Formal referral systems have been proposed as a strategy to improve access to secondary care, yet their implementation can be problematic. This paper describes data from referrals in one rural district in Nepal over a 4–year period. Whilst the characteristics of those patients attending hospital after referral were similar to those described in other developing countries, the rate (1.0/1000 population/year) is much lower, especially when compared to estimated need. Geographical and other barriers to access to secondary care in rural Nepal are discussed.
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