The Ministry of Health and Wellness Policy and Procedures Manual (2016) for referrals within the health care system, indicates that there is a bidirectional relationship in referrals between Primary, Secondary, and Tertiary Care. Though most referrals take place from primary upwards, there are occasions when there are referrals from tertiary or secondary care downwards.  Nonetheless, primary care is the first level of contact and acts as a gatekeeper system for access to secondary and tertiary care in the public health system.

References:

Ministry of Health Jamaica. (2016). Policy and Procedure Manual for the Referral and Transfer of Patients. Available from: https://moh.gov.jm/wp-content/uploads/2016/11/Revised-MOH-Policy-and-Procedure-Manual-for-the-Referral-and-Transfer-of-Patients-22.09.16.pdf