Lessons Learned from Implementing a Community Health Worker-Initiated Referral Strengthening Intervention in Haiti: A Mixed-Methods Program Case Study

Referral processes linking communities to facilities are under-appreciated and lack evaluation, particularly in humanitarian settings. Community health workers or agents de santé communautaire polyvalent (ASCPs) in Haiti refer communities to health facilities for a range of services. This program case study assessed implementation of a public-private referral strengthening intervention within on-going community health programming, including a triplicate referral form, supportive training, and follow-up structures. We applied mixed methods to describe referral trends using routine programmatic data, factors affecting implementation and referral completion through a pre-intervention referred patient survey (n = 525), meeting observations, and interviews with ASCPs, supervisors, and key stakeholders (n = 88). We found that the intervention demonstrates little influence on referral trends, but qualitatively enhances the referral process for ASCPs and supervisory stakeholders in Haiti. It improves supervision relationships and shows promise for enhanced community-integrated patient monitoring systems - when supported by financial support and non-governmental and governmental partners, but is vulnerable to sociopolitical, geographic, and insecurity challenges preventing referral completion. Integrating intervention activities within existing programming and scaling the triplicate referral form in Haiti can strengthen the national ASCP curricula. Globally, we suggest adapting the triplicate referral form as a promising job-aid and data-reporting tool within community health worker programs.