Determinants of an Appropriate Balance of Referral-Level Care
When one considers the ideal level of resources to be provided for referral hospital care and the appropriate balance between resources for referral hospitals and for other levels of the health care system, no simple formula is available that can be applied to different countries and contexts. However, certain key factors have an important influence on the need and demand for referral-level care, the resources that may be available to the health sector, and the ability of the health sector to provide adequate and effective care in different settings.
General Determinants
Arguably the most important determinant of demand for and ability to pay for referral hospital care is a society's level of economic development and wealth, captured (albeit imprecisely) by measures of GDP per capita. Extensive international evidence indicates that national health expenditure displays an unambiguously positive income elasticity both across countries and over time; that is, as a country gets richer, it spends relatively more on health (see, for example, Getzen 2000; Schieber 1990). Studies in developed countries indicate that in the United States, every 1 percent long-run increase in GDP leads to a 1.6 percent increase in health expenditure, and in other countries the increase is between 1.2 and 1.4 percent (Getzen 2000). Therefore, expecting developing countries to spend a higher proportion of their GDP on health care as they become wealthier seems to be reasonable. If the poorest countries were to focus their limited resources on highly cost-effective interventions in primary health care, somewhat better-off countries might be expected to spend progressively more on the referral hospital level as resources became available.
An overlapping set of demographic and geographical factors also plays an important role in determining the balance of referral care—namely, population size, population density, terrain, distances between main urban centers, and access. Populations of some millions are required to justify a major tertiary hospital with a full range of tertiary services. Small countries with populations of less than 1 million will certainly not be able to provide a full range of tertiary hospital services because of the need to achieve minimum volumes to ensure service viability and to attract a critical mass of specialized personnel. Countries with fewer than 100,000 inhabitants (generally island states) may find even secondary hospital services beyond their means and capabilities. Supranational referral, reliance on larger neighbors, or regional collaboration may be unavoidable for smaller countries, especially for tertiary care provision, with the Caribbean and southern Africa providing clear examples of many smaller states relying on referral facilities in larger or wealthier neighbors. Within larger countries, population density can complicate the planning of referral services. Compact countries or regions with dense populations can typically provide high levels of access to referral care at a relatively small number of sites, whereas countries or regions with more dispersed populations face more complex tradeoffs regarding number of sites, volume thresholds, and transportation systems.
The other main influence on the appropriate balance of referral services for a given country is its particular pattern and burden of disease. Although referral-level services will always be needed, as a society passes through epidemiologic and demographic transitions, it is likely to require more of those services typically found at referral hospitals. For example, rapidly increasing rates of heart disease and cancers are typically encountered in industrializing nations and aging populations, and these are diseases whose effective management requires access to the interventions, skills, and equipment that will typically be concentrated at the referral hospital level.
Health System Determinants
A number of factors specific to the particular context of a country's health system will also influence the appropriate balance between referral hospitals and lower levels of care. These factors are especially important in considering the appropriateness of plans to change the balance of care between levels. Broadly, they can be summarized as follows:
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capabilities of lower levels
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availability of specialized personnel
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training capacity, organization, and needs
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cultural issues, political issues, and traditions.
The first three factors are closely interrelated. If primary health care and district hospital services are weak, cutting resources for referral hospitals without destabilizing the system will be more difficult. In such circumstances, rapid rebalancing of resources is unlikely to be possible because careful efforts will be required to develop lower-level services first, while still maintaining the referral service. Where lower-level services are strong, devoting relatively fewer resources to referral hospitals may well be possible. However, even though an effective district health system will be able to treat a large proportion of patients at lower levels of care, it will also be better able to identify patients who require referral for more complex care and, thus, may generate a greater appropriate demand for referral hospital care.
Referral hospital services require a specialized staff to fulfill their mission. If specialized personnel are not available in a country, then attempting to develop referral hospitals on a large scale will clearly be infeasible. However, many countries arguably have too many specialized staff persons and too few well-trained generalists. Where large numbers of specialists exist, their presence will likely tend to draw resources disproportionately toward the referral level and away from district health systems. Wherever such imbalances exist, positive changes will require a substantial training or retraining agenda. The feasibility of such efforts is closely linked to the professional and social status of different professional groups and subgroups—for example, whether medical specialists are viewed as having a higher status than general practitioners—and to the premium a society places on having access to "advanced" medical care.
