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

Authors

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

Abstract

Background 
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.

Methods 
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.

Results 
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.

Conclusion 
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.

Keywords


  1. Alkire BC, Raykar NP, Shrime MG, et al. Global access to surgical care: a modelling study. Lancet Glob Health. 2015;3(6):e316-323. doi:1016/s2214-109x(15)70115-4
  2. Pollock JD, Love TP, Steffes BC, Thompson DC, Mellinger J, Haisch C. Is it possible to train surgeons for rural Africa? a report of a successful international program. World J Surg. 2011;35(3):493-499. doi:1007/s00268-010-0936-z
  3. Luboga S, Macfarlane SB, von Schreeb J, et al. Increasing access to surgical services in sub-Saharan Africa: priorities for national and international agencies recommended by the Bellagio Essential Surgery Group. PLoS Med. 2009;6(12):e1000200. doi:1371/journal.pmed.1000200
  4. McCord C, Kruk ME, Mock CN, et al. Organization of essential services and the role of first-level hospitals. In: Debas HT, Donkor P, Gawande A, Jamison DT, Kruk ME, Mock CN, eds. Essential Surgery: Disease Control Priorities. 3rd ed. Washington, DC: The International Bank for Reconstruction and Development, The World Bank; 2015. doi:1596/978-1-4648-0346-8_ch12
  5. Hensher M, Price M, Adomakoh S. Referral hospitals. In: Jamison DT, Breman JG, Measham AR, et al, ed. Disease Control Priorities in Developing Countries. 2nd ed. New York: Oxford University Press, The World Bank; 2006.
  6. Ologunde R, Maruthappu M, Shanmugarajah K, Shalhoub J. Surgical care in low and middle-income countries: burden and barriers. Int J Surg. 2014;12(8):858-863. doi:1016/j.ijsu.2014.07.009
  7. Provan KG, Fish A, Sydow J. Interorganizational networks at the network level: a review of the empirical literature on whole networks. J Manage. 2007;33(3):479-516. doi:1177/0149206307302554
  8. Henry JA, Bem C, Grimes C, et al. Essential surgery: the way forward. World J Surg. 2015;39(4):822-832. doi:1007/s00268-014-2937-9
  9. Pittalis C, Brugha R, Gajewski J. Surgical referral systems in low- and middle-income countries: a review of the evidence. PLoS One. 2019;14(9):e0223328. doi:1371/journal.pone.0223328
  10. Jumbam DT, Menon G, Lama TN, et al. Surgical referrals in Northern Tanzania: a prospective assessment of rates, preventability, reasons and patterns. BMC Health Serv Res. 2020;20(1):725. doi:1186/s12913-020-05559-x
  11. den Hollander D, Albert M, Strand A, Hardcastle TC. Epidemiology and referral patterns of burns admitted to the Burns Centre at Inkosi Albert Luthuli Central Hospital, Durban. Burns. 2014;40(6):1201-1208. doi:1016/j.burns.2013.12.018
  12. Goodman DM, Srofenyoh EK, Olufolabi AJ, Kim SM, Owen MD. The third delay: understanding waiting time for obstetric referrals at a large regional hospital in Ghana. BMC Pregnancy Childbirth. 2017;17(1):216. doi:1186/s12884-017-1407-4
  13. Nkurunziza T, Toma G, Odhiambo J, et al. Referral patterns and predictors of referral delays for patients with traumatic injuries in rural Rwanda. Surgery. 2016;160(6):1636-1644. doi:1016/j.surg.2016.08.006
  14. Pittalis C, Brugha R, Bijlmakers L, Mwapasa G, Borgstein E, Gajewski J. Patterns, quality and appropriateness of surgical referrals in Malawi. Trop Med Int Health. 2020;25(7):824-833. doi:1111/tmi.13406
  15. Schneider H, English R, Tabana H, Padayachee T, Orgill M. Whole-system change: case study of factors facilitating early implementation of a primary health care reform in a South African province. BMC Health Serv Res. 2014;14:609. doi:1186/s12913-014-0609-y
  16. Iverson KR, Svensson E, Sonderman K, et al. Decentralization and regionalization of surgical care: a review of evidence for the optimal distribution of surgical services in low- and middle-income countries. Int J Health Policy Manag. 2019;8(9):521-537. doi:15171/ijhpm.2019.43
  17. Elloker S, Olckers P, Gilson L, Lehmann U. Crises, routines and innovations: the complexities and possibilities of sub-district management. S Afr Health Rev. 2012;2012/13(1):161-173. doi:10520/ejc133690
  18. Morçöl G, Wachhaus A. Network and Complexity Theories: A Comparison and Prospects for a Synthesis. Adm Theory Prax. 2009;31(1):44-58. doi:2753/atp1084-1806310103
  19. Braithwaite J, Churruca K, Ellis LA, et al. Complexity Science in Healthcare - Aspirations, Approaches, Applications and Accomplishments: A White Paper. Sydney: Australian Institute of Health Innovation, Macquarie University; 2017.
