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Open Access Research article

Assessment of providers' referral decisions in Rural Burkina Faso: a retrospective analysis of medical records

Tegawende Pierre Ilboudo12, Yiing-Jenq Chou1 and Nicole Huang13*

Author Affiliations

1 Institute of Public Health, School of Medicine, National Yang Ming University, Section 2, Li-Nong Street, Taipei 112, Taiwan

2 Service de Lutte contre la Maladie et Protection des Groups Spécifiques, Direction Régionale de la santé du Centre-Est, Ministère de la Santé, BP 7009, Ouaga, Burkina Faso

3 Institute of Hospital and Health Care Administration, School of Medicine, National Yang Ming University, Room 201, The Medical Building II, No.155, Section 2, Li-Nong Street, Taipei 112, Taiwan

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BMC Health Services Research 2012, 12:54  doi:10.1186/1472-6963-12-54

Published: 8 March 2012



A well-functioning referral system is fundamental to primary health care delivery. Understanding the providers' referral decision-making process becomes critical. This study's aim was to assess the correctness of diagnoses and appropriateness of the providers' referral decisions from health centers (HCs) to district hospitals (DHs) among patients with severe malaria and pneumonia.


A record review of twelve months of consultations was conducted covering eight randomly selected HCs to identify severe malaria (SM) cases among children under five and pneumonia cases among adults. The correctness of the diagnosis and appropriateness of providers' referral decisions were determined using the National Clinical Guidebook as a 'gold standard'.


Among the 457 SM cases affecting children under five, only 66 cases (14.4%) were correctly diagnosed and of those 66 correctly diagnosed cases, 40 cases (60.6%) received an appropriate referral decision from their providers. Within these 66 correctly diagnosed SM cases, only 60.6% were appropriately referred. Among the adult pneumonia cases, 5.9% (79/1331) of the diagnoses were correctly diagnosed; however, the appropriateness rate of the provider's referral decision was 98.7% (78/79). There was only one case that should not have been referred but was referred.


The adherence to the National Guidelines among the health center providers when making a diagnosis was low for both severe malaria cases and pneumonia cases. The appropriateness of the referral decisions was particularly poor for children with severe malaria. Health center providers need to be better trained in the diagnostic process and in disease management in order to improve the performance of the referral system in rural Burkina Faso.

Diagnostic errors; Compliance; Healthcare quality improvement; Patient safety; Primary care