Why the referral system is choking major hospitals as patients suffer

Reuben Nyandika’s survival has come after days of uncertainty, delayed referrals and a desperate search for specialised care. The 56-year-old resident of Kasarani, Nairobi, suffered a stroke on Sunday, May 10, while taking a shower.

His wife, Veronicah Kimtu Omango, says the family rushed him to a public hospital in Kiambu, hoping for emergency treatment. Instead, his struggle had only begun. Doctors at the facility told them the hospital lacked a CT scan machine, forcing them to seek the service at a nearby private facility for Sh10,500.

The scan revealed Nyandika had internal bleeding in the brain and urgently needed specialised treatment. His condition continued to deteriorate.

According to Omango, the hospital lacked an Intensive Care Unit (ICU) bed, making it impossible to stabilise him adequately. Doctors recommended referral to Kenyatta National Hospital (KNH), but all ICU beds were full.

Desperate, Omango says she requested a transfer to Mbagathi Hospital, but was allegedly told the facility could not receive him because it is of the same referral level. As her husband’s condition deteriorated, the family says they were left stranded on what next.

At one point, she alleges some medics suggested she raise Sh100,000 to secure an ICU bed at a private hospital in Imara Daima. The family did not have the money. “It was traumatising watching my husband struggle to breathe as we searched for help,” says Omango.

She further claims while awaiting transfer, she was forced to purchase drugs and other medical supplies to stabilise him. “Even basic items had to be bought outside. At some point, I was told to remove my husband from the hospital,” she says.

Relief finally came on Monday morning when KNH contacted the family and accepted the referral. Nyandika was admitted and underwent successful surgery on Tuesday morning. “Watching my husband breathe gives me hope. It has been a painful journey getting a diagnosis, an ICU bed and surgery,” she says. “At KNH, I now believe he will recover and walk back home.”

In another case, Jeci Mubaiya from Kiserian, Kajiado County, narrowly escaped death after delays in accessing treatment for blood clot in the head. The condition presented with persistent severe headache, and doctors would diagnose him with thick blood, prescribing thinners.

But his condition worsened. Further assessment later revealed he had a blood clot in the brain requiring urgent neurosurgical intervention.

Because Kajiado County lacks neurosurgeons, Mubaiya was referred to Mbagathi Hospital in Nairobi. Unlike his earlier experience, he says Mbagathi acted swiftly. “I was taken straight to the theater. That quick intervention saved my life,” he says.

Mubaiya says the lack of specialists and diagnostic equipment in the county hospitals forces many patients to travel long distances, depleting their finances. “I had to come to Nairobi for treatment. If such services were available in counties, many lives would be saved,” he says.

The two cases highlight systemic weaknesses in Kenya’s referral system, where patients requiring emergency and specialised treatment only to suffer unavailable beds, missing equipment, lengthy transfers and out-of-pocket costs.

Health experts have warned that weak referral pathways, shortage of ICU beds, inadequate diagnostic capacity and concentration of specialists in Nairobi continue to undermine access to timely care. This is despite health being a devolved function.

The crisis persists even as President William Ruto champions the Universal Health Coverage (UHC) as a cornerstone of healthcare reforms. Kenya Medical Association (KMA) notes that that the country has built health facilities across all levels, but the systems connecting them remain fragmented and poorly coordinated.

“Kenya does not lack health facilities. What we lack is a properly functioning referral system that coordinates patient pathways,” says KMA president Dr Simon Kigondu, observes.

An effective referral system, he explains should ensure patients move seamlessly from community units, primary healthcare facilities, county and to national referral hospitals only when clinically necessary. The referral should also be accompanied by proper communication, referral documentation, financing, and feedback between facilities.

“A referral system is not just about moving patients. It is about ensuring the right patient gets the right care, at the right facility, at the right time,” says Kigondu.

