Using Network and Complexity Theories to Understand the Functionality of Referral Systems for Surgical Patients in Resource-Limited Settings, the Case of Malawi

Document Type : Original Article


1 Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland

2 Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands

3 Wellbeing and Preventable Chronic Disease Division, Menzies School of Health Research, Brisbane, QLD, Australia

4 College of Medicine, University of Malawi, Blantyre, Malawi

5 Department of Health and Society, Wageningen University and Research, Wageningen, The Netherlands

6 Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland


A functionally effective referral system that links district level hospitals (DLHs) with referral hospitals (RHs) facilitates surgical patients getting timely access to specialist surgical expertise not available locally. Most published studies from low- and middle-income countries (LMICs) have examined only selected aspects of such referral systems, which are often fragmented. Inadequate understanding of their functionality leads to missed opportunities for improvements. This research aimed to investigate the functionality of the referral system for surgical patients in Malawi, a low-income country.

This study, conducted in 2017-2019, integrated principles from two theories. We used network theory to explore interprofessional relationships between DLHs and RHs at referral network, member (hospital) and community levels; and used principles from complex adaptive systems (CAS) theory to unpack the mechanisms of network dynamics. The study employed mixed-methods, specifically surveys (n = 22 DLHs), interviews with clinicians (n = 20), and a database of incoming referrals at two sentinel RHs over a six-month period.

Obstacles to referral system functionality in Malawi included weaknesses in formal coordination structures, notably: unclear scope of practice of district surgical teams; lack of referral protocols; lack of referral communication standards; and misaligned organisational practices. Deficiencies in informal relationships included mistrust and uncollaborative operating environments, undermining coordination between DLHs and RHs. Poor system functionality adversely impacted the quality, efficiency and safety of patient referral-related care. Respondents identified aspects of the district-RH relationships, which could be leveraged to build more collaborative and productive inter-professional relationships in the future.

Multi-level interventions are needed to address failures at both ends of the referral pathway. This study captured new insights into longstanding problems in referral systems in resource-limited settings, contributing to a better understanding of how to build more functional systems to optimise the continuum and quality of surgical care for rural populations in similar settings.


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Volume 11, Issue 11
November 2022
Pages 2502-2513
  • Receive Date: 09 April 2021
  • Revise Date: 01 November 2021
  • Accept Date: 20 December 2021
  • First Publish Date: 22 December 2021