Causal Pathways Linking Health Economics Medical Focus Service Continuity to Referral Completion in Uganda: A Multilevel Mediation Design

Referral completion in Uganda's public health system remains persistently low despite policy attention to service continuity, yet the mechanisms connecting continuity of care to referral outcomes are poorly theorised and rarely estimated. Drawing on agency theory and the institutional economics of health care, the analysis specifies how each pathway operates across the district health system and where each is most likely to fail. The proposed design integrates a two-level structural equation model with instrumental variable estimation for the mediator-outcome relationship, addressing the endogeneity that has limited prior observational work. The framework generates testable propositions concerning the relative strength of information continuity versus management continuity in Uganda's decentralised referral network, and it identifies the conditions under which financing continuity moderates the lower-level pathways.