Primary, Secondary and Tertiary HealthCare

India’s healthcare system is organised into three levels — primary, secondary, and tertiary healthcare — each representing a distinct tier of medical service delivery. This hierarchical structure aims to provide comprehensive, accessible, and affordable healthcare to the population by ensuring a smooth referral mechanism between levels. The system forms the backbone of India’s public health infrastructure and reflects the principles of equity and universal health coverage.

Background and Overview

The Bhore Committee Report (1946) laid the foundation for India’s three-tiered healthcare delivery system. It recommended a network of primary, secondary, and tertiary institutions to ensure equitable healthcare services for both urban and rural populations. Over time, this framework was reinforced through the National Health Policy (1983, 2002, and 2017) and various health missions, including the National Rural Health Mission (NRHM) and Ayushman Bharat.
Each level of healthcare serves specific functions:

• Primary healthcare focuses on prevention, basic treatment, and early detection.
• Secondary healthcare provides specialised consultation and hospital-based services.
• Tertiary healthcare delivers advanced, super-specialised care.

Together, these tiers ensure a continuum of care from preventive to curative and rehabilitative services.

Primary Healthcare

Primary healthcare (PHC) constitutes the first level of contact between individuals and the healthcare system. It is the cornerstone of preventive and promotive health services, especially in rural and semi-urban areas.

Objectives and Scope

The main objectives of primary healthcare are:

• To provide accessible and affordable basic health services.
• To focus on disease prevention, health promotion, and early diagnosis.
• To serve as the first point of contact for individuals seeking healthcare.

The scope includes:

• Maternal and child healthcare.
• Immunisation and family planning.
• Treatment of common illnesses and minor injuries.
• Health education and sanitation improvement.
• Nutritional services and control of communicable diseases.

Infrastructure and Institutions

Primary healthcare in India is delivered through a network of:

• Sub-Centres (SCs): The most peripheral units, each covering about 5,000 people (3,000 in hilly/tribal areas). Staffed by Auxiliary Nurse Midwives (ANMs) and multipurpose workers, they focus on immunisation, antenatal care, and community health education.
• Primary Health Centres (PHCs): Each covers a population of around 30,000 (20,000 in hilly areas) and acts as a referral unit for 5–6 sub-centres. PHCs are staffed by medical officers, nurses, and pharmacists, providing outpatient care, basic laboratory services, and preventive health programmes.
• Community Health Centres (CHCs): Serving as the first-level referral centres, CHCs cater to around 1.2 lakh people and provide 30-bed inpatient facilities with specialists in medicine, surgery, obstetrics, and paediatrics.

Programmes and Examples

Primary healthcare delivery is supported by flagship programmes such as:

• National Health Mission (NHM) – integrates rural and urban health services.
• Universal Immunisation Programme (UIP).
• Janani Suraksha Yojana (JSY) and Janani Shishu Suraksha Karyakram (JSSK).
• Ayushman Bharat – Health and Wellness Centres (HWCs), which strengthen PHCs with comprehensive primary care services, including non-communicable disease screening.

Importance

Primary healthcare ensures community-level disease control, reduces hospital load, and promotes health awareness, thus forming the foundation for an efficient healthcare system.

Secondary Healthcare

Secondary healthcare constitutes the second tier, providing specialised medical services to patients referred from primary healthcare centres. It includes district hospitals and smaller sub-divisional hospitals that deliver both curative and limited diagnostic and surgical services.

Objectives and Scope

• To provide specialist consultation and treatment beyond the scope of PHCs.
• To act as an intermediary between primary and tertiary care systems.
• To deliver inpatient care and emergency medical services.

Services provided include:

• Internal medicine, surgery, paediatrics, gynaecology, and obstetrics.
• Diagnostic and imaging services such as X-rays, ultrasounds, and laboratories.
• Emergency care for trauma, deliveries, and infectious diseases.
• Blood transfusion, anaesthesia, and minor surgical procedures.

