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In-depth assessment of a referral system including emergency transportation of sick mothers and newborns in rural Bangladesh

Research Overview:

TRAction is currently funding a research study in Bangladesh exploring the effectiveness of several referral systems for maternal, neonatal & child (MNCH) emergencies in Bangladesh. For emergency events, geographic and financial barriers hold substantial influence over the decision to seek care, and act as major deterrents to completion of referral. Research into referral systems in Bangladesh have indicated a compliance rate just over 50 percent. Referral completion for younger neonates are even lower at 30 percent, in spite of efforts to address cost, transport & maternal and family training to detect neonatal danger signs.

In Bangladesh, most sub-district and district hospitals have very limited ambulance services available for transport of patients. Referral systems in Bangladesh, in general, are poorly designed and unreliable, and it is standard practice for patients to rely on public/private sector transportation during emergencies. In response, several large scale MNCH initiatives in the country, including efforts by BRAC & the International Center for Diarrhoeal Disease Research, Bangladesh (icddr,b), have taken innovative approaches to referral to decrease delay and increase referral compliance.

In Bangladesh, Save the Children in collaboration with the Ministry of Health and Family Welfare, national NGOs Shimantik and Friends in Village Development, and icddr,b, are implementing the MaMoni project under USAID's global flagship program MCHIP (Maternal, Child Health Integrated Program). MaMoni is implemented across 15 sub-districts of Sylhet and Habiganj districts in Sylhet division, covering a total population of 3.5 million. This TRAction study assesses the effectiveness of MaMoni project’s referral system, comparing it with other models currently operating in Bangladesh.

Study Objectives:

1. Determine the MaMoni referral system’s functionality in regards to utilization, timeliness of referral, response to referral and the outcome of care at referral facility.

2. Determine how different elements of the referral system link to each other, and any interdependencies

3. Compare the MaMoni referral system with referral in other program areas with regard reason of referral (disease event), time taken to reach facility, and transport cost.

4. Determine community perceptions of the MaMoni referral system with regard to efficiency, satisfaction and in terms of costs and benefit in comparison to alternatives.

Research into Action:

The results of this study hold implications to decrease referral delays, and ultimately reducing maternal, neonatal and child mortality and morbidity, in Bangladesh. Results will inform program design for the massive public & non-government primary health care programs dealing with MNCH issues, and other emergency cases, in Bangladesh. The potential for public-private NGO/private collaboration has positive implications for local uptake & long-term sustainability as well. 

Recommendations & Implications:

  • Household decision-making in emergency situations is affected by knowledge of available services at health facilities, as well as referral conditions. 
  • Having contact with referral transport drivers is cited to be extremely important by decision-makers during emergency events. Proximity is a factor, as community members tend to have the contact number of drivers who are residing nearby.
  • Community members cite previously existing knowledge of referral fare as an important factor in the decision to seek out referral.


Implemented by

International Centre for Diarrheal Disease Research (icddr,b)


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