Closed Loop for Referrals & Follow-up of Maternal, Neonatal and Child Health & Integrated Community Case Management

Though official Kenya Health Sector Referral Strategy proposes the use of Information and Communication Technologies (ICTs) to strengthen referrals and follow ups between community health volunteers (CHVs) and local facilities, many of these strategies have not been widely implemented. The objectives of the strategy are to realise improved capacity of health providers to identify clients who require referral, develop protocols that will lead to referral system efficiency and effectiveness, and promote and facilitate ICT to manage referrals, improve care, enhance capacity of the referral system in Kenya, provide communication and related equipment, and promote research and innovation for referrals. The technologies here include non-invasive diagnostics, smartphone-enabled testing, growth monitoring, and biometrics that show immense potential to transform healthcare delivery.

Referral cases are often high priority and time sensitive. In Kenya, CHVs verbally refer patients to health facilities but are not given the resources needed to reliably confirm or follow up if the client went to a health facility apart from a paper-based referral note. Currently, community health data systems are unable to track and verify whether the client went to a health facility, whether they were treated, the referral outcome, and any required or carried through follow up.

Living Goods’ Innovation Network aims to address these gaps and transform unreliable self-reported data by harnessing the power of mobile technology—specifically mobile tools to close the loop on the client referral and follow up process. Living Goods-supported CHVs are trained and equipped with smartphones that aid them in doing household registration, assessment, diagnosis, treatment and referrals. The proposed new system introduces a digital referral note as a redundancy to the paper based one. It also introduces triplicate copy of the referral note as opposed to duplicate copy and an autogenerated text message that is sent to the CHV when the referred client report to health facility. If CHVs have the mobile tools they need to track a client from the initial assessment, through the referral process, and into a follow up, the Innovation Network believes more lives can be saved.

To test this, the Innovation Network is conducting a quasi-experimental study in Ogembo, Kisii county Kenya across the six community units: Mangere, Keragia, Mogambi, Bosoti, Nyabioto, Buyonge with the support of Ministry of Health in Kisii County. The objective of the study is to evaluate a digitized closed-loop referral and follow-up system that ensures all health facility referrals and follow-ups made by CHVs are documented, actualized, and confirmed via verifiable and reliable digital data. The study focuses on two experiment health facilities, with 21 CHVs and two control health facilities, with 22 CHVs. The workflow visuals are illustrated in detail below followed by preliminary findings.

Key to the workflow:

1a. Paper referral copies filled in triplicate

1b. Digital referral report submitted by CHV

1c. Referral task sent to health facility

1d. Follow up task sent to CHV

  1. Patient goes to the health facility and Carries 2 copies of the MoH 100

3a. 2 Paper copies signed and stamped by nurse

3b. Digital Referral confirmation sent to server

3c. Digital Referral confirmation triggers an SMS notification to the CHV confirming the visit

4. Signed and stamped MoH copies

5. CHV’s follow up task completion.

Within a period of August 2018 – July 2019 the CHVs used the SmartHealth app running on android smartphone to do household assessments, diagnosis and refer severe cases to the health facility. In the case of a severe disease, the application generates a detailed referral summary which the CHV transfers to the now triplicate referral note. The original and the first copy are given to the client to go with to the health facility while the CHV retains the second copy. At the health facility, the healthcare worker signs and stamped the 2 documents and files the original while the CHV goes back to the household with the second copy.

The closed-loop innovation enabled digital linkage between community health services and healthcare facilities, enabling 360 view of patient management at the community level. Of the 476 referrals, 226 (47%) were referred to non-link facilities out of choice.

The patients who went to non-linked facilities never had the opportunity for the facility to confirm their referral.


There seems to be high levels of self-reported satisfaction with CHV visits and services. CHV initial visits and follow-up visits seem to occur at a high rate and in due time.


There seems to be a new appreciation of referrals notes at the health facilities. Referred patients reported being asked about the MOH 100 and subsequently receiving prioritized care at the health facility. The CHVs also reported to have been more motivated to receive back signed and stamped referral notes from the health facility.

Written by

Stephen Odindo

Senior Researcher
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