DPhil in Global Health: First Referral and District Hospital Service Provision in a Changing World at the University of Oxford

The DPhil theme in Global Health: First Referral / District Hospital Service Provision in a Changing World offers an opportunity to undertake advanced research into how first-referral hospitals, district hospitals and higher-level hospitals can evolve to meet changing healthcare needs in low- and middle-income countries (LMICs).

The research theme focuses on one of the most important challenges facing health systems today: determining which healthcare services should be provided, where those services should be delivered, how they should be organised, and which health workers should provide them.

The theme is particularly relevant to countries experiencing financial constraints, changing disease patterns, rapid population growth, shortages of trained healthcare workers, technological transformation and reductions in international development funding. It also considers the implications of climate change and advances in artificial intelligence and other technologies for the future organisation and delivery of healthcare.

The DPhil research is associated with the Health Systems Collaborative (HSC) and a multidisciplinary team led by Professor Mike English. The team has extensive experience researching first-referral hospitals and is currently involved in the multi-country AFRHiCARE Partnership, which explores the role and function of first-referral hospitals in Kenya, Uganda and South Africa.

Applicants from low- and middle-income countries are particularly encouraged to apply, with potential opportunities for research collaboration involving institutions and experts in countries including Nepal, Vietnam, Burundi and the Democratic Republic of Congo, as well as experts based in the WHO Eastern Mediterranean Region.

Background to the DPhil Theme

Healthcare systems in many low- and middle-income countries are operating in an increasingly complex environment.

Countries must continue expanding and improving healthcare services while dealing with long-term fiscal constraints, geopolitical uncertainty and declining or changing international development funding. At the same time, health systems are being affected by climate change, rapid advances in technology and artificial intelligence, shortages of trained health workers and, particularly in Africa, rapidly growing populations.

These pressures create difficult decisions for governments, health planners, healthcare providers and other stakeholders.

One of the central questions is how health systems should determine the services that need to be provided at different levels of care.

For example, some services may be appropriately delivered within communities or primary healthcare facilities, while other services require the infrastructure, equipment, specialist skills and technical expertise available at first-referral or higher-level hospitals.

These decisions can have significant consequences for:

• Healthcare equity
• Quality of care
• Health system efficiency
• Patient outcomes
• Health workforce planning
• Hospital infrastructure
• Medical technologies
• Referral systems
• Integration between different levels of healthcare
• The organisation of primary and hospital-based services

The DPhil theme therefore takes a systems-wide approach, placing patients and communities at the centre of healthcare planning and recognising that effective healthcare often depends on strong integration between community services, primary care, first-referral hospitals and higher-level hospitals.

What Are First-Referral Hospitals?

First-referral hospitals, often referred to as district hospitals or general hospitals, occupy an important position within healthcare systems.

They provide services that may not be practical, affordable or efficient to deliver in smaller primary healthcare facilities but that are nevertheless essential to populations.

Examples of services that may be provided at first-referral hospitals include:

• Emergency and trauma care
• Comprehensive emergency obstetric care
• Essential surgical services
• Diagnostic imaging
• Laboratory services
• Acute neonatal care
• Severe and complex childhood illness management
• Acute and complex adult medical care
• Potentially acute mental health services

However, first-referral hospitals should not be viewed as isolated facilities.

The research theme emphasises their role within Integrated Health Care Systems, where primary care, first-referral hospitals and higher-level hospitals have strategically planned and complementary responsibilities.

This means that decisions about hospital services must consider how different levels of the health system work together rather than examining individual facilities independently.

Focus of the DPhil Research

The DPhil theme examines how the roles of first-referral hospitals and higher-level hospitals are determined, planned and changed within integrated healthcare systems.

Research may examine these roles within:

• National public health systems
• Sub-national public health systems
• Private not-for-profit healthcare systems
• Private for-profit healthcare systems
• Integrated primary healthcare systems
• Primary care networks
• Referral systems connecting different levels of healthcare

The research can therefore explore both policy-level decisions and the practical implications of those decisions for healthcare delivery.

A central concern is how health systems can make evidence-informed decisions about the services that should be provided at first-referral hospitals while ensuring that patients receive appropriate care at the right level.

