Breaking the silence on first referral hospitals and universal health coverage
Authors: Mike English, Laetitia Rispel, Freddie Ssengooba, Nigel Edwards
Journal: The Lancet Global Health (2024)

Although large, specialised hospitals are influential and resource-intensive parts of health systems, first referral hospitals (FRHs), often known as district hospitals, are neglected in the current discourse on universal health coverage (UHC) in low-income and middle-income countries, where they should enhance primary health care (PHC).1WHODeclaration of Astana.https://www.who.int/publications/i/item/WHO-HIS-SDS-2018.61Date: 2018Date accessed: October 20, 2023Google Scholar FRHs are influenced by the tensions that are inherent in their position at the interface between PHC and more specialist care, and the perceived trade-offs between access, effectiveness, and efficiency (figure). FRH services typically include essential care for emergencies and trauma, internal medicine, surgery, obstetrics and gynaecology, and paediatrics (including neonatology). Generally, the workforce of FRHs consists of a small number of generalist doctors, with nurses, non-physician clinicians, and other categories making up the majority of the workforce.2McCord C Kruk ME Mock CN et al.Essential Surgery.https://www.ncbi.nlm.nih.gov/books/NBK333500/pdf/Bookshelf_NBK333500.pdfDate: 2016Date accessed: October 20, 2023Google Scholar FRHs should be the first level of referral or support for PHC clinics and initial contact before more highly specialised health care. However, FRHs vary substantially in their size, economic status, geographical location, distribution of the population they are expected to serve, and scope or sophistication of services. This variability is substantially affected by previous and extant policies on health-care financing and the ways policy makers choose to navigate the tensions and inherent trade-offs in decision making when prioritising services at different levels of the health system. Some countries might prioritise geographical accessibility of basic hospital care, a restricted set of services provided by a generalist workforce to small populations, and reduced costs. Hospitals serving small populations might integrate with and provide better support to PHC facilities than those serving large populations. However, such FRHs forgo the technical efficiency that might be found in hospitals with increased workloads, specialist services, and concentration of resources. Furthermore, these FRHs risk suboptimal quality of care and more referrals for a wider variety of cases or clinical conditions compared with large FRHs. Consequently, the future of FRHs will depend on how policy makers balance these tensions and how countries overcome multiple challenges of weak governance, financial constraints, poor infrastructure, and workforce gaps. All will affect the quality of care, which is often poor, and health-system responsiveness to patient needs.3Kruk ME Gage AD Arsenault C et al.High-quality health systems in the Sustainable Development Goals era: time for a revolution.Lancet Glob Health. 2018; 6: e1196-e1252Summary Full Text Full Text PDF PubMed Scopus (1458) Google Scholar In September, 2023, we attended a workshop to share experiences around FRHs, potential lessons for low-income and middle-income countries, and to highlight knowledge gaps. The workshop was held in Oxford, UK and included participants and experts from several low-income and middle-income countries, European countries, the World Bank, and WHO, among others. Some of the main conclusions from this workshop are conveyed below. First, there is insufficient evidence to guide FRH financing and contribution to UHC across diverse health systems. Evidence suggests that market forces alone will not produce a fit-for-purpose hospital system in any country, but much might be gained from an iterative and cross-country approach to learning from policy change or service-redesign initiatives. Second, planning should take an integrated-systems approach across regions and sectors. However, research and programmatic activity often focus only on a specific clinical condition or discipline. More research is needed to explore how FRHs should operate as part of integrated PHC systems while enabling access to more specialised care.3Kruk ME Gage AD Arsenault C et al.High-quality health systems in the Sustainable Development Goals era: time for a revolution.Lancet Glob Health. 2018; 6: e1196-e1252Summary Full Text Full Text PDF PubMed Scopus (1458) Google Scholar, 4Hanson K Brikci N Erlangga D et al.The Lancet Global Health Commission on financing primary health care: putting people at the centre.Lancet Glob Health. 