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Across India , healthcare workers are forced to make difficult decisions to refer patients to healthcare facilities every day. Whether it’s a woman in labour with high blood pressure, a patient in septic shock from a snakebite, or a child with breathing difficulties, the decision to refer a patient from a primary or secondary care centre to a higher-level hospital is a critical one.
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In most parts of the country, however, that decision is not guided by clear protocols or institutional support — wherein institutions have clear tie-ups with higher centres for formal referral.
India’s referral system is inhibited by a collectivistic culture that fosters decision-making, where multiple people weigh in. Although this is primarily done as a form of risk mitigation to ensure all perspectives are accounted for, it can completely derail medical planning.
A disorganised referral system
India’s health system is organised in pyramid form. People access preventive and basic care at primary-level health centres, and are then referred to district hospitals for more complex care, or tertiary centres for specialised interventions. However, this pyramid crumbles under pressure when both primary and secondary care centres lack the resources to manage patients and are forced to refer them to tertiary centres.
Lindsay Barnes, a midwife who helps run a childbirth centre in Jharkhand, in eastern India, describes an encounter she had with a pregnant patient suffering from hypertension and seizures. The woman came to her clinic by rickshaw after doctors at a larger district hospital in Bokaro, Jharkhand, gave her an unknown injection and referred her without a doctor’s note or case file.
“Without a doctor’s note [the patient] came to our rural centre, which is not equipped to handle such emergencies. We didn’t even know what drug she had been given or what dose, so we couldn’t even try to stabilize her. She had to be referred again, which was inconvenient for her and her family.”
According to Mrs. Barnes, disorganised referrals are the norm in her part of India.
“Almost all conditions receive first aid at the primary care level. If specialised care is required, a good referral must be made to a secondary or tertiary care centre,” says Sharad Iyengar, a paediatrician and secretary of Action Research and Training for Health (ARTH), a not-for-profit organization in Rajasthan that runs a nurse-led maternal health centre. “But currently there are no formal relationships between the centres operating at various levels in a given area.”
The burden of decision-making
According to Dr. Iyengar, deciding to refer a patient is a complicated process. Primary care providers walk a tightrope: if they refer a patient too early, they could waste a patient’s time and money; if they refer too late, it could cost a life.
“There is a zone of illness where referral is ideal — the patient is not so sick that he/she will die in transit, but isn’t well enough to be treated in a primary or secondary care set up. The provider needs to refer the patient in this zone promptly, rather than waiting until they worsen. The more you wait, the harder it is to reverse,” says Dr. Iyengar. “But decisions are often subjective, and the provider can never be fully sure.”
Furthermore, there are financial incentives and kickbacks that may compromise provider judgment.
Mrs. Barnes recounts a situation where she wanted to refer a patient whose haemoglobin levels were falling after having had a Caesarean section. Suspecting that the patient had internal bleeding, Ms. Barnes referred her to a centre with a blood bank. The patient’s relatives, however, had hired an ambulance driver who was getting kickbacks from several other private hospitals to bring patients to them. He took her to one of those hospitals, which did not have a blood bank. The patient needed to eventually go to a different hospital, but Mrs. Barnes has no further information on what happened to her.
Mrs. Barnes reveals that this is a common occurrence, with family members and other interlocutors, such as distant relatives or drivers also influencing where the patient ends up. “So many parties are involved in the decision-making process that, in many cases, the woman may be taken to a completely different centre than what was in the birth plan,” she says.
A lack of accountability
“The referral system is not so much broken as it is completely non-existent in our area [Jharkhand],” says Mrs. Barnes.
According to her, the referral network lacks structure, accountability, and basic human-centred planning: a system design that prioritises the needs, capabilities and limitations of people who will use it.
Any referral system should ensure that the patient has the maximum chance of reaching the referral centre alive. An ideal referral, according to Mrs. Barnes, should include a doctor’s note explaining the patient’s condition and the reason for referral. The referring physician should also confirm that the tertiary centre has the capacity to admit the patient and that there will be a health worker accompanying the patient, in an ambulance with amenities, who can intervene if the patient some help.
In India however, many patients are often sent away with nothing but vague instructions and little else.
These issues, Mrs. Barnes says, stem from a lack of accountability, organisation, and regulation in India’s healthcare system. In maternal care, where the stakes are especially high for women and health centres, hospitals do not want to take risks. Maternal deaths are notifiable, and are subject to government audits. “No one wants a death on their record,” Mrs. Barnes says. Instead of stabilizing the patient or coordinating a referral, many practitioners discharge the patient or encourage her to leave so that they are not liable for her death.
