In Nepal, the Sub-health Post (from an institutional perspective) is the first contact point for the basic health services (as mentioned in the Institutional Frameworks of DOHS and MOHP). However in reality, the SHP is the referral center for the volunteer cadre of TBA and FCHV as well as PHCORC and EPI clinics. Each level above SHP is a referral point in a network for SHP to HP to PHC, up to district, zonal and regional, and finally to specialty territory center in Kathmandu.

This referral hierarchy has been designed to ensure that the majority of population receives public health and minor treatment in places accessible to them and at a price they can afford, inversely the system works as a supporting mechanism for lower levels by providing logistical, financial, supervisory and technical support from the center to periphery.

There is an absence of an effective and efficient referral system linking community health services to higher level of care for modern and traditional system of medicine (public, NGO, and private), tertiary care facilities often are providing PHC services, an inappropriate use of financial, technical and human resource and functional relation between different level are not clearly defined e.g. DHO with PHCC, PHCC with HP/SHP, HP with SHP.

Referral system in Second long term health plan (1997-2017)

It can be anticipated that the development of an adequate network of fully functioning district and zonal hospital will enable more effective referral networks to be established with a reduction of a reduction of inappropriate cases presented to tertiary hospitals. (Strategic Plan for Human Resource fir Health (2003-2017).

Tenth five year plan has included; manage and strengthen referral system.

Improve hospital services and referral through integrated management of district health system. (Three Year Health Plan).

Needs indicated by SLHTP regarding referral system:

  • Develop appropriate referral system
  • Encourage Traditional faith healer to refer persons to the district health system and to provide basic preventive and promotive services.

The referral system

Problems in referral system

  • Basic primary service burden at tertiary center
  • People of actual need are deprived of need of those territory care
  • Referral units are not available so that referral case get first priority to receive treatment at each facility.
  • Under utilization of district hospital and mid-level health workers.
  • Feedback system not working.
  • Lip-words of government never translate to activities.
  • Under staffing of peripheral health units.

Tertiary care/referral facility should be functioning in two separate service basic one for first contact patient and another for referred patient.

Strengthen district hospital, PHCC, HP ensure capacity to deliver quality health services.

Special care for referred case in district hospital in terms of waiting time and opportunity cost.

There should be compulsory feedback mechanism at each level and the patient at tertiary level can be referred back to peripheral health facilities for some services.