Referral systems in health care have been globally recognized as the pillars and influencers of the demand for health services and their consumption time (Amoah and Philips, 2017). Although studies have been conducted to enlighten on why despite the existence of referral guidelines, their adherence is minimal; no such study has been conducted at Kenyatta National Hospital despite it being at the peak of the Kenyan health referral chain. This study sought to address this gap at Kenyatta National Hospital, Accident and Emergency department and whether its referral cases could be handled by lower levels of care, in a bid to solve its overcrowding situation. The main objective of the study was to assess the determinants of referral cases in a national hospital ─ a case study of Kenyatta National Hospital and to make policy recommendations on Referral Strategy 2019-2023 based on findings. Data from a sample size of 311 randomly selected participants was analyzed after being collected using a structured questionnaire. After conducting necessary descriptive statistics, diagnostic tests and a probit regression using STATA; It was observed that 65.9% of the respondents received referral letters; with 39.3% of those being from public health facilities (level 1 to level 6), and 32.6% of them being patient self-request referrals. It is also important to note that 62.4% of respondents resided in Nairobi County, with the overwhelming majority of respondents using private transport means to KNH (80%), with only 17.4% using ambulance services to the facility. Nairobi County also has the largest referrals to KNH (62.4%). There are indeed several significant factors that determine referral cases to KNH; among them being the age (p< 0.05), residence of patients (p< 0.05), as well as their mode of transportation (p< 0.05) to the hospital. Gender, source of income and education level are observed to have an insignificant impact on the likelihood of receiving a referral letter to KNH. The presence of the National Hospital Insurance Fund (NHIF) is most likely the ‘equalizer’ so that economic factors have less influence on access to referral care at KNH. The study recommends greater investment by national and county governments in lower-level institutions, especially outside Nairobi County, to increase their quality of care and build trust in local facilities thus reduce the numerous incidences of self-referrals. A policy brief based on study findings has also been submitted to Kenyatta National Hospital to aid actualize the current referral strategy 2019-2023.

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