Specific Aims of the Research

The DPhil theme has three closely interconnected areas of research.

1. Determining Which Services Should Be Provided at First-Referral Hospitals

The first area focuses on identifying the types of services that could or should be delivered at first-referral hospital level.

This involves examining changing healthcare needs and determining which services require the infrastructure, workforce, equipment and expertise available at these hospitals.

Research could explore how decisions about essential hospital services are influenced by:

• Population needs
• Disease patterns
• Available healthcare infrastructure
• Financial constraints
• Workforce availability
• Technological developments
• Referral arrangements
• Primary healthcare capacity
• Higher-level hospital capacity

2. Developing the Future Health Workforce

The second area focuses on how the healthcare workforce should evolve to provide first-referral hospital care in the future.

Healthcare roles are increasingly being defined by specific skills and competencies rather than solely by traditional professional categories.

This creates opportunities to investigate:

• Generalist and specialist roles
• New health worker roles
• Revised professional responsibilities
• Task-shifting
• Task-sharing
• Workforce distribution
• Workforce training
• Skills and competencies required for first-referral hospitals

Research in this area can help policymakers understand how health workforce strategies should respond to changing service requirements, technological advances and financial constraints.

3. Leveraging New Technologies

The third area examines how healthcare systems can benefit from new technologies.

Advances in technology and artificial intelligence have the potential to change:

• What healthcare services are provided
• Where healthcare is delivered
• Who provides healthcare
• How healthcare workers make decisions
• How health information is collected and analysed
• How quality of care is monitored
• How healthcare systems plan services

The research theme provides an opportunity to investigate how these technologies can be integrated responsibly and effectively within health systems in low- and middle-income settings.

Potential Research Questions

Applicants can develop research around a range of questions. The source identifies several examples that illustrate the scope of the DPhil theme.

1. How Are Technology and Artificial Intelligence Changing Healthcare Delivery?

One potential area of research is the impact of advances in technology and artificial intelligence on strategic healthcare planning and service delivery.

Research could investigate how technology may influence:

• What healthcare services are provided
• Where services are delivered
• Who provides healthcare
• How different levels of healthcare are connected
• How community, primary care, first-referral hospitals and higher-level hospitals interact

This area is particularly important as artificial intelligence and digital technologies increasingly influence healthcare systems around the world.

2. How Can Health Information Systems Improve Quality and Service Planning?

Another major research area concerns health information systems.

Many low- and middle-income countries collect large amounts of routine health information, but health systems may not yet have sufficiently developed systems to use that information effectively for strategic planning, quality monitoring and service improvement.

Research could therefore examine how routine health information can be:

• Collected effectively
• Analysed appropriately
• Used to monitor quality
• Applied to service planning
• Used to identify opportunities for improvement
• Integrated into decision-making at hospital, sub-national and national levels

There have also been substantial efforts to define quality indicators for essential hospital services. Research may examine examples of good practice and investigate how they can inform improvements in other health systems.

3. How Should Health Workforce Strategies Address Changing Hospital Roles?

A further research question concerns the changing roles of healthcare workers within first-referral hospitals.

The growing emphasis on skills and competencies, combined with experimentation with task-shifting and task-sharing, raises important questions about the future organisation of hospital workforces.

Research could investigate how first-referral hospital workforces may need to change in response to:

• Essential service requirements
• New technologies
• Artificial intelligence
• Fiscal constraints
• Changing disease burdens
• Workforce shortages
• New models of integrated healthcare

4. How Can First-Referral Hospitals Complement Integrated Primary Healthcare?

Another research area concerns the relationship between first-referral hospitals and integrated primary healthcare systems.

Research could examine how primary healthcare systems and primary care networks are being planned and implemented and determine what approaches are working in different geographical and health-system contexts.

The research can also consider the implications of the epidemiological transition and the increasing burden of non-communicable diseases (NCDs) for first-referral hospital services.

Research Approach and Methodology

DPhil students working within this theme are typically expected to have some skills in qualitative or quantitative data collection and analysis.

The specific research methods used will depend on the research question selected, the student’s interests and the needs of the project.

