Effective referral is a critical element of a well-functioning health system. While having a good referral policy in place is important, equally important is its effective implementation. Using the implementation of a policy on referral of obstetric emergencies in Shanghai as a case, we illustrate the application of the 'Inhabited Institutions' analytical approach for studying policy implementation. In doing so, our study highlights how 'referral' is a quintessential systems process embedded in institutional, social and historical contexts. We show that multiple institutional logics, in the form of explicit and tacit organizing principles and assumptions, intersect to influence and shape actors' actions, sometimes with good outcomes and sometimes with poor outcomes. We reveal the embedded agency of frontline healthcare managers and providers across different levels of care. We show how frontline managers and providers, operating under conditions of uncertainties and ambiguities in organizational processes, actively draw upon their experience and network capital to creatively adapt to get referrals done in a timely manner to save lives of critically ill pregnant women. From our findings, two sets of linked implications emerge for strengthening referral systems. Given that referral often involves ill and complicated cases, getting referrals right depends on the exercise of discretion and judgement by those at the frontline to arrive at timely and workable solutions-health systems need to recognize this. We also conclude that to get referrals right, while one needs clearly defined policies and implementation processes that are locally appropriate, well understood by all concerned and easy to follow, this is not enough. In addition, explicit measures that enable the exercise of discretion and judgement at the frontline need to be locally identified and adopted.
Keywords: China; Policy analysis; health systems; maternal health; maternity services; referral.
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