Table 3 Perceived barriers to completion of referral

Cost related factors^{a, b}

“So it is normally hard. They don’t have money. When you enter in Referral [a level 6 health facility], they tell you to pay first. At times transfer is normally hard due to finances…When you reach there you are stranded financially.” (Baraza, Mosoriot)

“I think also in line with that maybe sometimes you might have done a few tests here and the patient has been referred to MTRH where he repeats the tests again… but bearing in mind that economic status of this patient, you are also burdening him. So, in the end you have done the right investigations, you have found the right diagnosis but now you cannot treat the patient because in the end the patient cannot afford the drugs. It is like zero work.” (FGD, Clinical staff, Burnt forest)

Referral knowledge ^b

“People tend to believe that when you are referred to MTRH your disease is so critical that you are going to die. So, the patient will tell you he will not go to referral because that is where he will die. So some decline referral because of such beliefs. So instead of them knowing that they are going to be assisted, they believe that going there is a death sentence.” (FGD, Clinical staff, Burnt forest)

Supply Side Barriers

 Facility accessibility^{a, b}

“Another thing is the weather condition (All laugh). There are those that come from areas where when it has rained, you cannot move to the next facility.” (FGD, Clinical Staff, Kocholya)

 Service cost & availability^{a, b}

“My opinion is that if it were possible, in these big hospitals…there should be a place set aside where they come to be attended… It should be set aside for you to come for pressure to be treated.” (FGD, Patient, Burnt Forest)

“You can queue in the hospital then you get tired and you decide to head back home.” (FGD, Patient, Webuye)

 Referral management^b

“Our peripherals don’t communicate. We only know that there is a patient who had been referred, we don’t have any knowledge of a patient who is coming so that we do prior preparation to receive that patient.” (KII, Records, Kitale)

“It is also about the information given to the patient in the facility. ‘Why are you being referred to that facility?” That means the patient should be given the reasons and importance of being referred, and what should be done in that hospital.” (FGD, Clinicians, Kitale)

“There is also another point, like you are referring somebody and then you don’t have a point person to call on the other side… we don’t have that kind of connection, so it is a challenge.” (FGD, Clinical Staff, Kocholya)

“We have some very sick patients who need to be transferred to MTRH or maybe any other place through ambulance. Usually there is lack of ambulance to ferry the patient to the other facility. This patient cannot walk, this patient is not willing to take a matatu [public van], they won’t reach there” (KII, CO, Kitale)