Students may develop skills in a range of approaches, including:

• Policy reviews
• Scoping reviews
• Systematic reviews
• Qualitative research
• Realist reviews
• Statistical analysis
• Modelling
• Formal mixed-methods research
• Qualitative data collection and analysis
• Quantitative data collection and analysis
• Implementation science approaches

Students may also develop conceptual frameworks, Theory of Change models or Programme Theory as part of their research.

Specific studies may be designed to answer the research questions developed by individual DPhil students. Where required, students will prepare research proposals for ethical review.

Primary Research in Low- and Middle-Income Countries

Primary data collection in specifically identified low- and middle-income countries may be required depending on the research project and available funding.

However, the source notes that travel to low- and middle-income countries cannot be guaranteed.

This means that prospective students should consider the research requirements and funding circumstances associated with their specific project when developing their research plans.

New ethical approvals are also likely to be required for new research activities. These may take the form of amendments to existing ethical approvals or completely new, or de novo, applications.

Health Systems Collaborative and Research Environment

Successful DPhil students will join the multidisciplinary Health Systems Collaborative (HSC) research team.

The collaborative brings together expertise from areas including:

• Clinical medicine
• Epidemiology
• Health services research
• Implementation science
• Social science
• Systematic reviews
• Health economics
• Research methodology
• Realist evaluation
• Health policy and systems research

The research environment is international, with DPhil students and collaborators from multiple low- and middle-income countries.

Students can therefore become part of a research community that brings together different professional disciplines, methodological perspectives and geographical experiences.

Training Opportunities for DPhil Students

The DPhil theme also provides opportunities for students to strengthen their research and professional skills.

Students may have the opportunity to participate in classes associated with the MSc in Health Service Improvement and Evaluation (MSc HSIE).

Depending on their interests and circumstances, DPhil students may also contribute to the MSc programme as teaching assistants.

Beyond formal coursework, the Health Systems Collaborative holds regular internal learning and skills-building sessions covering the different methods used in health policy and systems research.

Students are also encouraged to participate in:

• Online meetings with collaborators
• Research workshops
• Project-related learning activities
• Methodological skills sessions
• Research discussions
• Training activities connected to the collaborative’s projects

These opportunities can help students develop a broader understanding of health systems research while strengthening the specific methodological skills needed for their individual DPhil projects.

International Research Collaboration

The research theme is strongly international in scope.

The Health Systems Collaborative is currently involved in research examining first-referral hospitals in:

• Kenya
• Uganda
• South Africa

The team also identifies potential opportunities for developing work with collaborating institutions in:

• Nepal
• Vietnam
• Burundi
• Democratic Republic of Congo

There may also be opportunities to work with experts based in the WHO Eastern Mediterranean Region.

Applicants from these countries and other low- and middle-income countries are especially encouraged to apply.

Supervisors for the DPhil Theme

The DPhil theme is led by Professor Mike English, whose expertise includes health services research and implementation science.

Depending on the specific research question pursued, students may work with one or more additional supervisors.

Professor Mike English

Professor Mike English has expertise in:

• Health services research
• Implementation science

He is based within the University of Oxford’s Department of Tropical Medicine.

Dr Claire Blacklock

Dr Claire Blacklock brings expertise in:

• Health services research
• Health professions
• Realist methodology

Dr Yingxi Zhao

Dr Yingxi Zhao has expertise in:

• Health services research
• Workforce research
• Quantitative methods
• Qualitative methods

Dr Claire Keene

Dr Claire Keene brings expertise in:

• Longitudinal data analysis
• Chronic disease care
• Implementation science

Dr Vira Ameli

Dr Vira Ameli has expertise in:

• Digital health
• Health policy

The combination of these supervisory areas allows prospective students to develop research projects that draw on different methodological and substantive perspectives.

Relevant Research and Publications

The research theme is supported by a body of work examining health systems, first-referral hospitals, workforce organisation, quality improvement and healthcare delivery.

Examples identified in the source include research on the relational culture of healthcare workplaces and improvement interventions in neonatal care in Kenya, observational research examining neonatal nursing in high-mortality hospital settings in Kenya, and research on integrating physician assistants or associates into hospital teams.

Other work has examined the role of first-referral hospitals in low- and middle-income countries and their relationship with universal health coverage.