The obstetrics and gynaecology specialist observes that majority of Kenyans prefer seeking care in county and referral hospitals, because lower-level facilities continue to struggle with shortages of essential medicines, limited diagnostics, inadequate theatre capacity, unreliable ambulance services and weak emergency preparedness.

The referral he notes causes congestion at the county and national hospitals that are reserved for specialised care.

These gaps according to KMA, contributes to delays in treatment, overcrowding at referral hospitals and avoidable deaths, more so in emergency, maternal and chronic disease cases. It also drives up the cost of care. “How would a patient get to a hospital where simple tests cannot be done, lacks doctor, and common drugs like painkillers?” poses Kigondu.

Further, lack of strong referral data systems, makes it for the government to identify gaps, monitor efficiency or improve patient flow.

Kigondu also links referral challenges to weak implementation of the Facility Improvement Fund (FIF), a financing model designed to allow hospitals retain and use revenue for daily operations.

Where FIF is poorly implemented, facilities struggle to procure commodities on time, maintain theaters, strengthen maternity services or sustain emergency operations.

The doctor points to counties such as Murang’a County as examples of what is possible when systems are aligned.

Murang’a has operationalised FIF, linked facilities through a shared hospital management information system integrated into Taifa Care, and strengthened unified ambulance referral services. In the county, public, faith-based and private facilities are connected, allowing hospitals to transfer patients, commodities such as blood, and even ambulance requests more efficiently.

Mbagathi and KNH are major hospitals in Nairobi that continue to suffer strain of referrals from counties, despite uproar among Kenyans on delayed care. KNH further gets referrals from neighbouring countries, being a health hub for the East African Region.

Mbagathi Hospital for example, has increasingly become a referral hub not only for Nairobi, but for patients from across the country seeking specialised and emergency care.

In 2025, the hospital served at least 280 inpatient referrals from Kajiado, Kiambu, Makueni, Embu, Machakos, wajir, Siaya, Murang’a, Kisii, Kirinyaga, Kitui, Kisumu, Lamu, Mombasa Vihiga and Mandera. The facility also receives influx of referrals in its Neonatal Intensive Care Unit (NICU), that has been a training unit for respective health providers across the country.

Mbagathi has a bed capacity of 485, attending to an average of 1,000 outpatients daily, and operates key departments including accident and emergency, maternal and child health, medical and surgical units.

The referrals are justified, particularly for neurosurgery, newborn complications and chronic disease management, but many according to hospital Chief Executive Officer (CEO) Dr Alexander Irungu, could be managed at lower levels if facilities were properly equipped. “Why should uncomplicated malaria or diarrhoea be referred here?” poses Dr Irungu. Irungu observes that stronger financing of lower-level facilities, especially Levels 2 and 3, would significantly reduce congestion at referral hospitals.

The Ministry of Health admits that despite the unprecedented increase in resources channelled to lower-level county facilities through the FIF Act, and the Social Health Authority (SHA), congestion at national referral hospitals like KNH and Mbagathi remains a challenge.

“While the financial architecture to support grassroots facilities is now in place, patient flow and health-seeking behaviours have not yet fully aligned with this new reality,” Health CS Aden Duale says.

Influx of patients to Nairobi’s major hospitals he observes is driven by historical habits where Kenyans bypass local dispensaries and health centres, holding a deep-rooted belief that only higher-level facilities offer superior care.

The CS further notes that higher-level facilities maintained more consistent stocks of medicines. To handle unstructured referrals, Duale notes that the ministry of streamlining specialised care, under SHA where patients must now initiate their treatment at the primary healthcare level (Levels 1, 2, and 3.

“We are tightening referral protocols to discourage self-referral for primary ailments, ensuring that Level 5 and 6 hospitals are reserved strictly for complex and critical care,” says Duale.

Additionally, he says the ministry is working closely with county governments to ensure FIF funds are strictly ring-fenced. “FIF money must be reinvested directly into the health facilities that generate them,” emphasises the CS.