Surgical ambulance referrals in sub-Saharan Africa - financial costs and coping strategies at district hospitals in Tanzania, Malawi and Zambia.

Cost considerations strongly influence referral decisions and practices, indicating a need for increases in budgetary allocations for referral services. High volumes of potentially avoidable surgical referrals provide an economic case - besides equitable access to healthcare - for scaling up surgery capacity at the district level as savings from decreased referrals could be reinvested in referral systems strengthening.