| Indicator ID | H15 |
|---|---|
| Indicator full statement | # of health facilities that have a functioning referral and counter-referral system to ensure the adequate management of children diagnosed with severe undernutrition. |
Purpose
| Importance | This indicator measures the establishment and utilization of referral and counter-referral systems in health facilities to manage severe undernutrition in children effectively where Tdh is conducting or supporting related activities. A functioning referral system ensures timely transfer of children with Severe Acute Malnutrition (SAM) to appropriate care, while a counter-referral system supports follow-up and continuity of care. This is crucial for improving child health outcomes and managing severe malnutrition effectively. |
|---|---|
| ToC pathway | This indicator aligns with the Health Theory of change, contributing to three interrelated pathways of change: 1) local health systems, 2) communities, and 3) mothers, children, and their families. |
| Related services | It is used depending on the service provided by Tdh. |
Definition
The number of health facilities that have operational systems in place for 1) referral, which is the process of directing children diagnosed with SAM from primary care to specialized care facilities or programs and 2) counter-referral, which is the process of returning children from specialized care back to primary care for continued management and follow-up.
A functioning referral system includes established protocols for 1) identifying and correctly diagnosing SAM according to national protocols, 2) referring children to higher levels of care with adequate transportation, and 3) ensuring communication and follow-up between referring and receiving facilities.
How to collect & analyse the data
| What do we count? | Number of Health Facilities with a functioning referral and counter-referral system designed to manage children diagnosed with severe undernutrition during a specified period where Tdh is conducting related activities. |
|---|---|
| Data sources | Routine facility data sources: Facility-based data capturing all SAM referrals and counter-referrals per health facility. Digital health platform records: Data from digital health platform that track the number of referrals and counter-referrals per health facility. Facility health care staff : information on the adoption and integration of a functional referral system for SAM can provide valuable insights, particularly in settings where routine health information systems are not yet fully digital and where access to facility-based data are scarce. |
| Data collection methods and tools | Secondary data review : Monthly, quarterly, and annual reporting from health facilities and HIS. Baseline, mid-term and endline studies through health facility survey/assessment to supplement routine data. |
| Disaggregation | Data should be stratified by
Where appropriate depending on the data source. |
| Important considerations |
Limitations and precautions
This indicator serves as a proxy to assess the quality of care for managing Severe Acute Malnutrition (SAM) at healthcare facilities. However, it does not indicate the availability of diagnostic tests or treatments, nor does it assess the timely prescription of referrals. It also does not directly evaluate health outcomes related to the referral system, such as mortality rates, recovery numbers, or patient satisfaction. Future analyses should explore the impact of the SAM referral system on these outcomes.
While this indicator is not designed to evaluate the nutrition program itself, it can be cross analyzed with other relevant indicators, including inpatient and outpatient care for individuals with SAM and community outreach efforts. The analysis might overlook critical factors influencing the referral system, such as financial burdens, transportation costs, and socio-economic issues affecting access to care.
Initial and follow-up assessments are essential to measure the practical feasibility and effectiveness of the referral system. Additionally, referral infrastructure must be evaluated to ensure quality care for children with SAM.
Functional referral systems may be concentrated in urban areas, potentially neglecting rural healthcare facilities. Disaggregating data by geographical location and facility type is crucial for reaching all relevant healthcare facilities in Tdh's operational area. Collaborating with government ministries and partnering with local and international organizations can help scale and sustain these referral initiatives, particularly in underserved regions. Finally, factors like access to curative care, immunization programs, and community engagement significantly influence the functionality of the referral system and should be included in the overall analysis.
What further analysis are we interested in?
To go further in the analysis, it is useful to calculate proportion of health facilities supported by Tdh that have a functional referral system compared to the total number of facilities in the same area or at national level.
This analysis is useful to reveal the coverage of referral systems within a district and/or region, allowing the analysis of possible gaps in terms of coverage and possible areas of interventions. GIS data linked to the indicator could also support this analysis.
Because the definition of a functional referral system should remain stable, this indicator directly evaluates the effectiveness of the system in improving management outcomes for children with SAM.
Additional guidance
Under the technical assistance of HQ, Tdh M&E and operational teams in each delegation should work closely with health authorities, Nutrition working and coordination group, if relevant in the context, and DHIS providers to collect and interpret the data.
Sphere Association. The Sphere Handbook: Humanitarian Charter and Minimum
Standards in Humanitarian Response, fourth edition, Geneva, Switzerland, 2018. Available at : http://www.spherestandards.org/handbook (Accessed 16 September 2024)
Guideline: Updates on the Management of Severe Acute Malnutrition in Infants and Children. Geneva: World Health Organization; 2013. PMID: 24649519. Available at: https://pubmed.ncbi.nlm.nih.gov/24649519/ (Accessed 16 September 2024)