The referral process and urban health care in sub-Saharan Africa: The case of Lusaka, Zambia

Much of the current reform of urban health systems in sub-Saharan Africa focuses upon the referral system between different levels of care. It is often assumed that patients are by-passing primary facilities which leads to congestion at hospital outpatient departments. Zambia is well advanced in its health sector reform and this case study from the capital, Lusaka, explores the patterns of health seeking behaviour of the urban population, the reasons behind health care choices, the functioning of the referral system and the users' evaluations of the care received. Data were collected across three levels of the system: the community, local health centres and the main hospital (both in- and out-patients). Results showed those who by-passed health centres were doing so because they believed the hospital outpatient department to be cheaper and/or better supplied with drugs (not because they believed they would receive better technical care). Few users were given information about their diagnosis or reason for referral. The most striking result was the degree of unmet need for health services and the large number of individuals who were self-medicating due to lack of money rather than the minor nature of their illness. The current upgrading of urban health centres into 'reference centres' may provide a capacity for unmet need rather than decongesting the hospital outpatient department as originally intended.