Inappropriate utilization of higher-level health facilities and ineffective management of the referral processes in resource-limited settings is increasingly becoming a concern in health care management in developing countries. This is characterized by self-referrals and frequent bypassing of nearest health facilities. On 1st July 2021, Kenyatta National Hospital (KNH) did enforce the national referral guidelines that required patients have a formal referral letter to reduce the number of self-referrals, decongest KNH and allow KNH to function as a referral facility as envisioned by Kenya Health Sector Referral Implementation Guidelines of 2014, Kenya 2010 constitution and KNH legal statue of 1987. The purpose of this study was to analyse the effect of enforcement of referral guidelines on facility referrals to KNH.This was a pre-posttest study design. The study was conducted amongst the orthopedic facility referrals in 2021 with 222 and 246 before and after enforcement of referral guidelines respectively. Data collection was done through data abstraction. Data was analyzed using frequency distribution, pearson chi-square test and logistic regression. Nairobi County and its environs constituted over four-fifth of all facility referrals to KNH. Over two-thirds of the facility referrals to KNH were from government facilities. There was significant reduction in health facilities tiers 2 and 3 referring patients directly to KNH after enforcement of referral guidelines (p=0.002). About 43 health facilities ceased referring patients to KNH with over two-thirds of these health facilities being private facilities. The major facility and patient factors that were associated with facility referrals to KNH were human resource capacity and availability and patient’s preference. In conclusion, enforcement of the referral guidelines significantly reduced the lower tiers health facilities referring to KNH. We recommend having written standard operating procedures on referrals based on the national referral guidelines with continued enforcement of the same to sustain the gains made.

The authors have declared no competing interest.

This study was partially funded by Kenyatta National Hospital. RFA 2020/21. The funders had no role in study design, data collection and analysis, decision to publish and in preparation of the manuscript.

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University of Nairobi/KNH Ethical Review Board. The study protocol was presented to UoN/KNH Ethics and Research Committee and was granted ethical approval (ERC No: P852/10/2021).

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