Transitions in care and other fuzzy boundaries: Uganda, Tanzania and Zambia

Please note that the following blog are my views and observations. It does not represent the views of AFEM or WHO.

Healthcare systems are complex and there is no one-size-fit-all way to strengthen it.  It’s up to each country to develop a sustainable healthcare system according to need, available resources and setting.

The WHO is developing a Basic Emergency Care course.  I was part of the team testing the course. The first pilot was held in Uganda, with facilitators from Uganda, Tanzania, Zambia and South Africa.  More pilots was held in Tanzania and Zambia with local participants, from various geographical settings and different tiers within the health system.

The handover exchange was one of the most valuable discussion points. Shared patterns and concerns emerged. Some of the key discussion points:

Fuzzy boundaries

According to the World Health Organisation (WHO) a healthcare system encompasses all organisations, people and actions with the primary intent to promote, restore or maintain health.

In Uganda and Zambia the first tier of care delivery, especially in rural areas are provided by community first aiders.  If required the patient is referred to healthcare professionals. This highlights the value of the Basic Emergency Care course and other elementary courses.

Thus a health system is more than the publicly owned facilities. If first aiders are providing basic care prior to referral; when do they become part of the formal system?  Where is the boundary?  It appears as if the informal care rendered are already “formalised” and established?

Taxies are a common transport method for ill or injured patients.  Thus taxi drivers are an important part of the emergency care system.

Fuzzy boundaries complicates governance and accountability. For example; if the boundaries are not clear how can regulations and best practice be disseminated? And who should be trained?

Transitions in care

Often there is limited out-of-hospital facilities e.g. ambulances and trained practitioners to accompany the patient.  Hence patients are transported via public transport (taxi, etc.) or if by ambulance accompanied by only the driver.  This limits the handover information and complicates continuity of care. Not to mention that the patient condition may detoriate during transit.

Some of the shared issues here was: pre-warning of referral, letter of referral and information regarding cost.  In Zambia; the pre-warning phone call is merely a courtesy as higher tier facilities may not refuse a patient.

Patients are referred from tier to tier.  Despite some benefits to such a rigid system, it creates a barrier when higher level care is required than what the next tier are able to render.

Participants requested feedback, stating that once a patient has left their facility they do not receive any feedback. This creates an opportunity for improvement and training opportunities.

Out-of-pocket expenditure

There is financial costs associated with referral. Patients/family members are expected to pay for certain procedures upfront or to purchase items from pharmacies that are not on the hospital grounds.  Who is responsible for the conversation regarding possible costs associated with the transfer? And what happens if it is unaffordable?  This is a tough one.  It is unreasonable to expect the referring facilities to know the potential costs and conduct the conversation. Yet it is unreasonable to commence dialogue regarding cost on arrival of the patient at the referral facility; this might inadvertently force a catastrophic expenditure as the patient/family might feel that there is no choice regarding expenditure.


Developing emergency care and enabling access to care is still not prioritised in most of Africa. Perhaps these discussions sounds trivial in a world filled with HIV, TB and other well-funded diseases.  Still, if the patient do not receive adequate and timeous emergency care, the patient dies.

Tolstoy said that happy families are all alike, and every unhappy family is unhappy in its own way.  Just like happy families are alike, health care systems in African countries are all alike.  And so is emergency care systems…In each of the countries visited, the practitioners are relentlessly improving the delivery of emergency care; doing tremendous work with limited resources.

Organisations such as AFEM creates a platform for collaboration across the African continent. Collaborative networks are crucial to advocate for and advance emergency care.  These networks fulfils an important function providing support.  It’s been a month since the first pilot.  On most days of this month there has been messages of motivation and support between the facilitators of the different countries.  The importance of these networks should not be underestimated.

When spider webs unite, they can tie up a lion.’ Ethiopian proverb

Post note

It’s been a privilege to participate in the three WHO pilot sessions.  Thank You AFEM for creating the opportunity.

Read more   strengthening health systems to improve health outcomes.  WHO’s Framework for action.  (2007)



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