  20. Thompson DS, Fazio X, Kustra E, Patrick L, Stanley D. Scoping review of complexity theory in health services research. BMC Health Serv Res. 2016;16:87. doi:1186/s12913-016-1343-4
  21. Cunningham FC, Ranmuthugala G, Westbrook JI, Braithwaite J. Tackling the wicked problem of health networks: the design of an evaluation framework. BMJ Open. 2019;9(5):e024231. doi:1136/bmjopen-2018-024231
  22. Provan KG, Milward HB. Do networks really work? a framework for evaluating public-sector organizational networks. Public Adm Rev. 2001;61(4):414-423. doi:1111/0033-3352.00045
  23. The Evidence Centre. Evidence Scan: Complex Adaptive Systems. London: The Health Foundation; 2010.
  24. Barasa E, Mbau R, Gilson L. What Is Resilience and How Can It Be Nurtured? A Systematic Review of Empirical Literature on Organizational Resilience. Int J Health Policy Manag. 2018;7(6):491-503. doi:15171/ijhpm.2018.06
  25. National Statistical Office. 2018 Malawi Population and Housing Census Main Report. Blantyre: National Statistical Office; 2019.
  26. The World Bank. Poverty headcount ratio at $1.90 a day (2011 PPP) (% of population). https://data.worldbank.org/indicator/SI.POV.DDAY. Accessed January 5, 2021.
  27. Government of the Republic of Malawi. Health Sector Strategic Plan II (2017-2022). Zomba: Government of the Republic of Malawi; 2017.
  28. The World Bank. Specialist surgical workforce (per 100,000 population). https://data.worldbank.org/indicator/SH.MED.SAOP.P5. Accessed January 5, 2021.
  29. Varela C, Young S, Groen R, Banza L, Mkandawire NC, Viste A. Untreated surgical conditions in Malawi: a randomised cross-sectional nationwide household survey. Malawi Med J. 2017;29(3):231-236. doi:4314/mmj.v29i3.1
  30. Borghi J, Munthali S, Million LB, Martinez-Alvarez M. Health financing at district level in Malawi: an analysis of the distribution of funds at two points in time. Health Policy Plan. 2018;33(1):59-69. doi:1093/heapol/czx130
  31. McDaniel RR Jr, Lanham HJ, Anderson RA. Implications of complex adaptive systems theory for the design of research on health care organizations. Health Care Manage Rev. 2009;34(2):191-199. doi:1097/HMR.0b013e31819c8b38
  32. Pittalis C, Brugha R, Crispino G, et al. Evaluation of a surgical supervision model in three African countries-protocol for a prospective mixed-methods controlled pilot trial. Pilot Feasibility Stud. 2019;5:25. doi:1186/s40814-019-0409-6
  33. Boyatzis RE. Transforming Qualitative Information: Thematic Analysis and Code Development. Thousand Oaks, CA: SAGE Publications; 1998.
  34. Turner JR, Baker RM. Complexity theory: an overview with potential applications for the social sciences. Systems. 2019;7(1):4. doi:3390/systems7010004
  35. Franco LM, Bennett S, Kanfer R. Health sector reform and public sector health worker motivation: a conceptual framework. Soc Sci Med. 2002;54(8):1255-1266. doi:1016/s0277-9536(01)00094-6
  36. Ifeanyichi M, Broekhuizen H, Cheelo M, et al. Surgical ambulance referrals in sub-Saharan Africa - financial costs and coping strategies at district hospitals in Tanzania, Malawi and Zambia. BMC Health Serv Res. 2021;21(1):728. doi:1186/s12913-021-06709-5
  37. Broekhuizen H, Ifeanyichi M, Mwapasa G, et al. Improving access to surgery through surgical team mentoring - policy lessons from group model building with local stakeholders in Malawi. Int J Health Policy Manag. 2021. doi:34172/ijhpm.2021.78
  38. Kornelsen J, Friesen R. Building rural surgical networks: an evidence-based approach to service delivery and evaluation. Healthc Policy. 2016;12(1):37-42. doi:12927/hcpol.2016.24779
  39. Gittell JH, Fairfield KM, Bierbaum B, et al. Impact of relational coordination on quality of care, postoperative pain and functioning, and length of stay: a nine-hospital study of surgical patients. Med Care. 2000;38(8):807-819. doi:1097/00005650-200008000-00005
  40. Karam M, Brault I, Van Durme T, Macq J. Comparing interprofessional and interorganizational collaboration in healthcare: a systematic review of the qualitative research. Int J Nurs Stud. 2018;79:70-83. doi:1016/j.ijnurstu.2017.11.002
  41. Bossyns P, Van Lerberghe W. The weakest link: competence and prestige as constraints to referral by isolated nurses in rural Niger. Hum Resour Health. 2004;2(1):1. doi:1186/1478-4491-2-1
  42. Milward HB, Provan K. Managing the hollow state Collaboration and contracting. Public Manag Rev. 2003;5(1):1-18. doi:1080/1461667022000028834
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