Strengthening Referral Systems for HIV Clients in Tanzania

A study in Tanzania suggests the importance of monitoring the HIV referral system between community and clinical services.

© 2005 John Horan, Courtesy of Photoshare
© 2005 John Horan, Courtesy of Photoshare
DAR ES SALAAM, Tanzania—Referral systems play an important role in health systems. Strong linkages between community and health facility services encourage clients to seek care and support and help them gain access to services. Additionally, they can help providers track the services that clients receive and then follow up on their healthcare needs.

Unfortunately, referral systems often do not function as intended. In Tanzania, MEASURE Evaluation–Tanzania is focusing on strengthening referral systems for HIV and AIDS clients and ties between community and health facility services.

MEASURE Evaluation, a project funded by the U.S. Agency for International Development (USAID) and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), produced the Referral System Assessment and Monitoring Toolkit in 2013 to determine how well a referral system functions and areas for improvement. Cristina de la Torre, DSc, a Senior M&E Specialist for MEASURE Evaluation, helped develop the toolkit, which has been used in Tanzania (and Kenya, as well).

Strengthening Linkages across the Care Continuum

The HIV care continuum outlines the series of steps that people living with HIV go through, from initial diagnosis through treatment with medication. To achieve the full continuum of care, HIV programs require strong linkages among prevention, testing, clinical care, and social support services, which are often delivered by different providers working in diverse locations that range from community to tertiary hospitals.

“Often, there’s a loss of clients at each step in the process,” says de la Torre. “Over time, different services happen at different facilities, or with different providers. Tracking clients referred across facilities and providers has been a challenge for most HIV programs.”

MEASURE Evaluation–Tanzania is working to improve referrals in Tanzania, by assessing systems, producing monitoring guidance for referral systems, and promoting the guidance as a national and subnational priority.

Assessing HIV Referral Systems in Tanzania

MEASURE Evaluation, in collaboration with the country’s National AIDS Control Programme (NACP) and FXBT Health, recently conducted an assessment to examine the current HIV referral system between community and clinical services. The assessment, conducted in Kyela, Waging’ombe, and Kinondoni districts in February 2016, involved key informant interviews with facility and community service providers, district coordinators, and staff from community-based organizations. The assessment team additionally reviewed various documents, including national HIV guidelines, training curricula, and paper tools used by service providers, such as referral forms, registers, and reporting forms.

The results will inform the design and implementation of interventions to strengthen the referral system. On July 19, 2016, de la Torre and her colleagues presented their findings at a meeting with staff from USAID and the U.S. Centers for Disease Control and Prevention (CDC)/Tanzania and discussed priorities to improve the implementation and monitoring of referrals.

The assessment revealed a lack of guidance about how referral systems should work and how providers should make, track, and follow up on referrals. Specific guidelines and referral protocols would improve the system, as would establishing a more systematic way to document referrals. This will ultimately lead to better patient care and ensure that patients remain in care. A meeting held with key stakeholders from the Ministry of Community Development, Gender, Elderly and Children, and the NACP shortly before the assessment was conducted reached similar conclusions.

With Charles Mushi, a colleague who contributed to the assessment, de la Torre coauthored a poster that illustrates some of these preliminary findings. Mushi submitted the electronic poster to the 21st International AIDS Conference, held in July in South Africa.

 “Our message is that without strong monitoring of referrals at the national and subnational levels, the referral system won’t function effectively,” de la Torre says. “We need to document referrals and assess the performance of the system adequately if we’re going to improve it.”

For more information

MEASURE Evaluation–Tanzania, a five-year award with funding from USAID, assists the government of Tanzania in strengthening monitoring and evaluation systems for health and social service programs, with a focus on the most vulnerable children, HIV, and malaria. Read more at

Filed under: HIV , Tanzania , HIV/AIDS , Referral Systems , MEASURE Evaluation Tanzania
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