# First referral hospitals in low-resource settings: a narrative review of expectations for clinical service provision

## TL;DR

This paper reviews what clinical services first referral hospitals should provide in low-resource settings, finding a gap between global expectations and local implementation.

## Contribution

The study systematically identifies 404 service expectations for FRHs, highlighting inconsistencies and gaps in global and national guidance.

## Key findings

- Some service categories have extensive recommendations due to historical priorities and vertical programming.
- Important areas lack clear guidance, showing gaps in policy and academic literature.
- National policy documents show significant variation in FRH service expectations across countries.

## Abstract

First referral hospitals (FRHs) have an important role to play in helping many countries achieve ‘Health for All’. However, their specific role and the clinical services they are expected to provide to achieve this are evolving. To explore this issue further, we undertook a narrative review to examine the clinical service expectations of FRHs outlined in academic and policy literature, which identified a total of 404 FRH service expectations. At a global level, some categories of services provide extensive specific service recommendations, likely resulting from historical priorities and the influence of vertical programming and professional interests. However, in several important areas we identified few or no recommendations. At the level of individual country case studies undertaken through this review, FRH clinical service recommendations within available policy documents vary considerably. Our findings suggest a disconnect between the ambition for FRH and the difficult, context-specific decision-making needed at the national level on the role of FRHs as a service delivery platform within integrated health systems helping countries achieve universal health coverage.