Sweety Pathak | October 2015
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Presentation at the Global Maternal Newborn Health Conference, October 19, 2015

Background: Maharashtra state has the highest number of people in India living in urban slums. Municipal corporations are responsible for providing health services to these urban poor through health posts, maternity homes, secondary and tertiary hospitals. Women and children are unable to access timely and appropriate health services because of inappropriate utilization of facilities and lack of standardized referral protocols. Baseline research suggested that a lack of effective referral systems contributed to under- and over-utilization of referral centres and poor quality of maternal and neonatal care. Referral systems that are readily scalable are urgently needed.

Methods: The Society for Nutrition, Education and Health Action (SNEHA) partnered with the multi-tier Mumbai Municipal Corporation to establish a maternity referral system across health facilities. Doing so required design of protocols, facilitation of regional referral meetings, obtaining buy-in from administrations, and institutionalizing documentation, monitoring, evaluation and feedback in health facilities.

Results: The project streamlined referrals, with 94% completeness of referral documentation and 71% of high-risk referrals in compliance with protocols. SNEHA is now scaling up the intervention to three adjoining low-resource municipal corporations in Maharashtra. Retaining the core elements of the Mumbai referral system, additional interventions included strengthening existing health services, developing context-specific referral protocols and referral linkages, training, iterative adaptation and evidence building through data. Mid-term evaluation showed a 19% increase in utilization of existing health services, a 35% increase in the use of referral linkages and that 76% of high-risk referrals complied with protocols.

Conclusions: These preliminary results demonstrated that the model has potential to be scaled up further and have substantial policy implications. Adherence to referral protocols, contextualization, developing accountability though ownership within municipal health systems, and continued monitoring and evaluation are recommended for effective scale-up. Evaluating a scalable model for strengthening referral systems will inform the implementation of urban public health systems around the world.