title: Monitoring iCCM referral systems: Bugoye Integrated Community Case Management Initiative (BIMI) in Uganda.
abstract: BACKGROUND
  In Uganda, over half of under-five child mortality is attributed to three infectious diseases: malaria, pneumonia and diarrhoea. Integrated community case management (iCCM) trains village health workers (VHWs) to provide in-home diagnosis and treatment of these common childhood illnesses. For severely ill children, iCCM relies on a functioning referral system to ensure timely treatment at a health facility. However, referral completion rates vary widely among iCCM programmes and are difficult to monitor. The Bugoye Integrated Community Case Management Initiative (BIMI) is an iCCM programme operating in Bugoye sub-county, Uganda. This case study describes BIMI's experience with monitoring referral completion at Bugoye Health Centre III (BHC), and outlines improvements to be made within iCCM referral systems.
  
  
  METHODS
  This study triangulated multiple data sources to evaluate the strengths and gaps in the BIMI referral system. Three quantitative data sources were reviewed: (1) VHW report of referred patients, (2) referral forms found at BHC, and (3) BHC patient records. These data sources were collated and triangulated from January-December 2014. The goal was to determine if patients were completing their referrals and if referrals were adequately documented using routine data sources.
  
  
  RESULTS
  From January-December 2014, there were 268 patients referred to BHC, as documented by VHWs. However, only 52 of these patients had referral forms stored at BHC. Of the 52 referral forms found, 22 of these patients were also found in BHC register books recorded by clinic staff. Thus, the study found a mismatch between VHW reports of patient referrals and the referral visits documented at BHC. This discrepancy may indicate several gaps: (1) referred patients may not be completing their referral, (2) referral forms may be getting lost at BHC, and, (3) referred patients may be going to other health facilities or drug shops, rather than BHC, for their referral.
  
  
  CONCLUSIONS
  This study demonstrates the challenges of effectively monitoring iCCM referral completion, given identified limitations such as discordant data sources, incomplete record keeping and lack of unique identifiers. There is a need to innovate and improve the ways by which referral compliance is monitored using routine data, in order to improve the percentage of referrals completed. Through research and field experience, this study proposes programmatic and technological solutions to rectify these gaps within iCCM programmes facing similar challenges. With improved monitoring, VHWs will be empowered to increase referral completion, allowing critically ill children to access needed health services.
authors.affiliation: School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. Lacey_English@med.unc.edu.
authors.forename: Lacey
authors.initials: L
authors.lastname: English
authors.affiliation: Harvard Medical School, Boston, MA, USA.
authors.forename: James S
authors.initials: JS
authors.lastname: Miller
authors.affiliation: Bugoye Health Centre III, Bugoye, Uganda.
authors.forename: Rapheal
authors.initials: R
authors.lastname: Mbusa
authors.affiliation: Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda.
authors.forename: Michael
authors.initials: M
authors.lastname: Matte
authors.affiliation: Global Primary Care Program, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Jessica
authors.initials: J
authors.lastname: Kenney
authors.affiliation: Bugoye Health Centre III, Bugoye, Uganda.
authors.forename: Shem
authors.initials: S
authors.lastname: Bwambale
authors.affiliation: Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda.
authors.forename: Moses
authors.initials: M
authors.lastname: Ntaro
authors.affiliation: Global Primary Care Program, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Palka
authors.initials: P
authors.lastname: Patel
authors.affiliation: Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda.
authors.forename: Edgar
authors.initials: E
authors.lastname: Mulogo
authors.affiliation: Global Primary Care Program, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Geren S
authors.initials: GS
authors.lastname: Stone
mesh_terms: D019090:Case Management / Q000458:organization & administration / Q000592:standards; D002675:Child, Preschool; D003153:Community Health Services / Q000379:methods* / Q000458:organization & administration; D003150:Community Health Workers / Q000193:education; D003967:Diarrhea / Q000175:diagnosis*; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008288:Malaria / Q000175:diagnosis*; D008297:Male; D011014:Pneumonia / Q000175:diagnosis*; D012017:Referral and Consultation / Q000706:statistics & numerical data; D012189:Retrospective Studies; D014454:Uganda
keywords: Africa; Case management; Child mortality; Paediatric malaria; Referral