compliance with referral of sick children a survey in five districts of afghanistan background recognition and referral of sick children to a facility where they can obtain appropriate treatment is critical for helping reduce child mortality a wellfunctioning referral system and compliance by caretakers with referrals are essential this paper examines referral patterns for sick children and factors that influence caretakers compliance with referral of sick children to higherlevel health facilities in afghanistanmethods the study was conducted in 5 rural districts of 5 afghan provinces using interviews with parents or caretakers in 492 randomly selected households with a child from 0 to 2 years old who had been sick within the previous 2 weeks with diarrhea acute respiratory infection ari or fever data collectors from local nongovernmental organizations used a questionnaire to assess compliance with a referral recommendation and identify barriers to complianceresults the number of referrals 99 out of 492 cases was reasonable we found a high number of referrals by community health workers chws especially for ari caretakers were more likely to comply with referral recommendations from community members relative friend chw traditional healer than with recommendations from health workers at public clinics and hospitals or private clinics and pharmacies distance and transportation costs did not create barriers for most families of referred sick children although the average cost of transportation in a subsample of 75 cases was relatively high us1128 most families 63 who went to the referral site walked and hence paid nothing most caretakers 75 complied with referral advice use of referral slips by health care providers was higher for urgent referrals and receiving a referral slip significantly increased caretakers compliance with referralconclusions use of referral slips is important to increase compliance with referral recommendations in rural afghanistan