There is also a lack of data transparency according to Mrs. Barnes. “If a patient dies after being referred, it is difficult to determine whether that death came from illness or medical neglect,” she says.
The burden of care
According to Shirish Rao, an emergency medical officer in a government-run secondary hospital in Mumbai, over referrals to tertiary care centres are burdening the system beyond its capacity, making ideal referrals impossible. The cause for that is clear — there is a lack of infrastructure and trained personnel at primary and secondary level centres .
Dr. Rao works at a secondary hospital, but it lacks a 24-hour pharmacy, diagnostic and radiological services, and an emergency operating theatre. “At night, there is no point in registering a patient here because we know nothing is available, especially if a surgical intervention is needed. This patient will then be sent to one of the tertiary care centres, which become completely overloaded, so often, this patient cannot enter that saturated system at all,” he says.
According to him, oftentimes, only one doctor is posted in the emergency department; and a formal referral would require them to accompany the referred patient to the tertiary care centre. If they accompany the patient, the emergency department remains unmanned. To prevent this, many centres have started intimidating patients into leaving. This is colloquially known as “negative counselling against admission.” Physicians tell patients that the facilities they require are not available and that they could either stay and wait at their own risk or leave for a different centre. “More often than not, the patient decides to leave for a different centre,” he says.
The problem with this method, however, is that there is no one is to ensure the safety of the patient as they travel to the next health facility. There is also no guarantee that they will be treated in the other facility, either.
Because many tertiary hospitals lack the resources to take on additional patients many patient relatives as well as health providers from tertiary centres have begun resisting referrals.
A gynaecologist based in Tiruvallur said that she had to apply fundal pressure on a birthing woman whose labour was not progressing properly, because the relatives insisted that the patient did not want to be referred. “They kept saying do whatever you can here, we will not take her out of the hospital. It was almost as if they knew they were completely on their own if they stepped out, with no one to take accountability if something went wrong during transit or if there were no beds or facilities available in the bigger hospitals.”
Towards better referrals
Both Mrs. Barnes and Dr. Rao believe that the solution lies in systemic reform.
“There must be better infrastructure at district hospitals, which are most often the tertiary care centres receiving referrals,” says Mrs. Barnes. “Blood banks, diagnostics, and consistent communication with smaller clinics will make primary providers more confident about sending patients there.”
Dr. Rao adds: “There needs to be accountability in the system. More than trying to inculcate a sense of moral responsibility in health workers to ensure optimal referrals, the system must redesign its infrastructure to allow such a referral to occur conveniently,” he says.
Feedback loops are also essential. When referral centers explain why a referral was unnecessary or poorly managed, it helps primary-level workers learn and improve. Currently, no such mechanisms exist. Infrastructure in smaller centres could also be improved to reduce the load on tertiary care centres.
Investing in infrastructure
A group of researchers recently analysed causes for increased referral rates in a sub-district hospital in Tamil Nadu. The analysis revealed several inadequate resources, such as a lack of diagnostic services and insufficient staffing. Once these were addressed, the referrals to higher centres dropped more than 48%.
To support infrastructure necessary for such referrals, State governments need to develop databases that shows the locations of public and private hospitals, clinics, and centres along with the services they offer . Providers should be able to access the information in real-time so they can make informed referrals.
In Udaipur, Rajasthan, the non-profit ARTH worked on developing an efficient referral model. According to their internal audit data, only 9% of patients who visit their birthing centers are referred, as most complications are managed at the primary level by trained nurse-midwives. ARTH’s system trains staff to recognise danger signs and document them clearly in a referral card that lists vital signs and clinical observation for every patient. “The credibility of our institution depends on the information we send with the referral. Clean, spelled-out clinical criteria help a busy, overworked team at the referral hospital feel respected — and act faster,” says Dr. Iyengar.
To help ensure a seamless transfer, a helpline worker calls the receiving hospital in advance, and a navigator escorts the patient’s family, guiding them through the receiving hospital and helping to locate food stalls, toilets, labs, and even arranging psychosocial support. Between 2014 and 2018, with funding from the MacArthur Foundation (a U.S.-based foundation), this model handled over 14,200 referrals, reducing maternal and newborn deaths, decongesting tertiary centres, and earning the trust of families.
However, when funding dried up in 2018, the State quietly allowed it to end.
According to Dr. Iyengar however, it is still a success story: it shows what is possible when concerted effort is put into ensuring an intervention goes smoothly. “That is what a referral is. It is more than just transferring a person from one centre to another. It is, by itself, a medical intervention and when done right, can be lifesaving.”
(Dr. Christianez Ratna Kiruba is an internal medicine doctor with a passion for patient rights advocacy. christianezdennis@gmail.com)
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