

Challenges

Processing of the referral card has taken a long time to get off the ground (seven months) and still the intervention clinics are not able to cover their catchment area due to drop out and shortage of CTC providers. Some CTC providers and clinic managers shared that sometimes the clients have the tendency not to take the referral card with them or not to show it to the service center due to misconception that if the client brings or shows the card, the CTC provider would disclose her secret to her community or would get extra monetary benefit.

Recommendations and next steps

CTC providers recommended that the cover page of the referral book should be colorful with the address and logo of the clinic; and the name of referrer should be placed on the top of the referral book.

Continuing referral training, availability of the referral card and its regular distribution to CTC providers, documenting the information of the referral card in the organisations’ health information system, and ongoing monitoring of the information received in the referral card are important requirements for this restructured referral card.

Conclusion

The revised referral card has brought changes in the intervention areas of both the implementing partners. If the intervention will be scaled up to the other clinics of the partner organizations, it will be more feasible.

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The journey of a referral card: Implementation, embedment and challenges