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مؤسسة منار العلمية للدراسات والبحوث الصحية


Abuse of the System of Referral Letters:

Rural Health Centre Lose their Role as Service Points

*Dr. A. A. Nouman


In the Republic of Yemen, there are several levels at which medical services are provided to the public. The most basic service is provided at the level of medical units. Here some emergency, deliveries, family planning, nutrition, and vaccination services are are dispensed. These units are located in Villages, however, often by-pass them to go to health Centres, because the units are often manned ( or womanned) by a nurse. The health Centres are often located in small towns and secondary cities, which are gateways to the countryside. Here, there are usually general practitioners or physicians who offer various kinds of services. Except for major surgeries and operations, the health Centres are supposed to cater to the needs of the public.  

Unfortunately, over the last several years, the health Centres have been simply passing on the job to the major Hospitals, which are in the major cities. They have developed what is now known as the letter referral system. This is exactly what the name implies- the patient is given a letter by the health Centre to go to the Hospital.

Unfortunately, there has been a dramatic deterioration in the role and service of health Centres. The health Centres' excuse is that they do not have the equipment,  facilities, drugs, and even skilled personnel. The solution, thus, has been to pass on the job.


I have gone on short visits to some of the health Centres in trying to understand why is it the general practitioners have difficulty in arriving at correct diagnosis and treatment of illnesses. Why do they make mistakes, even in the service they provide - writing referral letters.

Basically, the factor that lead to poor quality referral letters are, in my mind, the following:-

1 - Bad handwriting and grammar.

2 - Incomplete information.

3 - The Physician's ignorance of the importance of mentioning negative as well as positive findings.

4 - Poor medical knowledge and skills on part of the physicians.

5 - Weak interpretation of laboratory tests due to the weak skills and qualifications of laboratory technicians.

6 - Absence of records of the environmental and medical conditions of the area.

7 - Absence of records of the patients.


The result of poor quality referral letters are:

1. The over-crowding of Hospitals.

2. The expected benefits of referrals from public health care Centres to Hospitals are negligible. As Hospitals are over loaded with cases that could have been managed at the health Centres.    

3. The Health Centres Physicians gradually lose their medical knowledge and skills as they refer almost all cases to the Hospitals.

4. Patients lose confidence in and refuse to go to Health Care Centres, seeking services directly at the Hospitals. In some cases, the patients pack up and go abroad rather than the City Hospitals.

5. Referral letters lose their value as an important means for communication between physicians at Centres and Hospitals. The Hospital Specialist end up not taking into consideration referral letters and dose not answer them.

6. Of course, the cost to the patients, and to society at large, are enormous.


1. The Health Centre general physician is the starting point of any corrective measures. First, referral letters must be used only in cases where the service can not be locally provided. In this case, the referral letter must be complete file.

That means patients must carry ideal referral letters which include the following information:

a- General information.

b- Patient Medical History.

c- Vital Signs.

d- Complaints of patient.

e- Examination Findings.

f- Investigations.

g- Diagnosis.

h- Treatment, if any.

i- Place and need for referral.

j- Request for Feedback.

2. Programs must be introduced for continuous medical education and training of the physicians at Public Health Centres to update and refresh their information.

3. Whatever new equipment and maintenance for them must be provided for. Adequate allocations are important for the Centres to do their job.

4. Poor use of the Centres' laboratory and pharmacy facilities must be made before referral letters are written.

5. The medical profession must introduce good data base compilation and documentation.

6. The Ministry of Health must introduce a good system of checks and balances to control the level and quality of service.

7. Enabling private medical services to function side by side, especially in the country side.

8. Introducing consumer protection efforts among the citizens through better legal awareness.

* Dr.Ahmed Abdulaziz Nouman  





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تاريخ التعديل: 2007/12/29