Background: Implementation of a well-managed and functional referral system leads torngood health care quality. The referral system is an important public health issue. However, inrnEthiopia, there is no available literature that assesses the quality of the referral system ofrnHealth Centers. So these results will help health managers as a baseline in decision making.rnObjective: To assess the quality of the referral system among Health Centers in EasternrnZone of Tigray, Northern Ethiopia, 2019.rnMethod: Institutional based cross-sectional quantitative study was conducted. Eight HealthrnCenters were selected using simple random sampling. A total of 422 sample size wasrncalculated and allocated to each health center using probability allocation technique. Threerndata collection tool was used, data on the availability of inputs were collected throughrnobservation, patient interview questionnaire was used to assess patient satisfaction, andrnrecord review form was used to gather data from referral paper and feedback paper for thernprocess part at the study period. Study participants were selected using the systematicrnsampling technique every krnthrn value. Collected data were entered using epi info version 7 .2.0rn.1. Data were also cleaned and analyzed using SPSS version 25. Descriptive and, binaryrnlogistic regression was performed using SPSS version 25.rn rnResult: The response rate was 98.5%. Half (50%) of Health Centers had referral registryrnform, 22% of patients were provided ambulance, 63.6 % of patients were referred withrnreferral paper and none of the health centers had a focal person (liaison). Concerning referralrnpapers, 17 % of them were good in quality. Feedback to health centers was sent for 15% ofrnreferral; of those feedbacks 35 % were good in quality. Patient satisfaction was 47 % andrnthere were no statically significant socio-demographic factors.rnConclusion and recommendation: the quality of a referral system of Health Centers wasrnpoor. It needed to be strengthened by selecting a focal person at Health Centers, availingrnregistry form and referral papers to health centers, and by strengthening feedbackrnmechanism. Further study will be also helpful to assess the predictor of poor quality ofrnreferral system.