Table 1 Understanding surgical triage and referral intervention within the WHO Health Systems Framework

Blocks 1 & 2: Governance & Finance

a) Public sector insurance scheme covering referral care for all patients eliminates need for independent funding mechanism (includes travel, food and lodging, and free treatment for all patients in the program).

b) Logistics partnerships, such as lodging in Kathmandu, have greatly improved patient comfort during long treatments far from home.

c) Partnerships with care providers, such as an orthopedic rehabilitation hospital, provide services otherwise unavailable locally.

d) A regulatory framework, likely embedded within financing system, is required to hold providers accountable to quality, access, and safety.

Blocks 3: Medical Products

a) Need for improved supply chain around essential surgical triage and diagnostics, including blood products, x-ray, ultrasound, splinting, and advanced imaging. Yet at a local level, human resources are more fundamental bottlenecks.

Block 4: Human Resources

a) Partner physicians at private and academic centers provide phone and telemedicine consultations to physicians.

b) Staff training on cases meeting criteria for funding to encourage active case finding.

c) Staff training on the diagnostic and therapeutic options, and limitations at referral sites.

d) Staff training on pre-surgical referral patient management and triage.

e) Staff training on diagnosis of commonly referred surgical diseases (e.g. fracture, rheumatic heart disease, and osteomyelitis).

f) Visiting surgical teams for on-site training and local co-management of cases.

Block 5: Information Systems

a) Staff maintain a follow-up registry that automatically alerts staff regarding whom and when to follow-up.

b) Staff maintain an up to date contact list for patients, referral care providers, support staff, CHWs, and partner organizations providing logistics support.

c) Ultimately, an integrated electronic health record is required, and the Possible team has deployed this following the study.

Block 6: Delivery Systems

a) First level hospital Community Health Program as “focal point” in coordinating referral surgical care.

b) Active case finding in the community through coordination with CHWs.

c) Frequent phone communication between patients, families, and staff and home visits by CHWs.

d) In hospital follow-up of all referred patients by staff and clinical staff at one month post-surgery.

e) Part time staff at referral center assures timely provision of care and further coordinates with local staff.

f) Subsidized transportation to and from referral center (often >12 h by bus each way) and transport for follow-up care.

g) Emailed and phone conversations between staff at local and referral sites of care for coordination.

h) Use of performance metrics including follow-up rates and complications.

i) Community Health Program staff coordinate with local clinicians, patients, and referral care centers.

j) Staff accompany patients and help navigate distant medical centers assuring proper care is received.

k) Staff coordinate follow-up with referral centers and patients, organizing travel and other logistics.

l) Focus of referral relationships on collaboration with local teams and local staff education.

m) Hospital staff work closely with CHWs for follow-up and patient education.

m) Clinical staff provide patient education specific to condition and where patient is in referral care loop.

o) CHWs provide emotional support and can help with referral process if complication occurs.