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XIBMS – Referral System in Health Services

XIBMS – Referral System in Health Services


XIBMS – Referral System in Health Services

Punjab is one of the vital states of Indian Union consisting of 17 districts. Punjab has a vast network of public health care facilities comprising of 217 hospitals excluding three tertiary level hospitals, 104 community health centres, 484 primary health centres and 1462 subsidiary health centres, dispensaries. The teritary care facilities in Punjab consists of three Govt. Medical Colleges, two private medical colleges and a prestigious Post-Graduate Institute of Medical Education and Research (PGIMER), Chandigarh under the Ministry of Health and Family Welfare, Government of India.

Punjab Health Systems Corporation established under the world bank project aims to develop secondary health care. It has taken up 151 health institutions including all district hospitals. 42 Sub-divisional hospitals and 87 Community, Health Centre,  6 Area hospitals. Under the World Bank project, Punjab Health Systems Corporations is responsible for:

  1. Renovation of hospital buildings to provide appropriate space for services.
  2. Upgrading and updating of clinical skills of Medical Officers and staff nurses through an effective training programme.
  3. Provision of ambulances for transporting critical patients.
  4. Installations of phone, fax in hospitals.
  5. Strengthening of Secondary level health care shall support the primary health care and thus there is need to formulate and implement an ideal and effective referral system. This is the right time and situation for Referral System to work and is the rationale for this system to develop.



The Punjab Health Systems Corporation has initiated to strengthen the functioning of the hospitals for referral system through the following measures:

  • Renovating and upgrading hospital buildings to provide appropriate space for services.
  • Upgrading and updating clinical skills of medical officers and staff nurses through an effective training programme.
  • Providing ambulances for transporting critical patients.
  • Installing phone, fax and paging systems in hospitals.
  • Financial powers to Senior Medical Officers in charge of the hospitals to accord necessary single sanction up to Rs. 5,000 (Rs. Five thousand only) and Deputy Medical Commissioners, Civil Surgeon, Medical Superintendent up to Rs, 10,000 (Rs. Ten thousand only) to meet the emergency.
  • The user’s charges are to he retained at the site of collection. These are to be used by the Senior Medical Officer In charge of the hospital. Norms of services have been designed for each level of faculty.



  1. Referral Network and Zoning

To identify the various referral levels, the whole district is divided into several zones and the referral levels are indicated for each zone. To facilitate and for convenience of patients, certain number of Primary Health Centres are grouped and linked to community health centre (C.H C.) /Tehsil Hospital/Area Hospita ls / District Hospitals depending upon the distance, availability of services, facilities of transportation, etc. But adopting a grouping system, uniform referral pattern has been developed. In this system the patient will know the course of further treatment, in case one is referred for some special procedure at appropriate level of care. Similarly, a good rapport and faith in the referral system will be developed. This is called zoning.

It helps in evolving a chain for the health units beginning at the primary level moving up through the middle tier and finally reaching the tertiary hospitals. Let us explain it with the help of Kiratpur Sahib.

After dividing the district into zones, the same is to be depicted on the map. The map should reflect all the health institutions, roads, river, bridges, Bus Stand, Railway route, Railway station, Police station, Post offices, etc.

These maps will have to be displayed at the reception counter in each of the health institutions.



  1. Transportation Facilities

lo build up an effective Referral System, a dependable transportation arrangement has been provided where the health personnel shall be able to send the patients to the next appropriate level of care at the earliest, as the flow of patients is expected to be from primary health centres to the tertiary level.


  1. Referral-cum-Feed-back Card 

Referral system is a two way process. The patient referred will be given the referral-cum-feed card. The colour coding has been done. The patient referred from CHC shall get blue cards. The patients referred from Tehsil hospital/Area hospital shall get green card. The patients referred from Distt. hospital shall get white card. The patient referred from P.H.C. or Subsidiary Health Centres shall have pink card.

The referral card contains—General information about the patients such as name, age, gender, address, Chief complaints, clinical findings, vital signs. Investigations done, Treatment given, procedure done where referred, and purpose of referral, i.e. for admission, Investigation or expert opinion.

At the referred hospital, patients could report directly to the unit or department to   which he or she has been referred through a special counter for referred patients.


  1. Referral Procedure

In the referral procedure, there are two types of referral— (i) Emergency, (ii) Routine referral. In routine referral the patient will have to make his own transportation arrangement, however proper counseling needs to be done. The patient shall be given referral card. The regular hospital   hours   8.00 a.m. to   2.00   p.m. In  summer and 9.00 am to 3.00 p.m. in winter with half an hour break L30 p.m. to 2.00 p.m. For investigations, the best suitable time 9.00 AM. to 11.30 A.M. However emergency patients who are to be attended round the clock.


  1. Receiving of Referred Patients 

Referral units should receive the patients directly at a place identified in each hospital without waiting in general outdoor patient department (OPD).


The receiving hospital must ensure that a referred patient enjoys the following privileges.

(i) Queue Jump: The referred patient will not stand in queue for general out-patients. He/She directly goes to the doctor referred on priority through a special counter of referred patients on routine.

(ii) No need of new OPD ticket. The referral card itself to he used as OPD ticket. The entry is to be made in the referral registers at the reception counter.

(iii) No purchee fee for referred patient with referral card.

(iv) Feed-back——After dealing with patient and at the time of discharge in case of admission, the doctor should fill up referral-cum-feed-back card. This will help the referring doctor to know whether the patient that he had referred, had got the relief. The specialist may send the feed back on slip (from slip pad) through S.M.O. 1/C of the health institution.

(v) Provision of low cost transportation—in emergency patients, it is clear that the actual fuel charges are to he paid by the patient. In poor patients (unknown, yellow card holders, natural Calamities, Disaster), this can be exempted.

(vi) From jail Hospitals, the patients are referred through the Police    guard.

  1. Norms of Service

Norms of Services have been worked out for institutions at various levels in terms of facilities, staffing, equipment, services, etc.


  1. Maintenance of Register

Two registers both by referring institutions and referred institutions are to be maintained to keep a proper records. Besides, there are large number of details which have been drawn to make the system functional. However, the systems has not taken roots and is still in its infancy.

For making referral system successful, Punjab Health System Corporation has taken the following steps:

  1. Intensive Training ro all personnel from top to bottom to make them aware of the potentialities and limitations of referral systems.
  2. Equipping the health institutions with the prescribed norms of services.
  3. Making the people aware through maps of zoning and also through a video cassette “Know your Hospital”.
  4. Arranging transport facilities.
  5. Delegation and decentralisation of administrative and financial powers.
  6. Overseeing the implementation.
  7. Conducting research to diagnose the problems which stand in the way of efficient functioning of referral system.

By now, referral system has been introduced in all districts of Punjab. It is hoped that this would bring a revolution in health services in Punjab.

Issues to be discussed

  1. Facts of the case.
  2. Analyse the Referral System based on the case and taking out of case examples as well.
  3. Based on the analysis do you perceive increased effectiveness in the health services? Justify your view.

XIBMS – Referral System in Health Services

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