Research report (MMed) -- Interdisciplinary Health Sciences, Stellenbosch, 2010. / ENGLISH ABSTRACT: Background The referral system is an important component of the health care system. In public health facilities, a high number of patients’ attendance has lead to a huge burden on the secondary and tertiary level of the care system in terms of manpower, equipments and resources. Public health in South Africa consumes around 11% of the government's total budget. The state contributes about 40% of all expenditure on health; the public health sector is under pressure to deliver services to about 80% of the population. Despite the huge spending on health care in most developing countries, health outcomes and services remain poor. Few studies are available to give insights into reasons for this disparity. Therefore the findings of this may help to explain some of the reasons for this overburden of public health facilities and further to make recommendations on how health service delivery may be improve on. The results of this study can be useful in future planning; this may lead to a reduction in huge health expenditure incurred by most developing countries. Methods A cross sectional survey of three different groups of people which comprises of 273 patients, 28 referral centre participants and 19 referring centre participants was carried out. All patients referred from Motherwell community health centre to Dora Nginza hospital were eligible for the study. Questionnaires were interview administered to patients after they had finished consultations in Dora Nginza Hospital. Health professionals from both facilities were also interviewed with the use of self administered questionnaires. Results Three out of every four patients interviewed were of the opinion that their referral to hospital was appropriate which is consistent with the results from referring health professionals, eighteen of nineteen respondents. However, only one-quarter (7) of the referral centre health professionals felt the referrals from referring centre to hospital were appropriate p<0.01.The majority of the patients were satisfied with the level of service received at the referral centre. 77% (210) reported that the staff at the referral centre was friendly and 84% (230) were happy with the explanation given for their illness. However, a source of concern is that, in most of the referred patients 58% (215), there was no formal response back to their primary care. In the referring centre, participants identified transportation of patients to referral centre as the major problem encountered when referring patients 68 % (13), whereas 32 % (6) felt it is communication. In addition, 73 % (14) were of the opinion that transportation was inadequate and 89 % (17) reported the response rate of transport was unsatisfactory. In the referral centre, results showed participants were more concerned about the adequacy of information provided in the referral letters with 78% (22) reporting they were often not adequate information on the referral letters. However, half of the respondents agreed that they do not have clear referral guidelines. Conclusion Primary care health professionals and patients in this study view the referrals to higher levels of care as appropriate. However, the referral centres health professionals were of the opinion that most referrals were inappropriate. The opinion of the referral centre can be attributed to their negative attitudes towards referrals. The referral centres needs to provide more support to primary care for a more efficient referral system .They also need to improve on the continuity of care by providing feedback to referrals. On the other hand, the primary health care needs to be strengthened in terms of resource allocation in order to gain more confidence from both patients and referral centres. / AFRIKAANSE OPSOMMING: geen opsomming

Transgender and gender nonconforming (TGNC) people who pursue gender affirming medical interventions, such as hormone therapy and surgery, are required to supply their physicians with referral letters from mental health professionals (Coleman et al., 2012). The process by which TGNC people are required to obtain referral letters before accessing gender affirming care is often referred to as gatekeeping in the TGNC literature (Budge, 2015; Cavanaugh, Hopwood, & Lambert, 2016). Despite implications that the current gatekeeping system may have for the relationship between TGNC clients and their therapists, few studies have examined TGNC individuals’ experiences related to obtaining referral letters in therapy (Bess & Stabb, 2009; Elder, 2016). This study used semi-structured interviews and a grounded theory approach to qualitatively examine the experiences of 15 TGNC individuals who have obtained a referral letter for gender affirming medical intervention from their therapists. Thematic analysis revealed two core themes: (1) “blessings” that TGNC individuals experienced because of the referral letter requirement and (2) “bullsh*t” (or “BS”) participants endured due to this requirement. Implications for psychotherapy practice and training, as well as healthcare policy, are discussed.

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