A 3-month-old infant died from excessive bleeding following circumcision performed at home. Despite attempts at pre-referral treatment, transport difficulties, delays, and communication failures proved fatal. This tragedy — perhaps repeated in many forms across Ghana — highlights critical gaps in our paediatric referral system that demand immediate and sustained action.
A referral system is a mechanism that enables a patient’s health needs to be comprehensively managed using resources — human and otherwise — beyond those available at the immediate point of care. Ghana’s hierarchical health system allows care to be sought serially or haphazardly. Referrals of children are particularly complex, involving not just medical considerations but caregiver acceptance based on perceived necessity, facility experiences, costs, and anticipated outcomes.
The referral system involves four primary actors: referring facilities, receiving facilities, transportation services, and system managers. Each bears specific responsibilities in ensuring optimal outcomes for children.
The referring facility — the initial point of care — must provide clear communication about the rationale for referral to caregivers, and comprehensive documentation of all pre-referral interventions. Ghana’s improving telecommunications infrastructure enables real-time consultations that can provide effective treatment closer to home while maintaining family support systems.
For quality improvement, systematic dissemination of referral feedback to care teams, regular audits, and direct contact between lower-tier providers and specialist paediatric units are essential. This approach allows many cases to be managed locally under expert guidance, reducing unnecessary referrals while building local capacity. Facilities must also prepare for follow-up care of discharged patients to ensure continuity.
The receiving facility bears ultimate responsibility for providing high-level care to sick children. Its team should be readily accessible via social media platforms, telephone, and email to offer timely referral advice. WhatsApp, for example, can facilitate real-time consultation and pre-referral treatment guidance — a practice that exists in some health systems but can be significantly improved with the specific needs of child health in mind.
Oversight arrangements, where complex cases are managed remotely, boost the morale of referring facilities and improve overall care quality. On discharge, receiving facilities should provide detailed care plans and a reliable contact for further follow-up. Planned specialist outreach programmes and training in cost-effective, life-saving modules — such as Emergency Triage and Assessment (ETAT) and the Integrated Management of Neonatal and Childhood Illnesses (IMNCI) — would enhance the skills, confidence, and capacity of lower-level health workers to deliver better pre-referral care.
Ambulances must be staffed by trained emergency medical teams equipped with oxygen sources, airway protection devices, defibrillators, and emergency medications. Rapid response times are critical, yet cost barriers routinely force families to seek inadequate alternative transport. A free ambulance service for all children — particularly those under five years — would significantly reduce life-threatening delays.
As an immediate step, the free maternal health policy under the National Health Insurance Scheme should be extended to cover emergency transport for pregnant women and sick children below three months of age. This single measure could directly reduce maternal, neonatal, and infant mortality.
Government health agencies, religious organisations, and managers of public and private health facilities also play a vital role. They must address staff welfare — including remuneration — as well as limited and frequently broken-down equipment. Effective customer experience, complaints resolution, and standard care practices must be demanded and enforced.
System managers must demonstrate leadership through sound budgeting, closing gaps in equipment and human resources, and resolving barriers to point-of-care services for sick children. Hospital managements that attract and retain highly skilled team members inspire confidence and foster learning across the entire workforce.
These solutions represent achievable improvements in the implementation and coordination of paediatric referrals. The question is not whether we can afford to make them — the question is whether we can afford not to. Every child, irrespective of where they are born or live, depends on our collective response to this crisis.
By Dr. Richard Bright Danyoh
The writer is a Paediatrician
Editor’s note: Views expressed in this article do not represent that of The Chronicle
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