Chiara Pittalis - Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
Ruairí Brugha - Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
Leon Bijlmakers - Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
Frances Cunningham - Wellbeing and Preventable Chronic Disease Division, Menzies School of Health Research, Brisbane, QLD, Australia
Gerald Mwapasa - College of Medicine, University of Malawi, Blantyre, Malawi
Morgane Clarke - Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
Henk Broekhuizen - Department of Health and Society, Wageningen University and Research, Wageningen, The Netherlands
Martilord Ifeanyichi - Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
Eric Borgstein - College of Medicine, University of Malawi, Blantyre, Malawi
Jakub Gajewski - Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland

Background  A functionally effective referral system that links district level hospitals (DLHs) with referral hospitals (RHs) facilitates surgical patients getting timely access to specialist surgical expertise not available locally. Most published studies from low- and middle-income countries (LMICs) have examined only selected aspects of such referral systems, which are often fragmented. Inadequate understanding of their functionality leads to missed opportunities for improvements. This research aimed to investigate the functionality of the referral system for surgical patients in Malawi, a low-income country.Methods  This study, conducted in ۲۰۱۷-۲۰۱۹, integrated principles from two theories. We used network theory to explore interprofessional relationships between DLHs and RHs at referral network, member (hospital) and community levels; and used principles from complex adaptive systems (CAS) theory to unpack the mechanisms of network dynamics. The study employed mixed-methods, specifically surveys (n = ۲۲ DLHs), interviews with clinicians (n = ۲۰), and a database of incoming referrals at two sentinel RHs over a six-month period.Results  Obstacles to referral system functionality in Malawi included weaknesses in formal coordination structures, notably: unclear scope of practice of district surgical teams; lack of referral protocols; lack of referral communication standards; and misaligned organisational practices. Deficiencies in informal relationships included mistrust and uncollaborative operating environments, undermining coordination between DLHs and RHs. Poor system functionality adversely impacted the quality, efficiency and safety of patient referral-related care. Respondents identified aspects of the district-RH relationships, which could be leveraged to build more collaborative and productive inter-professional relationships in the future.Conclusion  Multi-level interventions are needed to address failures at both ends of the referral pathway. This study captured new insights into longstanding problems in referral systems in resource-limited settings, contributing to a better understanding of how to build more functional systems to optimise the continuum and quality of surgical care for rural populations in similar settings.

Complexity Science, Network analysis, Systems Thinking, Referrals, Surgery, Developing Countries