Infrastructure and Institutions

• Sub-District Hospitals: Function as first-level referral units with basic specialist services.
• District Hospitals: Act as apex hospitals for districts, with 100–500 beds depending on the population served. They are equipped with specialised departments, operation theatres, and diagnostic facilities.
• Community Health Centres (CHCs): Serve as secondary-level facilities in rural settings, providing referral care to PHCs.

Role in the Healthcare System

Secondary healthcare bridges the gap between community-level facilities and advanced hospitals. It reduces the burden on tertiary institutions by handling moderate cases and ensuring continuity of care.

Tertiary Healthcare

Tertiary healthcare represents the highest level of medical care, providing super-specialised treatment for complex and advanced health conditions. These services are usually available in major hospitals and medical institutions equipped with advanced technology and expert specialists.

Objectives and Scope

• To provide comprehensive and specialised care for severe diseases and complicated conditions.
• To offer teaching, research, and training facilities for medical education.
• To conduct advanced diagnostic and therapeutic procedures.

Services include:

• Specialities such as neurosurgery, cardiology, oncology, nephrology, endocrinology, and organ transplantation.
• Advanced diagnostic imaging such as MRI, CT scans, and molecular testing.
• Intensive care units (ICUs) and specialised rehabilitation services.
• Medical research and training for health professionals.

Infrastructure and Institutions

Prominent tertiary care institutions in India include:

• All India Institute of Medical Sciences (AIIMS) – New Delhi and other branches.
• Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh.
• Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry.
• King George’s Medical University (KGMU), Lucknow.
• Super-specialty wings of state medical colleges and large private hospitals like Apollo, Fortis, and Max.

These centres serve as referral institutions for patients requiring highly specialised or critical care unavailable at lower levels.

Integration and Referral System

The success of the three-tier healthcare model depends on an effective referral system, ensuring patients are treated at the appropriate level of care:

• Primary level: Prevents and identifies diseases early.
• Secondary level: Manages more complex cases referred from the primary level.
• Tertiary level: Handles advanced and life-threatening conditions.

This structured system reduces unnecessary crowding at tertiary hospitals, optimises resource utilisation, and promotes timely treatment. However, in practice, referral systems in India often face challenges such as poor communication, inadequate infrastructure, and patient preference for tertiary centres even for minor ailments.

Challenges Across Levels

Despite considerable progress, India’s healthcare system faces several challenges at each tier:
At the Primary Level:

• Shortage of trained healthcare professionals and infrastructure.
• Inadequate medicine and equipment supply.
• Limited awareness and preventive health coverage in rural areas.

At the Secondary Level:

• Overburdened district hospitals with insufficient specialist doctors.
• Inconsistent quality of services and inadequate diagnostic facilities.
• Weak referral linkages between PHCs and district hospitals.

At the Tertiary Level:

• High patient load leading to long waiting times.
• High treatment costs in private hospitals.
• Concentration of advanced facilities in urban areas, causing regional disparities.

Government Initiatives and Reforms

To strengthen healthcare delivery across all levels, the government has launched several initiatives:

• Ayushman Bharat (2018): Comprises two components — Health and Wellness Centres (for primary care) and Pradhan Mantri Jan Arogya Yojana (PM-JAY) (for secondary and tertiary care insurance).
• National Health Mission (NHM): Strengthens rural and urban healthcare infrastructure.
• Indian Public Health Standards (IPHS): Set quality benchmarks for facilities at each level.
• National Digital Health Mission (NDHM): Promotes digitalisation of health records and telemedicine access.
• Public–Private Partnerships (PPP): Improve access to specialised care and infrastructure.

These reforms aim to create a unified, patient-centred, and efficient healthcare system across India.

Comparative Overview

Significance of the Three-Tier System

The three-tier structure ensures that healthcare delivery in India is:

• Comprehensive: Covering preventive, promotive, curative, and rehabilitative services.
• Accessible: Providing healthcare at the community, district, and national levels.
• Equitable: Ensuring affordable care irrespective of income or geography.
• Efficient: Distributing patient load across tiers for optimal utilisation of resources.