2022; 10: e715-e772Summary Full Text Full Text PDF PubMed Scopus (103) Google Scholar Third, examples of large-scale service-redesign initiatives suggest that strategic redesigns of FRHs will not result from microlevel quality improvement approaches, although these are needed too.3Kruk ME Gage AD Arsenault C et al.High-quality health systems in the Sustainable Development Goals era: time for a revolution.Lancet Glob Health. 2018; 6: e1196-e1252Summary Full Text Full Text PDF PubMed Scopus (1458) Google Scholar Instead, sustainable transformation requires systems thinking, people's involvement, and continuous learning. Fourth, a deviation from traditional hierarchical management models is needed. To transform FRHs, leaders need to complement clinical skills with abilities to nurture staff and respond to and manage relationships with communities and multiple different stakeholders.5Rispel LC de Jager P Fonn S Exploring corruption in the South African health sector.Health Policy Plan. 2016; 31: 239-249Crossref PubMed Scopus (46) Google Scholar Corruption, which might be common, is damaging and inhibits change. Leaders should be protected from the risks of tackling it.6Belrhiti Z Van Damme W Belalia A Marchal B The effect of leadership on public service motivation: a multiple embedded case study in Morocco.BMJ Open. 2020; 10e033010 Crossref Scopus (16) Google Scholar Fifth, the involvement of patients, communities, and other groups from civil society can improve planning and decision making. There has been some genuine patient involvement in planning and service delivery in high-income countries and some community engagement in FRH governance, but further, multicountry research is needed. 7Robert G Cornwell J Locock L Purushotham A Sturmey G Gager M Patients and staff as codesigners of healthcare services.BMJ. 2015; 350g7714 Google Scholar Sixth, investment in the workforce is crucial for both FRHs and UHC. Knowledge gaps exist in workforce distribution, skill mix, demographics, retention, wellbeing, and their intersection with technology and climate change.8Boniol M Kunjumen T Nair TS Siyam A Campbell J Diallo K The global health workforce stock and distribution in 2020 and 2030: a threat to equity and 'universal' health coverage?.BMJ Glob Health. 2022; 7e009316 Crossref PubMed Scopus (96) Google Scholar Lack of alignment between the education sector, professional aspirations, and health-system needs can incentivise the production of specialists. This focus on production of subspecialists risks centralising health care and generating demand for private, specialist care. In high-income countries, specialists and subspecialists have delivered some benefits, but fragmentation of care can reduce health-system resilience and its ability to deal with multimorbidity. Nursing care is poorly studied in low-income and middle-income countries, but substantially affects patient experiences and health-system outcomes. Seventh, planning investments in FRHs require accurate information about their activities, staffing, budgeting, patient populations, service outcomes, and patient experiences. High-quality data are also important for local managers, service improvement, accountability, and good governance. Finally, new infrastructure investment will be needed. However, that centralisation will deliver improved outcomes and economies of scale should not be assumed.9Vaughan L Browne J Reconfiguring emergency and acute services: time to pause and reflect.BMJ Qual Saf. 2023; 32: 185-188Crossref Scopus (2) Google Scholar New buildings will offer opportunities for designs that increase wellbeing, sustainability, safety, environmental protection, and resilience to external shocks, such as extreme climate events. We propose a comprehensive approach that increases the focus on FRHs in the UHC discourse and shows that they are integral to enhancing PHC in low-income and middle-income countries. This idea is not new but seems neglected.10de Savigny D Adam T Systems thinking for health system strengthening.https://ahpsr.who.int/publications/i/item/2009-11-13-systems-thinking-for-health-systems-strengtheningDate: 2009Date accessed: October 20, 2023Google Scholar Planning FRHs, in their interface position, requires prioritisation of needs, good leadership and governance, a shared purpose, health-systems research, and a methodology for learning and policy engagement to achieve structural changes. Researchers have a crucial role in generating new knowledge on these urgent questions and in partnering with key policy actors to support sustainable change and implementation. ME is supported by a Wellcome Senior Clinical Research Fellowship (grant number 207522). ME, LR, and FS receive funding from Wellcome for research on African first referral hospitals (grant number 227396/Z/23/Z). LR's Chair is funded by the South African National Research Foundation. We thank all our colleagues for their inputs to the workshop on first referral hospitals.