Background: Referral services has two parts, the first part begins by the referring health facility communicating relevant patient information to the receiving health facility, and it ends by the receiving facility to communicate back to the referring health facility with the information and plan for a continuum of care. In Ethiopia, the existing referral systems have various facets, which include: referral network organization; have guiding document; and established tracking mechanisms. However, magnitude of referral services, facilitators, and barriers patient experiences has limited information. Therefore, the aims of this study were to assess referral services rates, facilitators and barriers at primary health care entities in four regional states of Ethiopia.

Method: The study employed a mixed research method and collected data from three sources, that includes 1139 patient exit interview, 459, 455 medical record review and 52 in-depth key informant interviews. The study was conducted in four purposively selected woredas Amhara, Tigray, Oromia and Southern nations, nationalities and people’s regions from October 2018 to September 2019. The quantitative data was analyzed using Statistical Package for Social Sciences (SPSS IBM V 20). Results are presented using rates, frequency tables and figures. In addition, qualitative data were transcribed verbatim, read and re-reads several times, codes were labeled, categories and themes were emerged using open code software.

Results: The mean and standard deviation of patients participated in exit interview was 31.5 ± 9.7 years. The majority 967 (84.9%) were females. The key informants were 5 were Medical Doctors, 9 were midwives, 11 were nurses, 11 were health officers and 16 were health extension workers. The medical records in four primary hospitals and 8 health centers were reviewed for one-year period. The referral rates were 0.45% (1128/251364) and 0.63% (1318/208091) for health centers and primary hospitals. Out of 1139 formally referred patients, 86.0% reported at receiving health facility without delay. The qualitative data analysis emerged with two major themes, namely facilitators and barriers of the referral services. On one hand, some of the facilitators were availability of ambulance services at woreda and cluster level, and good interaction between the health workers and patients or care takers were frequently mentioned by respondents. On the other hand, some of the barriers emerged were, lack of adequate infrastructure, shortage of human resources to accompany referred patients and shortage of budget to cover the cost of health workers accompanying referred patients, of lack electric power and telephone services seriously affects the referral services related communications.

Conclusions and recommendations: The referral rates in both health centers and primary hospitals were below the national standard, 1.2%, which shows that patients were denied referral services which may help them to recover from their ill health. More than one fifth of referred patients were reported to receiving facilities without delay. On hand, availability and improved ambulance services were the facilitators for referral services. On the other hand, lack of infrastructure, telephone services and shortage of budget were barriers for the referral services. Improving patient identification for referral services and infrastructure were recommended.

Keywords: referral, barrier, facilitators, primary health care,