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Acute Care Referral Systems in Liberia: Transfer and Referral Capabilities in a Low-Income Country

  • Jimin Kim (a1), Maria Barreix (a2), Christine Babcock (a3) and Corey B. Bills (a4)

Following two decades of armed conflict in Liberia, over 95% of health care facilities were partially or completely destroyed. Although the Liberian health system has undergone significant rehabilitation, one particular weakness is the lack of organized systems for referral and prehospital care. Acute care referral systems are a critical component of effective health care delivery and have led to improved quality of care and patient outcomes.


This study aimed to characterize the referral and transfer systems in the largest county of Liberia.


A cross-sectional, health referral survey of a representative sample of health facilities in Montserrado County, Liberia was performed. A systematic random sample of all primary health care (PHC) clinics, fraction proportional to district population size, and all secondary and tertiary health facilities were included in the study sample. Collected data included baseline information about the health facility, patient flow, and qualitative and quantitative data regarding referral practices.


A total of 62 health facilities—41 PHC clinics, 11 health centers (HCs), and 10 referral hospitals (RHs)—were surveyed during the 6-week study period. In sum, three percent of patients were referred to a higher-level of care. Communication between health facilities was largely unsystematic, with lack of specific protocols (n=3; 5.0%) and standardized documentation (n=26; 44.0%) for referral. While most health facilities reported walking as the primary means by which patients presented to initial health facilities (n=50; 81.0%), private vehicles, including commercial taxis (n=37; 60.0%), were the primary transport mechanism for referral of patients between health facilities.


This study identified several weaknesses in acute care referral systems in Liberia, including lack of systematic care protocols for transfer, documentation, communication, and transport. However, several informal, well-functioning mechanisms for referral exist and could serve as the basis for a more robust system. Well-integrated acute care referral systems in low-income countries, like Liberia, may help to mitigate future public health crises by augmenting a country’s capacity for emergency preparedness.

Kim J , Barreix M , Babcock C , Bills CB . Acute Care Referral Systems in Liberia: Transfer and Referral Capabilities in a Low-Income Country. Prehosp Disaster Med. 2017;32(6):642650.

Corresponding author
Correspondence: Corey B. Bills, MD, MPH Department of Emergency Medicine University of California San Francisco Zuckerberg San Francisco General Hospital and Trauma Center 1001 Potrero Avenue San Francisco, California 94110 USA E-mail:
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Conflicts of interest/funding: The authors have no financial or non-financial conflicts of interest. Funding support was provided by the Pritzker School of Medicine, University of Chicago (Chicago, Illinois USA). Administrative and logistical support was provided by the Clinton Health Access Initiative (CHAI; Boston, Massachusetts USA), Montserrado County Health Team (Liberia), and the Ministry of Health and Social Welfare of Liberia (Monrovia, Liberia).

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