These publications provide useful background for understanding the broader research environment in which this DPhil theme is situated.

Why First-Referral Hospital Research Matters

First-referral hospitals can play a critical role in ensuring that patients receive services that cannot be efficiently provided at primary-care level.

However, their role needs to be carefully designed within the wider health system.

If first-referral hospitals are not appropriately integrated with primary healthcare and higher-level hospitals, patients may experience difficulties accessing appropriate care, while health systems may experience inefficiencies in the use of workforce, infrastructure and technology.

Research into first-referral hospitals can therefore contribute to broader health system goals, including:

• Improving access to essential healthcare
• Strengthening referral systems
• Improving quality of care
• Supporting more efficient health workforce planning
• Strengthening hospital service delivery
• Improving the use of health information
• Supporting evidence-based health policy
• Integrating new technologies into healthcare
• Responding to changing disease patterns
• Addressing the needs of growing populations

Who Should Consider This DPhil Theme?

This research theme may be particularly suitable for prospective doctoral researchers interested in global health, health systems, health services research, healthcare policy, hospital service delivery, implementation science, health workforce research, digital health, artificial intelligence in healthcare, primary healthcare integration and health systems improvement.

Applicants with interests in low- and middle-income country health systems may find the theme especially relevant.

The research environment is multidisciplinary, meaning that the theme can accommodate research questions drawing on different academic and methodological backgrounds, provided that the proposed research aligns with the overall focus of first-referral and higher-level hospital service provision within changing health systems.

Location and Academic Setting

The theme is associated with the NDM Centre for Global Health Research.

The supervisory and research environment is connected to the University of Oxford’s work in global health, health services research and health systems research.

The DPhil theme reference number is 1718.

Application and Admissions Information

Prospective applicants should refer to the relevant University of Oxford admissions information and the specific requirements associated with the DPhil programme when preparing an application.

The research theme is intended to provide a framework for developing a doctoral research project rather than prescribing a single research question for every student.

Applicants should therefore consider how their proposed research interests align with the theme’s focus on:

1. First-referral and district hospital service provision.
2. Integrated healthcare systems.
3. Health workforce development.
4. Health information systems.
5. Technology and artificial intelligence.
6. Primary healthcare and referral networks.
7. Quality improvement.
8. Health policy and systems research.
9. The changing burden of disease.
10. Healthcare delivery in low- and middle-income countries.

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Deadline

The deadline for applications to be considered for internal funding for entry in 2027 is Tuesday 1st December 2026. We recommend that you submit your application well in advance of the deadline – two or three weeks earlier.

There are three routes via which you can apply:

• Via an advertised DPhil theme
• By submitting your own project proposal as agreed with a supervisor
• Via an allied funded programme

Visit HERE to learn more about the DPhil in Global Health.

Conclusion

The DPhil in Global Health: First Referral / District Hospital Service Provision in a Changing World provides a research-focused opportunity to investigate how health systems can adapt first-referral and higher-level hospitals to changing healthcare needs.

The theme recognises that healthcare delivery is being reshaped by financial pressures, workforce shortages, demographic changes, climate change, evolving disease patterns, technological advances and artificial intelligence. Against this background, it seeks research that can help policymakers and health systems determine which services should be delivered, where they should be delivered and how healthcare workers and technologies can be organised to provide high-quality care.

With access to the multidisciplinary Health Systems Collaborative, opportunities to engage with health policy and systems research methods, and potential connections to research programmes across several low- and middle-income countries, the theme offers a strong environment for doctoral research focused on practical health system challenges.

The research can contribute to important questions about the future of district and first-referral hospitals, including how they can complement primary healthcare, strengthen referral systems, use health information more effectively, develop appropriate workforces and take advantage of new technologies while keeping patients and communities at the centre of healthcare planning.

For prospective researchers interested in improving healthcare delivery in low- and middle-income countries, this DPhil theme offers an opportunity to undertake rigorous doctoral research on issues with significant implications for health policy, healthcare quality and health system performance.

Source: University of Oxford DPhil theme information, Global Health: First Referral / District Hospital Service Provision in a Changing World, theme reference 1718.

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