title: Frequency, cost and impact of inter-island referrals in the Solomon Islands.
abstract: BACKGROUND
  Providing quality health services to people living in remote areas is central to global efforts to achieve universal access to health care. Effective referral systems are especially critical in resource-limited countries where small populations are separated by considerable distances, geographic challenges and the limitations of human resources for health. This study aimed to build an evidence base on inter-island referrals in the Solomon Islands, in particular regarding the number of referrals, reasons for referrals, and cost, to ultimately provide recommendations regarding referral practice effectiveness and efficiency.
  
  
  METHODS
  Data were taken from the referral database collected and maintained by the National Referral Hospital (NRH) in the capital, Honiara. Data included age, sex, ward or department visited, date of travel back to home port, home port and province. Data were available and included for 2008, 6 months of 2009, all of 2010 and 1 month of 2011; a total of 31 months. Travel costs were taken from NRH administrative information and included in the analysis. In addition, 10 qualitative interviews were conducted with clinicians and policy-makers in the tertiary hospital and one provincial hospital to gather information regarding inter-island referrals, their appropriateness and challenges faced.
  
  
  RESULTS
  In the Solomon Islands, referrals from outer islands to the NRH are substantial and are gradually increasing over time. The two most populous provinces outside of the capital, Western and Malaita, represented 51% of all referrals in the study period. Of those referred, 21% were less than 15 years of age - even though 40% of the country's population is under 15 - with 30% being young adults of 15-24 years. Orthopaedic conditions comprised the largest number of referrals, with obstetric and gynaecological conditions a close second. The cost of referrals is rapidly increasing and was almost US$350,000 per year for the NRH alone. The amount budgeted for patient travel from the provinces to the NRH was a fraction of what is needed to cover the current number of referrals leading to a substantial budget shortfall. There did not appear to be a clear link between number of doctors in each province and the rate of referrals.
  
  
  CONCLUSIONS
  Improving the appropriateness of referrals can have a substantial impact on access, quality of care and costs. Improvements in equipment in remote facilities, in human resources for health and in information technology can strengthen the quality of care in outer islands. Reducing the burden on referral facilities will allow them to provide appropriate care to those most in need while building public trust in all layers of the health system.
authors.affiliation: University of Sydney, Sydney, New South Wales, Australia. joel.negin@sydney.edu.au
authors.forename: Joel
authors.initials: J
authors.lastname: Negin
authors.forename: Alexandra L C
authors.initials: AL
authors.lastname: Martiniuk
authors.forename: Penny
authors.initials: P
authors.lastname: Farrell
authors.forename: Tenneth
authors.initials: T
authors.lastname: Dalipanda
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002391:Catchment Area, Health / Q000706:statistics & numerical data; D002648:Child; D002675:Child, Preschool; D003159:Community-Institutional Relations; D016208:Databases, Factual; D055317:Evidence-Based Practice / Q000379:methods; D005260:Female; D017408:Guidelines as Topic; D006748:Hospital Departments / Q000706:statistics & numerical data; D006801:Humans; D007223:Infant; D008297:Male; D008542:Melanesia; D008875:Middle Aged; D009774:Obstetrics / Q000706:statistics & numerical data; D018802:Patient-Centered Care / Q000458:organization & administration; D011787:Quality of Health Care / Q000592:standards*; D012017:Referral and Consultation / Q000191:economics / Q000706:statistics & numerical data*; D040841:Resource Allocation / Q000706:statistics & numerical data / Q000639:trends; D019035:Rural Health Services / Q000191:economics* / Q000706:statistics & numerical data / Q000639:trends; D014195:Travel / Q000191:economics; D000078329:Workforce